Pudendal Neuralgia Anouk Speek VCU DPT Class of

Pudendal Neuralgia Anouk Speek VCU DPT Class of 2017 27 July 2016

What is Pudendal Neuralgia? Mechanical or Inflammatory irritation of the pudendal nerve 2/3 of sufferers are women 1/100, 000 Often misdiagnosed and inappropriately treated

Anatomy Lumbo-Sacral Plexus (L 4 -S 4)>Pudendal nerve(S 2 -S 4)> Inferior rectal nerve (sensory) Anal canal, peri-anal skin, rectum, external anal sphincter Perineal nerve (sensory) Perineum, Vagina, Urethra, male scrotum, Labia, transverse perineal muscle, urethral sphincter Dorsal nerve of the clitoris/penis (sensory) Skin of the clitoris/penis, bulbocavernosus muscle, ischiocavernosus muscle Motor portion External anal sphincter, sphincter muscles of bladder, muscles of pelvic floor Sensory (80%) and Motor fibers (20%) Only nerve with both autonomic and somatic fibers: ^ Heart Rate ^ Blood Pressure ^ Perspiration Decreased motility of colon Decreased blood flow

Symptom location Females: vulva, clitoris, vagina, perineum, rectum Males: glans penis, scrotum (excluding testicles), perineum, rectum A – pudendal nerve B – inferior cluneal nerve C – Obturator nerve D – ilioinguinal and genitofemoral nerves

Pudendal Nerve- Female

Pudendal Nerve - Male The pudendal nerve comes from the sacral plexus (S 2 -S 4) and enters the gluteal region through the lower part of the greater sciatic foramen. It runs through the pelvis around ischial spine and between the sacrospinous and sacrotuberous ligaments through Alcock’s Canal. It splits up into the rectal/anal, perineal and clitorial/ penis branches.

Pelvic Floor Anatomy Three layers: 1. Superficial perineal Layer (Pudendal Nerve Innervation) 1. Bulbocavernsus, Ischocavernosus, Superficial transverse perineal, External Anal Sphincter 2. Deep Urogenital Diaphragm layer (Pudendal Nerve Innervation) 1. Compressor Urethra, Uterovaginal Sphincter, Deep transverse Perineal 3. Pelvic Diaphragm (Sacral Roots S 3 -S 5) 1. Levator Ani (Pubococcygeus, Iliococcygeus), Coccygeus/Ischiococcygeus, Piriformis, Obturator Internus

Possible causes Childbirth Entrapment at Alcock’s canal/“Cyclist’s Syndrome” Entrapment between sacrospinous and sacrotuberous ligaments Trauma (Fall, pelvic fx, etc. ) Pelvic sling operations Stretching (HS) Prolonged sitting Endometriosis Anatomy/genetic predisposition Compression from tumour Prolonged straining/passing stool Inflammatory/Auto-immune Frequent infections Asymmetric skeleton/muscle imbalance ** entrapment is most likely caused by Levator Ani or Obturator internus spasm, ligament pressure (sacrospinous or sacrotuberous), scar tissue from surgery or trauma

Top Causes Women Men Pelvic Surgery *especially for prolapse/incontinence Pelvic Trauma Pelvic trauma/falls Childbirth

Diagnosis – Clinical! Image-guided Pudendal nerve block (also a treatment) Pudendal nerve Motor latency test (replaced by nerve block) MRI/CT scan Nantes’ Criteria (Pudendal n. entrapment) Inclusion criteria: Pain situated in the anatomical territory of the pudendal nerve, worsened by sitting, the patient is not woken at night by the pain, no objective sensory loss is detected on clinical examination, and positive pudendal nerve block Exclusion criteria: purely coccygeal, gluteal, or hypogastric pain, exclusively paroxysmal pain, exclusive pruritus, presence of imaging abnormalities able to explain the symptoms Red flags: waking up at night, excessively neuropathic nature of the pain, specifically pinpointed pain Symptoms/history Internal exam; Levator Ani, Obturator Internus, sensitive Bladder, sacrospinous ligament Tinell’s sign

Differential Diagnoses Low back Pain SI joint dysfunction Sacral radiculopathies Endometriosis Piriformis dysfunction Hip pain/labrum/joint Tumours Pelvic Floor Dysfunction Disease of the skin/spine Gynecological, urological, proctological conditions, Prostatodynia Nonbacterial Prostatitis Vestibulitis Idiopathic vulvodynia Idiopathic proctalgia Idiopathic penile pain syndrome Interstitial cystitis Other nerves; lateral femoral cutaneous, posterior femoral cutaneous, genitofemoral, Obturator nerve

Signs/Symptoms Pelvic pain relieved with standing and/or sitting on a toilet** Hyperesthesia; discomfort with tight clothing** Bladder/bowel sx (hesitancy, frequency, urgency, retention, constipation, pain) Dyspareunia Low abdomen pain Erectile Dysfunction Pain with orgasm Genital pain Anal pain Relief of sx with Pudendal nerve block Itching, burning, tingling, cold feeling, shooting pain, stabbing, pin pricking, numbness, twisting, pulling Unilateral or bilateral (even if entrapment is unilateral) Posterior thigh pain Groin pain Allodynia; pain with nonpainful stimulus

PT Treatment/Intervention Patient Education Strength, mobility, endurance, manual therapies to Pelvic floor, abdominal, gluteal, hip rotator muscles Pudendal nerve mobilisation Connective tissue mobilization (external and internal) Myofascial release (external and internal) Trigger Point Release Normalise structure and mechanics i. e. pelvic obliquities, hip mechanics, neuromuscular control of core Posture correction Relaxation techniques What to avoid? Depends on the patient…PFM contraction, positioning, etc. Precautions Hip flexion past 90 degrees and ER End range ER/IR

Intervention progression PT, PT!! PT 2 -3/week, HEP, Relaxation techniques for 6 months Anti-depressants/Anti-Convulsants/Muscle Relaxers Trigger point injections/Pudendal nerve block/Steroid injections/Botox injections Radiofrequency ablation/Cryoablation** IV infusion therapy/Spinal Cord Stimulation (SCS)/Intrathecal pumps Surgery 1. Trans-Ischio-rectal 2. Trans-gluteal 3. Trans-perineal 4. Laprascopic Complications from surgery: pain at incision site, scar tissue, SI jt dysfunction, gluteal tearing, sciatic nerve tension Back to PT?

Prognosis Depends on the patient! Psychosocial component International Pudendal Neuropathy Association (Tipna. org)

Differential Diagnosis of Pelvic Floor Dysfunction in Orthopaedics Pain/shooting/stabbing straight through hip Anterior to posterior Bladder/bowel dysfunction Low back pain with L/S and LE ruled out Pelvic Obliquities Low abdominal pain Breathing dysfunction Check Tr. A activation! OLS for load transfer ASLR (bulging) Ant compression ASIS – Tr. A/ lower IO Post compression PSIS – Multifidus Ant compression pubic symphysis – anterior PFM/low Tr. A/IO Post compression IT – posterior PFM

References Pudendal Neuralgia. Michael Hibner MD, Ph. D Nita Desai MD, Loretta J. Robertson PT, and May Nour MD, Ph. D. Journal of Minimally Invasive Gynecology, The, 2010 -03 -01, Volume 17, Issue 2, Pages 148 -153, Copyright © 2010 AAGL Dr. Amanda Miller, Gender Health Lecture, VCU 2/29/2016 Pudendal Neuralgia due to Pudendal Nerve Entrapment: Warning signs Observed in Two Cases and review of the literature. Ploteau S, Cardaillac C, Perrouin-Verbe MA, Riant T Labat JJ. Pain Physician, 2016 Mar; 19(3): E 449 -54 Percutaneous CT-guided cryablation for the treatment of refractory pudendal neuralgia. Prologo JD, Lin RC, Williams R, Corn D. Skeletal Radiol. 2015 May; 44(5): 709 -14. doi: 10. 1007/s 00256 -014 -2075 -3. Epub 2014 Dec 17. http: //www. beyondbasicsphysicaltherapy. com/pudendal-nerve-neuralgia https: //www. urmc. rochester. edu/medialibraries/urmcmedia/imaging/patients/documents/pudendal_neuralgi a_brochure. pdf http: //ainsworthinstitute. com/conditions/pudendal-neuralgia/ http: //www. pudendalhope. info/node/8#5 https: //www. glowm. com/section_view/heading/Pudendal%20 Neuralgia/item/691 https: //www. studyblue. com/notes/note/n/anatomy-gluteus-and-anal-regions/deck/1890005