The pudendal nerve along its course passes through various gorges, which are described as possible points of pudendal nerve entrapment.
- The clamp formed between the sacrotuberous and sacrospinous ligaments (70% of the cases of entrapment studied are located in this area).
- Alcock’s canal (20% of cases).
- The falciform process of the sacro-tuberosus ligament.
- Any location along the course of the pudendal nerve or its branches.
Diagnosis of Pudendal Neuralgia
The diagnosis of Pudendal neuralgia is made primarily on the basis of symptoms. Imaging tests (X-ray, MRI, CT, ultrasound) may only be indicated to rule out other pathology.
Electromyogram (EMG) can be helpful, but is not always conclusive.
What can we do in the Pain Unit with pudendal neuralgia?
Most of the patients who come to the Pain Unit specialist’s office have already taken various medications such as analgesics/anti-inflammatory drugs, muscle relaxants or neuropathic pain medication, such as Amitryptiline (Tryptizol), Pregabalin (Lyrica), Gabapentin (Neurontin) without improvement.
Treatment of Pudendal Neuralgia
I will not describe surgical treatment, because it is not my specialty, although it may be another alternative in cases that do not improve with conservative techniques. The problem that most patients encounter with surgery is that there are not many specialists dedicated to this pathology.
One of the treatments recommended in all the guides is physiotherapy or pelvic floor rehabilitation. There are units and centers specialized in this type of physiotherapy that are often helpful.
In those cases that also do not improve with this treatment, in the Pain Unit we initially perform anesthetic blocks of the pudendal nerve. This treatment is simple; it is usually uncomfortable but not painful and in many cases the pain usually improves for months. When the pain returns, they can be repeated without any problem.
In cases where the improvement with anesthetic blocks is not lasting, pulsed radiofrequency treatment of pudendal nerves is performed. This treatment is performed in the operating room, on an outpatient basis, with local anesthesia and if necessary sedation of the patient (those who require it due to anxiety or nervousness). It is done with the help of ultrasound or x-rays to locate the nerves and consists of the application of a type of high frequency current (radiofrequency) for 6 minutes which reduces the irritability of the nerves and usually improves pain significantly. It is not a definitive treatment and may need to be repeated after several months or years.
In more difficult cases that have not improved with any previous treatment, the next step is the implantation of sacral stimulation electrodes.
Sacral electrodes are also implanted in the operating room, under sedation and local anesthesia. It is performed in 2 phases: an initial test phase, in which the patient wears the electrodes for a period of 2-4 weeks and if improvement is obtained, then a battery, generator or battery (similar to a pacemaker) is implanted, which will administer the energy for pain relief. This treatment usually has a high degree of efficacy in difficult cases.