Diagnostic and therapeutic algorithm for pudendal nerve entrapment syndrome

Advancing the diagnosis and management of pudendal nerve entrapment: The role of neurophysiological studies and imaging-guided infiltrations

PURPOSE

Pudendal nerve entrapment (PNE) diagnosis is not standardized. This leads to diagnosis delays, impacting quality of life and therapeutic outcomes. The main goal is to find the role of neurophysiological study (NFS) and Imaging-guided pudendal nerve infiltration (ImPNI) in PNE diagnosis and patient selection for surgery.

METHODS

A retrospective, multicentric study was conducted. Patients with PNE refractory to conservative treatment were included. Patient data, including NFS results, ImPNI, and surgical outcomes, were evaluated. A visual analogue scale was used to assess intervention response. Test performance metrics for NFS and ImPNI and binary logistic regression were used to determine their predictive value for postoperative improvement.

RESULTS

88 patients were diagnosed with PNE. All had NFS, and ImPNI was performed in 69 (78.4%), with 60 (68.2%) showing symptom improvement. Among the 40 patients (85%) who underwent pudendal nerve decompression surgery, 75% improved after surgery, and 20% did not. The combination of NFS and ImPNI showed a sensitivity of 79% and a specificity of 85.7%, with a Positive Predictive Value (PPV) of 98% and a Negative Predictive Value (NPV) of 30%. NFS and ImPNI were significant predictors of surgical success with p-values of 0.013 [ 95% CI: -23.6-19.9] and 0.003 [95% CI: -20.6 -18.5], respectively. Primary limitations: retrospective design and the absence of a control group.

CONCLUSIONS

NFS and ImPNI are essential and highly reliable tools for diagnosing PNE. ImPNI is a valuable predictor of surgical outcomes. These findings enable precise patient selection for surgery, ensuring optimal surgical outcomes.

The Golden Year? Early Intervention Yields Superior Outcomes in Chronic Pelvic Pain with Pudendal Neuralgia: A Comparative Analysis of Early vs. Delayed Treatment

BACKGROUND

Chronic pelvic pain (CPP) associated with pudendal neuralgia (PN) significantly impacts quality of life (QoL). Pudendal nerve infiltration is a recognized treatment, but the optimal timing of intervention remains unclear.

METHODS

This prospective study included 81 patients diagnosed with PN and treated with pudendal nerve infiltrations. Outcomes were assessed using the Visual Analog Scale (VAS), Spanish Pain Questionnaire (CDE-McGill), and the SF-12 health survey. Significant improvement was defined as a VAS reduction > 4 points and a QoL increase > 15 points. An ROC curve analysis identified a 13-month time-to-treatment threshold (sensitivity 78%, specificity 72%), categorizing patients into early (n = 27) and delayed treatment groups (n = 54).

RESULTS

The early treatment group showed significantly greater reductions in VAS scores (5.4 vs. 3.4 points, p < 0.01) and QoL improvements (18 vs. 8 points, p < 0.01) compared to the delayed group. Early intervention reduced reinfiltration rates (10% vs. 35%, p < 0.05) and decreased medication use, with 81% discontinuing gabapentin compared to 41% in the delayed group. Similar trends were observed for tryptizol (44% vs. 35%) and tramadol (74% vs. 30%). Multivariate analysis confirmed time to treatment as the strongest predictor of outcomes, with each additional month delaying treatment associated with a 0.18-point increase in final VAS scores (p < 0.001). Delayed treatment was linked to higher final doses of gabapentin (p = 0.01), dexketoprofen (p < 0.001), and tramadol (p = 0.012). Minimal complications were reported (15%, Clavien I).

CONCLUSIONS

Early intervention in PN significantly improves pain, QoL, and reduces reinfiltration and medication reliance, supporting timely treatment for optimal outcomes.

Chronic Primary Pelvic Pain Syndromes in Women: A Comprehensive Review

Chronic pelvic pain (CPP) in women is a multifactorial and complex condition. It often remains undiagnosed or inadequately treated. Despite its high prevalence, CPP continues to be a taboo subject, leading to delays in seeking medical care. Chronic primary pelvic pain syndromes (CPPPS) are pain conditions without an obvious underlying diagnosis, including painful bladder syndrome, vulvodynia, genito-pelvic pain/penetration disorder, levator ani syndrome, proctalgia fugax, myofascial syndrome, pudendal neuralgia, and coccyx pain syndrome. A comprehensive review of the literature was conducted to understand the most common forms of CPPPS in women, focusing on diagnostic criteria, pathophysiology, and treatment options. Due to the complexity of CPPPS and varied treatment responses, management requires a multidisciplinary approach. Although various treatment modalities exist, no single strategy is universally effective, emphasizing the need for individualized care. Future research should prioritize refining diagnostic criteria and investigating new therapeutic strategies.

Management of pudendal neuralgia with electrical stimulation. A systematic review

INTRODUCTION AND OBJECTIVE

Pudendal neuralgia is a severely intense, painful, neuropathic condition, involving the dermatome of the pudendal nerve (S2, S3, S4). The diagnosis is complex and usually takes many years to be made. Techniques that use electrical current have been shown to decrease pain and improve quality of life in patients with this condition. The aim of this review was to analyze the existing literature on the effects of electrical current in the treatment of patients with pudendal neuralgia.

MATERIAL AND METHODS

A literature search was carried out in PubMed, Cinahl, Medline, Cochrane Library, ENFISPO, PEDro, Scopus and Web of Science databases, using the search terms "Electric Stimulation Therapy", "pudendal neuralgia" and "pudendal nerve entrapment".

RESULTS

The most frequently repeated intervention is pulsed radiofrequency. Other techniques used are transcutaneous electrical nerve stimulation, pulsed electromagnetic field therapy and neuromodulation. All studies show significant improvement in pain, analgesic intake, depression-anxiety or quality of life.

CONCLUSIONS

The application of electrical current seems to be effective in the management of pudendal neuralgia. The scientific evidence is scarce, of poor methodological quality, and its use is based on the efficacy demonstrated in other indications of chronic pain.

Ossification of Bilateral Sacrotuberous Ligaments: Two Cases Report and Literature Review

Ossification of the sacrotuberous ligament is a rare occurrence in soft tissue, with only 15 cases reported in the past few decades. We reported two cases of bilateral ossification in sacrotuberous ligaments and provided a concise review of the literature on this pathology. Clinical data, radiographic outcomes, and diagnostic and treatment details were obtained. This study aimed to summarize this disease's characteristics and investigate its pathogenesis through a review of literature from the last thirty years. This condition is often incidentally confirmed in elderly males via imagiological examination or gross anatomy and presents a low morbidity rate. Its pathogenesis may be related to stress concentration, excessive intake of element ions, injury repair, and improper operative technique. The majority of patients may not exhibit any clinical symptoms or signs and typically do not require medical interventions. It may be complicated with pudendal nerve entrapment syndrome. The long-term effects of surgical resection and the most effective treatment approach remain areas for further research.

First case-series of robot-assisted pudendal nerve release: technique and outcomes

OBJECTIVE

Pudendal Nerve Entrapment (PNE) may determine chronic pelvic pain associated with symptoms related to its innervation area. This study aimed to present the technique and report the outcomes of the first series of robot-assisted pudendal nerve release (RPNR).

PATIENTS AND METHODS

32 patients, who were treated with RPNR in our centre between January 2016 and July 2021, were recruited. Following the medial umbilical ligament identification, the space between this ligament and the ipsilateral external iliac pedicle is progressively dissected to identify the obturator nerve. The dissection medial to this nerve identifies the obturator vein and the arcus tendinous of the levator ani, which is cranially inserted into the ischial spine. Following the cold incision of the coccygeous muscle at the level of the spine, the sacrospinous ligament is identified and incised. The pudendal trunk (vessels and nerve) is visualized, freed from the ischial spine and medially transposed.

RESULTS

The Median duration of symptoms was 7 (5, 5-9) years. The median operative time was 74 (65-83) minutes. The median length of stay was 1 (1-2) days. There was only a minor complication. At 3 and 6 months after surgery, a statistically significant pain reduction has been encountered. Furthermore, the Pearson correlation coefficient reported a negative relationship between the duration of pain and the improvement in NPRS score, - 0.81 (p = 0.01).

CONCLUSIONS

RPNR is a safe and effective approach for the pain resolution caused by PNE. Timely nerve decompression is suggested to enhance outcomes.

Dorsal Root Ganglion Stimulation Therapy for Refractory Idiopathic Pudendal Neuralgia

Dorsal root ganglion stimulation is a relatively new treatment option for chronic pain conditions such as pudendal neuralgia, which is a chronic pain condition affecting the pudendal nerve in the pelvic region. Pudendal neuralgia is a debilitating condition that can significantly affect the patient's quality of life. In dorsal root ganglion stimulation, a small device is implanted that delivers electrical impulses to the dorsal root ganglion to modulate pain signals coming from the pudendal nerve. The procedure is considered investigational and has been investigated in case series and case reports with promising results. However, more research is needed to fully understand its safety and effectiveness. This case report highlights the potential of dorsal root ganglion stimulation as a treatment option for pudendal neuralgia and the need for further research to establish it as a standard treatment option.