Recommendations on the management of pudendal nerve entrapment syndrome: A formalised expert consensus

BACKGROUND

Since the development and publication of diagnostic criteria for pudendal nerve entrapment (PNE) syndrome in 2008, no comprehensive work has been published on the clinical knowledge in the management of this condition. The aim of this work was to develop recommendations on the diagnosis and the management of PNE.

METHODS

The methodology of this study was based on French High Authority for Health Method for the development of good practice and the literature review was based on the PRISMA method. The selected articles have all been evaluated according to the American Society of Interventional Pain Physicians assessment grid.

RESULTS

The results of the literature review and expert consensus are incorporated into 10 sections to describe diagnosis and management of PNE: (1) diagnosis of PNE, (2) patients advice and precautions, (3) drugs treatments, (4) physiotherapy, (5) transcutaneous electrostimulations (TENS), (6) psychotherapy, (7) injections, (8) surgery, (9) pulsed radiofrequency, and (10) Neuromodulation. The following major points should be noted: (i) the relevance of 4+1 Nantes criteria for diagnosis; (ii) the preference for initial monotherapy with tri-tetracyclics or gabapentinoids; (iii) the lack of effect of opiates, (iv) the likely relevance (pending more controlled studies) of physiotherapy, TENS and cognitive behavioural therapy; (v) the incertitudes (lack of data) regarding corticoid injections, (vi) surgery is a long term effective treatment and (vii) radiofrequency needs a longer follow-up to be currently proposed in this indication.

CONCLUSION

These recommendations should allow rational and homogeneous management of patients suffering from PNE. They should also allow to shorten the delays of management by directing the primary care.

SIGNIFICANCE

Pudendal nerve entrapment (PNE) has only been known for about 20 years and its management is heterogeneous from one practitioner to another. This work offers a synthesis of the literature and international experts' opinions on the diagnosis and management of PNE.

Fibrinolysis and hemorheology in chronic venous insufficiency: a double blind study of troxerutin efficiency

Abnormal increase of erythrocyte aggregation and reduction of profibrinolytic activity are the two most frequent biological perturbations found in chronic venous insufficiency (CVI). A randomised, controlled, double blind trial was undertaken on 85 patients suffering from grade 1 and 2 CVI, to compare troxerutin with placebo. Two types of biological parameters were measured after 15 days of treatment. Erythrocyte aggregation as evaluated with a Myrenne erythroaggregometer by the indices M (stasis) and M1 (3s-1) progressed favorably in the troxerutin group. The values of M1 at D15 (p < 0.05), and the progression of M (p < 0.001) and M1 (p < 0.01) from D0 to D15, are significantly better in the troxerutin group. Progression of fibrinolytic activity at rest was not significantly different between the 2 groups. Conversely, the progression from D0 to D15 of the values after occlusion of euglobulin lysis time (p < 0.01), tPA (p < 0.01), and PAI activity (p < 0.05) are significantly better in the troxerutin group. The fibrinolysis capacity estimated by euglobulin lysis time (p < 0.01) and tPA (p < 0.05) also progressed favorably in the troxerutin group. These results confirm the anti-erythrocyte aggregation effect of troxerutin, and suggest a favorable effect on blood fibrinolytic activity. They could explain the positive action of this drug on stasis, capillary perfusion and trophic complications of CVL.

Chemonucleolysis: correlation of results with the size of the herniation and the dimensions of the spinal canal

The aim of this study was to determine whether the results of chemonucleolysis are related to the size of the disc herniation and to the dimensions of the spinal canal. Short and long-term results (average follow-up 4 and a half years) of 148 patients were evaluated. Measurements made with a divider included the size of the disc herniation related to the sagittal diameter of the spinal canal at the discal level and the transverse interligamentous diameter at the level of the facet joints. The morphology of the lateral recess was also assessed. Measurements were initially made by five observers and were repeated eight times and on eight computed tomography (CT) scans in order to assess intra- and interobserver variability. Measurements of the entire series were then made by the two observers demonstrating a good intra- and interobserver reproducibility. Of the 148 patients 74% had an overall successful result. No significant difference was disclosed when comparing the various parameters of the clinical results with the size of the herniation. Similarly, a lack of correlation was also found between the clinical results and the dimensions of the spinal canal and of the lateral recess. In this series, the results were not significantly influenced by the size of the herniation or the morphology of the spinal canal.

[Venous insufficiency and varicose disease. Sequelae of lower limb thrombosis. The role of crenotherapy]

The writers reminded that a consensus on Classification of veinous diseases, necessary to build up homogeneous samples, was being set up. Now, they are introducing a thermal nosology that is as useful. Next, the history of spas, the characteristics of Thermal Springs and thermal practices as well as their results are described. The writers present a standardization of the observation and control parameters of the therapeutic effects. The rigorous and scientific process was defined by an interdisciplinary scientific process was defined by an interdisciplinary scientific Council and it is based on the creation of a Computerized Laboratory of Research and a Thermal University. It has become an example in the field of thermalism. According to the results and the modern indications, the water cure has to be prescribed at an early stage. The practitioner must think about it and insert the water cure in the arsenal of veinous diseases. According to the hydrogeologists' estimates, BARBOTAN les thermes, the first European spa with about 22,000 patients is thought to possess enough water to allow from 40,000 to 60,000 people to be treated yearly. A thermal environment is the ideal place for an efficient vascular rehabilitation and functional re-education. In phlebology, more than one million people should benefit from a water cure yearly ... Only 70,000 follow this treatment. Everyone has to wonder about this situation, which, to those who do not benefit from a thermal cure in phlebology, is as astonishing as prejudicial.

[Evaluation of venous therapy. Venous tonics, vascular protectants and thermal cures. What are the advantages for the patient?]

In the first section, the authors describe some epidemiological features and give an account of the capillary structure and the structure of different veins. They describe the venous physiology and its modulations, in order to be able to give a precise description of different venous affections: venous senescence, chronic venous insufficiency, thrombophlebitis. The particular features of these three pathologies and their action mechanisms enable the authors to envisage appropriate phleboactive therapy, and to evaluate it in advance. As far as the actual notion of evaluating these venous therapies is concerned, the authors make clear that there is no difference between thermal therapies and phleboactive allopathic therapies. They concentrate on describing a unique methodology in two stages considering the thermal establishment as a pharmaceutic laboratory and as an out-patient hospital for follow-up treatment. This therapeutic evaluation comprises two sections: preparation at the laboratory (pharmaco-clinical stage, animal experimentation) and the second stage of therapeutic clinical tests on humans. The authors define a rigorous, quantified methodology based on homogeneous samples in the framework of a computerised medical file consisting of a base and polyvalent satellites. Satellite 3, assembling the elements of the therapeutic form, deals, for example, with phlebotonics, vascular protectors and thermal cures. A detailed list of different phleboactive therapies is drawn up, making it possible to analyse their specific respective effects, and therefore to give specific prescriptions. The patient can hope for preventive measures and a cure with fewer after-effects in the context of a general, well-conducted sanitary education. The authors conclude that patients, doctors and the organizations concerned will benefit greatly from this.

[Measurement of the effects of Barbotan-les-Thermes waters on the venous filling and drainage in patients with phlebitis and varicosities using plethysmography with a measuring gauge]

The effects of Barbotan waters have been tested using plethysmography with a mercury gauge, with venous occlusion in 73 patients taking the cure with venous pathology; 43 legs with phlebitic sequelae, 72 varicose legs. The principal parameters of filling and emptying were measured. Dynamic pictures made it possible to show the variation in these parameters. The publication demonstrates a remarkable normalization effect in the venous functions. In it we discuss classification by the plethysmographic means alone and the eventuality of the venous areas. We conclude by linking this normalising effect on the venous functions with the antispasmodic effect already discussed in an earlier work.

[Effect of the Barbotan treatment on patients with vascular disorders associated with gonarthrosis]

Barbotan Spa has two types of thermal strata: the mesothermal waters (35-37 degrees) and the vegeto-mineral mud. This double layer allows the treatment of patients with circulatory disorders combined with rheumatic affections. This study is based on 15 parameters of venous gonarthritic disorders in 20 patients. These parameters were measured in the two first and the two last days of the cure, notably by means of foot volumetry with venous occlusion. The publication describes the technique, the classification of patients, and the immediate results. The discussion enables the authors to draw up significant parameters and it confirms the results obtained by other authors, and tries to give a physiopathological explanation. This work concludes that mixed treatment is more than 75% effective; the authors insist on the need to resist contributory factors such as obesity and endocrinic disorders. The thermal cure should be the complete taking in hand of the patient.

[Experimental monitoring of the effects of hand and foot douches at Barbotan on peripheral circulation]

New techniques, the manudouche and the pedidouche, were tested at Barbotan on various diseases of the peripheral circulation (artery, vein, lymphatic) after an overall assessment of the treatment based on more than 200 patients and on rheographic recordings. These treatments aim to relieve the vascular spasm in the limbs and to reduce the threshold of sympathetic excitability. This paper outlines the techniques, the thermal agents used and the immediate results. The author concludes that these techniques are of value in the treatment of peripheral circulatory disease and proposes a review of the general thermal nomenclature involving the classification and the indications of thermal resorts aimed at treating vascular disease (heart, artery, vein, lymphatic).