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Clinical Information > Neurological
There are several neurological causes of pelvic pain. Nerve entrapment and nerve damage in the pelvis may result from various causes such as disease (cancer, endometriosis ), accident, surgery etc.
Pelvic nerves that may be affected include the ilio-inguinal, genitofemoral, pudendal, sciatic and inferior cluneal nerves. These conditions which can cause extreme pain and disability may be overlooked by clinicians especially when a careful history is not taken. Even if a clinician suspects neuropathic pain, this may not be shared with the patient who can remain unaware of
the reason for such pain. Diagnosis is an important step in planning care, enabling the patient to take an active part in decision making regarding treatment and in helping the patient to take control in the effort to reduce the impact of such pain on their quality of life.
Pudendal nerve entrapment
Pudendal nerve entrapment is a possible diagnosis in patients with anoperineal pain. The pudendal nerve follows a very difficult path. It supplies sensation to almost the entire pelvic area as well as motor function to the pelvic floor muscles and urethral sphincter. The junction of the sacrotuberous and sacrospinous ligaments and the pudendal canal of Alcock are two major areas of entrapment. CT guided local anaesthetic ischial spine or the Alcock’s canal can help with diagnosis. Some patients undergo surgery to decompress the pudendal nerve. There are various surgical techniques with one published randomized controlled trial suggesting improvement in two thirds of patients at one year follow up. (Robert R et al ) There are few surgeons performing such surgery worldwide.
The clinical history and physical examination are a crucial part of the workup. Patients frequently present with extreme pain on sitting which may be relieved by standing. (Labat JJ et al ) Patients will often stand during a consultation or if they sit, it may be in an awkward position with the weight on one buttock or slouched backwards in the chair to relieve the pressure on the painful area. They may also use various cushions with a cut out. This difficulty with sitting can easily be overlooked by a health professional. It can also take a great deal of courage on the part of the patient to discuss such difficulties. The first thing that is suggested to a patient on entering a consulting room is to take a seat. It can be extremely difficult for a patient to refuse a seat and to insist on standing. Many patients may force themselves to endure extreme pain for the duration of a consultation.
A video of an interview with a patient who had pudendal decompression surgery via the transgluteal approach can be viewed via the following link. A video of the removal of a suture involving the pudendal nerve can also be viewed here
References:
Diagnostic criteria for pudendal neuralgia by pudendal nerve entrapment (Nantes criteria )JJ Labat, T Riant, R Robert, G Amarenco et al
Neurourol Urodyn 2007 Sep 7
Decompression and transposition of the pudendal nerve in pudendal neuralgia: a randomized controlled trial and long-term evaluation. R Robert, JJ Labat, M Bensignor et al
Eur Urol 2005 Mar; 47(3);403-8
A more detailed booklet about the diagnostic criteria and management of pudendal neuralgia can be obtained from info@pelvicpain.org.uk
