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Pudendal neuralgia - a urogynecological approach
IUGA Academy. Masata J. Jun 30, 2018; 213272; 149 Topic: Pelvic Pain
Prof. Dr. Jaromir Masata
Prof. Dr. Jaromir Masata

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149

Pudendal neuralgia – a urogynecological approach

Masata, J1; Svabik, K1; Hubka, P1; Martan, A2

1: Charles University, First Faculty of Medicine and General University Hospital Prague; 2: Petr Hubka <petr.hubka@centrum.cz>

Introduction: Pudendal neuralgia is a rare condition which is often not properly diagnosed. Unfortunately most patients with this condition seek answers from their physicians in vain as to the cause. The diagnosis is frequently mistaken, and they may undergo inappropriate or unnecessary surgery or be referred to psychiatry because examination is unable to diagnose the condition. Pudendal neuralgia as defined in the ICS/IUGA terminology report is vaginal or vulval burning pain (between the anus and clitoris) associated with tenderness of the pudendal nerves. Five essential criteria (Nantes criteria) have been proposed: (a) pain in the anatomical region of pudendal innervation, (b) pain that becomes worse with sitting, (c) no waking at night with pain, (d) no sensory deficit on examination, and (e) relief of symptoms with a pudendal block. We can form a diagnosis based on history taking and excluding other causes such as infection, tumor etc. No clinical examination is able to diagnose pudendal neuralgia clearly.

Objective:The objective of this work is to present a typical patient with pudendal neuralgia with the complex possibilities of the treatment and a video presentation of laparoscopy surgical pudendal nerve decompression.

Methods: Case presentation: a 55-year-old women (G2/92, height 170 cm, weight 70 kg) was referred to our department with chronic vulvovaginal discomfort, following repeated urogynecological procedures. She complained of pressure pain around the pubic bone, vulvar itching, a tingle in the lower abdomen; the discomfort appeared after her second delivery. The discomfort eased at rest and worsened with movement. Walking induced urgency, and walking upstairs induced pain. She had increased frequency (15 per day), urgency incontinence, no nocturia, and stress urinary incontinence with fecal incontinence. In 2011 she underwent retropubic TVT without any effect; in 2013 she received transobturator tape which worsened the tingling sensation and pelvic pain, followed by tape removal at a specialized urogynecology center in 2014. In 6/2015 she underwent laser therapy, without any effect, and in 8/2015 laparoscopy assisted vaginal hysterectomy with posterior vaginal wall repair. She repeatedly received antibiotic treatment for E. coli in the vagina, without any effect.

Results: Clinical examination revealed palpable pain along the pudendal nerve; pressure on the nerve induced the pain described by the patient. Palpation exam also reveal hypertonus of m. ilecoccygeus, bilateral avulsion of puborectalis muscle and slightly painful os coccyges and rectocoelae. Ultrasound indicated the presence of anal sphincters defect. Urodynamics established stress urinary incontinence and bladder oversensitivity with decreased capacity. Following a pudendal block there was immediate relief of the pain. 3T MRI revealed hypertrophy of the right pudendal nerve. These findings indicated surgical pudendal nerve decompression surgery. The video shows this surgical procedure step by step. Surgery produced significant relief of the discomfort (using the VAS there was 80% improvement). Controlled urodynamics established persistence of stress urinary incontinence and normal filling cystometry.

Conclusions: Pudendal neuralgia is seldom properly diagnosed and treated. For some patients with suspected pudendal nerve entrapment syndrome, pudendal nerve decompression surgery is appropriate and can bring relief in up to 70% of cases.

Disclosure:

Work supported by industry: no.

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