1. Pudendal Nerve Entrapment
Michael Hibner, MD, PhD
Director, Division of Gynecologic Surgery
Director Arizona Center for Chronic Pelvic Pain
St. Joseph’s Hospital and Medical Center
Assistant Professor of Clinical Ob/Gyn
University of Arizona College of Medicine

2. Pudendal neuralgia Pain caused by the injury to the pudendal nerve.
Pain is in:
♀♂ perineum, rectum
♀ vulva, vagina, clitoris
♂ penis, scrotum (not testicles)

3. Anatomy Originates in S2-S4
Exits pelvis through greater sciatic foramen
Wraps around sacrospinous ligament
Enters perineal region
Provides motor, sensory and autonomic innervation to pelvic organs, pelvic floor muscles and external genitalia

4. Neuropathic pain
Burning
Paresthesia
Allodynia
Hyperesthesia

5. Pudendal neuralgia
Injury to the pudendal nerve most commonly caused by the entrapment of pudendal nerve (PNE)
Analogous to carpal tunnel syndrome
PNE may be
Idiopathic
Traumatic
Iatrogenic

7. Area of distribution
Only the area in yellow concerns the pudendal nerve. The red area concerns the iliohypogastric nerve, the ilioinguinal nerve and the genitofemoral nerve. The blue area concerns the inferior cluneal nerve which is a branch of the posterior cutaneous nerve of the thigh. These differents areas co-inside which means that there is not necessarily loss of sensitivity
A. iliohypogastric, ilioinguinal and genitofemoral nerves
B. pudendal nerve
C. inferior cluneal nerve (perineal ramifications of the posterior cutaneous nerve of the thigh)

8. Pudendal neuralgia may present as
Urinary hesitancy, urgency and frequency.
Interstitial Cystitis
Prostatodynia
Anal spasm/pain
Scrotal/Labial pain/Vulvodynia
Pain with orgasm or sexual arousal
Persistent sexual arousal

9. Pain with pudendal neuralgia
Usually only present when sitting down
Not present when lying down or standing up
Not present on the toilet
Progressively getting worse
Worsening as the day goes by

10. Pain is… Not responsive to pain medications Some response to
antiseizure meditations (Neurontin, Lyrica)
antidepressants (Amitryptiline)

11. Diagnosis History Physical examination PNMTL
Quantitive threshold sensory testing
Diagnostic CT guided injection

12. Diagnosis of PNE
Mean time to make the diagnosis is 4 years with a range of 1-15 years.
The number of physicians consulted before the diagnosis is made is

13. Physical Examination Rule out other reasons for chronic pelvic pain
Rule out vulvar/vaginal/rectal/perineal lesions
Rule out other neuropathies
Obturator
Inferior cluneal
Sciatic
Rule out coccygodynia
Rule out piriformis muscle syndrome

14. Physical Examination No motor deficits
Pain on the vaginal/rectal examination
Area of the ischial spine
Obturator internus muscle
Levator ani muscle

16. Laboratory testing

17. PNMTL

18. Therapy for PNE Behavioral changes Conservative therapy Surgery
Physical therapy
Oral medications
CT guided injections
Surgery

20. Medical treatment Gabapentin (Neurontin) Amitryptiline (Elavil)
Start slowly
Titrate to mg/day
Pregabaline (Lyrica)
Start 75 mg BID
May increase to 600 mg/day
Beladonna and Opium (B&O) suppository

21. CT guided injections

22. CT guided injection – Alcock’s canal

23. Surgery
Offered to the patients in whom physical examination ruled out other causes for neuropathy
Offered only to the patients that had an immediate improvement after the injection
No age limits or duration limits, but results better in younger patients with a shorter period of compression

24. Surgery – transgluteal approach
30 angle
6-7 cm
3 fb

26. Surgery - transgluteal

27. Surgery
cranial
medial

28. Surgery

29. Surgery

30. Surgery

31. Incidence of PNE at Various Sites
Sacrospinous Ligament – 58%
Sacrotuberous Ligament – 69%
Falciform Process – 42%
Ischial Spine – 11%
Piriformis – Sacrospinous Ligament – 17%
Obturator Fascia – 48%
Unilateral entrapment in 70% of patients.

32. Results No improvement Worse 33% 1% No pain or Moderate improvement
significant
improvement
Moderate improvement
23%
44%

33. Results First improvement 3-4 months from surgery
Maximum improvement 1 year
Worse results (30% success) if
Age > 70
Symptoms > 10 years

34. Postop Management Hospital stay 1 day No postop restrictions *
Early ambulation
Continue Neurontin up to 3200 mg/day or Lyrica up to 600 mg/day
If no significant improvement – CT guided injection at 4 months