Dr. David Prologo, pioneer of pudendal nerve cryotherapy
People recovering from pudendal neuralgia will tell you there is a lack of understanding about this diagnosis and treatment options in the medical community. Week after week, our blog, How do I know if I have PN or PNE, is one of our most read posts. Recently there has been discussion about cryotherapy treatment for pudendal neuralgia. Sara Saunders, PT, DPT of Sullivan Physical Therapy in Austin, TX investigated the topic by interviewing the doctor who is doing this procedure. PHRC thanks Sara for taking the time to interview Dr. Prologo and for sharing her blog post with us.
Meet Dr. Prologo, by Sara K. Sauder, PT, DPT
Have you heard of him? I had not until just a few weeks ago. I heard a rumor that he is doing some great stuff with pudendal neuralgia. He is an interventional radiologist located at Emory in Atlanta, Georgia. He is doing cryoablation to the pudendal nerve with use of CT-guidance.
See, interventional radiologists are the guys that are doing pudendal blocks with CT-guidance in the first place. They are also the vein guys. They treat pelvic congestion. So, how perfect that Dr. Prologo treats both. Makes sense, right? Especially if pelvic congestion created your pudendal neuralgia. (The varicose veins can distend so much that it puts pressure on your pudendal nerve – or other nerves.) If you don’t know much about pelvic congestion, then check out my post on it. Click here.
So I hear about Dr. Prologo, I google him and the first image that pops up is the face of a very cheerful man. I think, “Oh. He is happy. Good. I will email this happy doctor.” And I do. And he writes back. Right away. He allows me to basically interrogate him. Here is a bit of our conversation:
- Sara: Is your technique for treating pudendal neuralgia called cryoablation or is it different from cryoablation?
Dr. Prologo: This technique is indeed cryoablation. The unique thing about what we are doing, though – is the implementation of image guidance. We are using our interventional radiology training and evolving image guidance techniques to access nerves that are deep in the body and otherwise inaccessible for injections or ablations, in this case the pudendal canal.
- Sara: How is your technique different from pulsed radiofrequency ablation?
Dr. Prologo: Radiofrequency ablation is heat mediated tissue destruction. Cryoablation creates shifts in osmotic gradients and intracellular ice crystals that ultimately results in the shutting off of nerve signals, more like turning down the volume of the stereo vs. blowing it up with a bomb.
- Sara: Why do you prefer freezing versus burning?
Dr. Prologo: 1) Cryoablation is great for pain procedures because it is not painful 2) Cryoablation creates an “ice ball” that we can see on CT. Therefore there is no guesswork involved with where we ablated 3) Cryoablation initiates a unique immune response that a) results in longer lasting results and b) stops neuroma formation (vs. radiofrequency ablation or surgery)
- Sara: What are the results you are getting?
Dr. Prologo: Our results have been largely durable and positive. That is, the great majority of our patients experience complete relief from their symptoms. That said, pain can be complicated and outcome depends heavily on patient selection.
- Sara: Have you followed your patients from four years ago?
Dr. Prologo: I am in touch with most of the patients that were done and they are still doing well.
- Sara: What are the side effects?
Dr. Prologo: We have not seen any side effects to date.
- Sara: Any long term issues?
Dr. Prologo: Not that we are aware of at this point.
- Sara: Is it possible that you are inadvertently treating the posterior femoral cutaneous nerve as well?
Dr. Prologo: No. The ablation zone and CT scanning are both exquisitely precise. This is actually the epicenter of the new therapies and innovation. That is, it isn’t really the cryo that is new, it’s the advanced imaging guidance to treat pain. The techniques are so precise that we can literally treat 2mm nerves in the skull base.
- Sara: Who is an appropriate referral?
Dr. Prologo: This is key. Patients who have been diagnosed with pudendal neuralgia are most likely to benefit. That said, many patients come with a wide variety of backgrounds and symptom descriptions. As a result, we can get everyone to the same starting point by performing a diagnostic “test injection.” Again, because we have CT, we can see with 100% certainty where our injection ends up. As a result, there is not guess work. If the patients symptoms improve with the test injection, then they will do well with the cryo. If not, then they don’t have pudendal neuralgia and some other therapy is warranted. That said, interventional radiologists also treat pelvic congestion syndrome, which can be misdiagnosed as pudendal neuralgia.
- Sara: Explain the process. Do patients fly in for an evaluation and receive treatment or do they have to fly back for treatment?
Dr. Prologo: No. We have developed a system in which patients who have stories reflecting underlying pudendal neuralgia – or some close variant – come in for a consultation and injection on the same day. Usually, we also schedule the cryo for the following day so everything can be done in one trip. If the patient fails the injection, we just cancel the cryo.
- Sara: What does treatment consist of?
Dr. Prologo: We place a needle in CT in the pudendal canal. The needle is configured to create a 3cm x 2cm ablation zone about its center. We freeze for 8 minutes, thaw for 4 minutes, freeze for 8 minutes, and thaw for a final 4 minutes – after which we pull the needle/probe.
- Sara: How long do patients stay in town after the treatment for pudendal neuralgia?
Dr. Prologo: I encourage patients to at least stay the night of the procedure. That way, if there happens to be a complication (bleed, for example) we can take care of them here.
- Sara: Do you freeze the whole nerve or different branches of the nerve?
Dr. Prologo: We freeze the portion that runs in Alcocks’s canal (the pudendal canal).
- Sara: Are you doing a pelvic exam to confirm your diagnosis of pudendal neuralgia or are you going by verbal report of symptoms alone?
Dr. Prologo: No. It is all about the injection. We have the luxury of being able to make the diagnosis based on the injection because of precision imaging. We shut down the nerve with 100% certainty in order to make or exclude the diagnosis of pudendal neuralgia.
- Sara: Are you familiar with Interstitial Cystitis?
Dr. Prologo: Yes.
- Sara: Are you seeing your patients’ Interstitial Cystitis symptoms resolve?
Dr. Prologo: We usually don’t treat this condition with this procedure. I think it may be helpful for folks to understand the larger picture. We have been lucky enough to be able to treat many conditions by accessing nerves with image guidance (phantom limb pain, occipital neuralgia, cancer pain, and more). Pudendal neuralgia is one of these subsets.
- Sara: Does insurance cover treatment?
Dr. Prologo: So far >90% of cases have been covered without incident. Sometimes we need to call or write a letter if the patient is out of network.
- Sara: Will you be presenting your treatment at any pelvic pain conferences?
Dr. Prologo: I have thought about this, but have not pursued it. I presented a few years back at our conference (Society of Interventional Radiology) but I think more interested parties may be at the pelvic pain conferences.
I would like to add that 1) I didn’t invent this. I was trying to help patients with cancer pain using cryoablation and God put these patients with nerve pain in my path (pudendal, greater occipital, phantom limb, etc) so I feel like it is my responsibility to do the best I can to help them. I have been so fortunate and blessed to have met so many beautiful people because of the way this thing has worked out. In the end, my only motivation for continuing to do this is to help folks. 2) as I mentioned earlier, the therapy is one application in a much larger picture – the use of image guidance for the treatment of pain. As data emerges regarding the safety and efficacy of these procedures, we will continue to grow and hopefully help even more patients. We appreciate the privilege to participate in each and everyone of these patients’ lives, hopefully toward the better.
Thank you Dr. Prologo for metaphorically sitting down with me, letting me shine a super bright light in your eyes and continuing to answer my questions despite my Cheetoh breath and complete lack of etiquette. You are patient. I am a salivating, rabid dog hungry for some answers.
………
Patients and providers are constantly on the lookout for effective treatment options. Research has shown that interdisciplinary treatment plans that include physical therapy, pain physiology education, medical management and self care are the most effective for managing any pain syndrome, including pudendal neuralgia. We are cautiously optimistic that cryotherapy may have a place in pudendal neuralgia treatment plans. Thank-you Sara and Dr. Prologo for this informative post!
For more information on and to reach Dr. Prologo, please visit: https://www.catchingpoint.com/dr-prologo
Please your comments and questions below, we look forward to hearing from you!
FAQ
What are pelvic floor muscles?
The pelvic floor muscles are a group of muscles that run from the coccyx to the pubic bone. They are part of the core, helping to support our entire body as well as providing support for the bowel, bladder and uterus. These muscles help us maintain bowel and bladder control and are involved in sexual pleasure and orgasm. The technical name of the pelvic floor muscles is the Levator Ani muscle group. The pudendal nerve, the levator ani nerve, and branches from the S2 – S4 nerve roots innervate the pelvic floor muscles. They are under voluntary and autonomic control, which is a unique feature only they possess compared to other muscle groups.
What is pelvic floor physical therapy?
Pelvic floor physical therapy is a specialized area of physical therapy. Currently, physical therapists need advanced post-graduate education to be able to help people with pelvic floor dysfunction because pelvic floor disorders are not yet being taught in standard physical therapy curricula. The Pelvic Health and Rehabilitation Center provides extensive training for our staff because we recognize the limitations of physical therapy education in this unique area.
What happens at pelvic floor therapy?
During an evaluation for pelvic floor dysfunction the physical therapist will take a detailed history. Following the history the physical therapist will leave the room to allow the patient to change and drape themselves. The physical therapist will return to the room and using gloved hands will perform an external and internal manual assessment of the pelvic floor and girdle muscles. The physical therapist will once again leave the room and allow the patient to dress. Following the manual examination there may also be an examination of strength, motor control, and overall biomechanics and neuromuscular control. The physical therapist will then communicate the findings to the patient and together with their patient they establish an assessment, short term and long term goals and a treatment plan. Typically people with pelvic floor dysfunction are seen one time per week for one hour for varying amounts of time based on the severity and chronicity of the disease. A home exercise program will be established and the physical therapist will help coordinate other providers on the treatment team. Typically patients are seen for 3 months to a year.
What is pudendal neuralgia and how is it treated?
Pudendal Neuralgia is a clinical diagnosis that means pain in the sensory distribution of the pudendal nerve. The pudendal nerve is a mixed nerve that exits the S2 – S4 sacral nerve roots, we have a right and left pudendal nerve and each side has three main trunks: the dorsal branch, the perineal branch, and the inferior rectal branch. The branches supply sensation to the clitoris/penis, labia/scrotum, perineum, anus, the distal ⅓ of the urethra and rectum, and the vulva and vestibule. The nerve branches also control the pelvic floor muscles. The pudendal nerve follows a tortuous path through the pelvic floor and girdle, leaving it vulnerable to compression and tension injuries at various points along its path.
Pudendal Neuralgia occurs when the nerve is unable to slide, glide and move normally and as a result, people experience pain in some or all of the above-mentioned areas. Pelvic floor physical therapy plays a crucial role in identifying the mechanical impairments that are affecting the nerve. The physical therapy treatment plan is designed to restore normal neural function. Patients with pudendal neuralgia require pelvic floor physical therapy and may also benefit from medical management that includes pharmaceuticals and procedures such as pudendal nerve blocks or botox injections.
What is interstitial cystitis and how is it treated?
Interstitial Cystitis is a clinical diagnosis characterized by irritative bladder symptoms such as urinary urgency, frequency, and hesitancy in the absence of infection. Research has shown the majority of patients who meet the clinical definition have pelvic floor dysfunction and myalgia. Therefore, the American Urologic Association recommends pelvic floor physical therapy as first-line treatment for Interstitial Cystitis. Patients will benefit from pelvic floor physical therapy and may also benefit from pharmacologic management or medical procedures such as bladder instillations.
Who is the Pelvic Health and Rehabilitation Team?
The Pelvic Health and Rehabilitation Center was founded by Elizabeth Akincilar and Stephanie Prendergast in 2006, they have been treating people with pelvic floor disorders since 2001. They were trained and mentored by a medical doctor and quickly became experts in treating pelvic floor disorders. They began creating courses and sharing their knowledge around the world. They expanded to 11 locations in the United States and developed a residency style training program for their employees with ongoing weekly mentoring. The physical therapists who work at PHRC have undergone more training than the majority of pelvic floor physical therapists and as a result offer efficient and high quality care.
How many years of experience do we have?
Stephanie and Liz have 24 years of experience and help each and every team member become an expert in the field through their training and mentoring program.
Why PHRC versus anyone else?
PHRC is unique because of the specific focus on pelvic floor disorders and the leadership at our company. We are constantly lecturing, teaching, and staying ahead of the curve with our connections to medical experts and emerging experts. As a result, we are able to efficiently and effectively help our patients restore their pelvic health.
Do we treat men for pelvic floor therapy?
The Pelvic Health and Rehabilitation Center is unique in that the Cofounders have always treated people of all genders and therefore have trained the team members and staff the same way. Many pelvic floor physical therapists focus solely on people with vulvas, this is not the case here.
Do I need pelvic floor therapy forever?
The majority of people with pelvic floor dysfunction will undergo pelvic floor physical therapy for a set amount of time based on their goals. Every 6 -8 weeks goals will be re-established based on the physical improvements and remaining physical impairments. Most patients will achieve their goals in 3 – 6 months. If there are complicating medical or untreated comorbidities some patients will be in therapy longer.
Comments
This gives me hope, but If the pudendal nerve carries the motor supply to various pelvic muscles, the external urethral sphincter and the external anal sphincter, how can there be no side effects from a pudendal Cryoablation?
Thank you.
Hi Pam,
Dr. Prologo cannot answer individual questions. Please contact his hospital directly to setup a phone consultation.
Regards,
Admin
This sounds hopeful. Radio frequency ablations gave me good relief for 2-3 months. Do you know how long the relief averages for cryoablations.
Hi Brenda,
Dr. Prologo cannot answer individual questions. Please contact his hospital directly to setup a phone consultation.
Regards,
Admin
What a wonderful way to treat PN as well as other chronic pain syndromes.
Thank you both for sharing this most valuable information.
Sincerely, M.M. M.D.
I believe I have PN. I have tried various forms of PT over the past 5 years, but they have not helped. For the past year, the bottom of both my feet have begun tingling. My doctor put me on Gabapentin with the hope that it would help both problems, but that isn’t helping either of them. Just in the past month, my lower lip has begun to go numb. It coincides with the PN flare ups and the tingling feet episodes. My doctor is baffled. I happen to have a friend that also has PN symptoms. She told me her feet tingle and her lower lip goes numb also. I have to just to the conclusion that somehow, these sypmtons are related. What are your thoughts? Have you ever heard of these other symptoms in relation to PN? Is there any other treatment other than Cryotherapy that I should be trying? Thank you!
Hi Debbie,
Dr. Prologo cannot answer individual questions. Please contact the hospital directly to setup a phone consultation with him.
Regards,
Admin
I have had pudendal neuralgia which after 2 years I found a neurologist at Emory ( no longer there) butt treated me with tramadol , clonazapam,Wellbutrin and abilify. The combination worked beautifully for 5 years. I also had tingling and numbness on the bottom of both feet. Especially my toes. At the time both the pudendal pain went away and the foot pain also stopped. Now my foot pain in both feet are back but no pudendal pain. I think the foot pain comes from issues in my back where I have spinal stenosis
Hi Dr Prologo, I am writing to you from Australia. Do you know of any doctor providing this treatment in Australia ? I have pudendal neuralgia but my case is a bit different to most. I have a feeling of deep anal aching pain but I have had all of my colon and rectal stump removed in an operation to form an ileostomy. However I do have an external sphincter muscle left. I have perineal pain and sphincter muscle pain and aggravation. Sometimes after strong orgasm, I will have a 6 week flare up of the nerve. Of course sitting makes the pain worse. I think my neuralgia was brought on by chronic straining to pass urine over a long period. I am medicated with Endep, Lyrica and Targin and I am fed up with the symptoms of this combination. Would you consider training doctors in Australia to perform this procedure ? The Royal Women’s Hospital in Sydney has a pelvic pain clinic. Many thanks, I would appreciate very much any comments and recommendations you might have for me. With thanks and regards, Robyn Kirkman
Hi Robyn,
Dr. Prologo cannot answer individual questions, please contact his hospital directly to set up a phone consultation.
Regards,
Admin
This sounds interesting, i hope he does this procedure in men too
Hi I live in South Africa and I’ve had PN 2 yrs now…post heamarroid procedure. I’ve had 3erve blocks with some relief.
If I could afford it , I would definitely make a trip to see Dr Prologo. Desperate for help.
I have extreme pelvic pain associated with bowel movements