By Stephanie Prendergast
Pudendal Neuralgia seems to be a diagnosis that is more polarized and controversial than other pelvic pain diagnoses.
Over a series of posts we will look at the evolution of this diagnosis, and why we need the perspective of a pelvic floor physical therapist, pain management specialist Dr. Sheldon Jordan, and gynecologist/pelvic pain specialist/pudendal surgeon Dr. Mark Conway, to explain how to manage this literal pain in the ass.
This week we hear from Stephanie:
When PN was first described in 1988, it was viewed as a compression entrapment syndrome, similar to carpal tunnel syndrome. The treatment protocol consisted of three corticosteroid nerve blocks, medications, relaxation therapy and then surgical decompression. Pelvic floor physical therapy was not an option or part of the treatment protocol.
A lot has changed since 1988.
Our colleagues in Nantes, France were one of the first groups to develop a surgical decompression procedure for the pudendal nerve. In a paper published in the European Journal of Urology, they reported that between the years of 1988 and 2004 they evaluated over 700 number of patients with PN and performed surgical decompression on 400. They decided to perform a prospective study comparing surgical decompression to conservative care, published in 2005. (1)
Conservative care consisted of pudendal nerve blocks, medication, and relaxation/biofeedback therapy. The surgical group was given the same treatment options as the conservative group and surgical decompression. Initially 16 people were in each group.
Surgery was considered a ‘success’ if the self-reported measures include a 3-point reduction in a 10-point Visual Analog Scale. 50% group that had surgery showed a positive change in the VAS scores. 50% of the group the had surgery did not report enough a change to be considered a ‘success’. The group that received conservative care did not report a significant enough change to be be considered a “success”
These results left a lot to be desired, prompting the group to take a closer look at how they were diagnosing PNE. During that period of time, electrophysiological testing was being done to try to confirm a PNE diagnosis. They concluded that these tests are neither sensitive nor specific to identify PN by PNE and therefore CANNOT be used to confirm this diagnosis. (2)
This was GREAT news because these tests are so painful, they make a root canal seem pleasurable.
In their next paper, the Nantes team suggested clinical criteria that can be suggestive of PNE (3):
- Pain in the territory of the nerve.
- Pain is predominantly experienced when sitting.
- Pain does not wake the patient at night.
- Pain with no objective sensory impairment.
- Pain relieved by diagnostic PNB
The conclusion was that entrapment is one cause of Pudendal Neuralgia but other causes also exist.
Over the next several years, the volume of papers describing the role of the pelvic floor and girdle muscles in pelvic pain syndromes increased exponentially. It turns out the majority of people with pelvic pain have neuromuscular abnormalities that are contributing to their pain. Along with other diagnoses such as Vulvodynia, Interstitial Cystitis, and Chronic Nonbacterial Prostatitis, Pudendal Neuralgia became classified as a neuromuscular and/or neuropathic pelvic pain syndrome, changing how it is diagnosed and treated.
Everyone with PN has asked the question, why did I get this when someone else doing the same thing did not?
We recognize now that certain people may be anatomically predisposed to developing a neuralgia. Impairments and pain develop when a particular event exceeds what that individual’s body is capable of handling. The particular event may seem as benign as sitting, but if your pudendal nerve is running through the sacrotuberous ligament, sitting on a chair may feel like you are actually sitting on a fire poker. Thus, a particular person’s activities, comorbidities, genetics, etc or a combo of all or some of the above can create a ‘perfect storm’ and wreak havoc.
Of note, 30% of the average population has an “entrapped” nerve in cadaveric studies. This means that 30% of the population could be vulnerable to developing a neuralgia when entering that “perfect storm”. However, clearly 30% of all people do not have neuralgia. The cadaveric studies show that abnormalities can exist without symptoms. Therefore, a differential diagnosis is necessary to determine the right course of treatment for the particular person in question. Additionally, the impairments associated with PN can be divided into two broader categories: a pain impairment (central nervous system) and peripheral dysfunction (nociception).
I should emphasize that pain and peripheral dysfunction are not the same and both need to be addressed for a successful outcome.
The Biopsychosocial Approach to PN
Sandy Hilton, MS PT and Caroline Van Dyken, BHSc,PT, Cred MDT CCMA (Acup) beautifully describe a comprehensive framework to managing pelvic pain syndromes such as pudendal neuralgia: “The framework integrates the current understanding of local tissue dysfunction with the wider context of sensitized protective mechanisms within the spinal cord and brain. Treatments address both the local tissue complaints and the central nervous system sensitivity by teaching patients about the biological processes underpinning their pain, graded imagery, and graded exposure”. (4)
We cannot ignore the mind while we treat the body. Sometimes the body isn’t ready to be treated until the mind is managed. Other times, physical therapy for the body and psychotherapy for the mind are not effective until the pain is better controlled by therapies directed at the central nervous system. Every now and then, we need surgery.
What I hope is clear, is that there is no standard protocol for treating PN.Every case of PN is different, even if two individuals have the exact same symptoms. The trick is to identify which impairments are the predominant problem in each person, and then develop an effective strategy to treat these impairments.
I repeat my statement from last week’s blog: It is the norm, not the exception, that people getting on the path to healing will fail to respond or not tolerate at least one medication, procedure, physical therapy session or series. It is not uncommon for symptoms to persist, and or reappear. The good news is that if this is happening to you now, you and your healthcare providers can troubleshoot and overcome treatment challenges in an interdisciplinary treatment model!
This wraps up part one in our series. In the next post, we are will talk about the following common scenarios, NOT RESPONDING, and NOT TOLERATING treatment. Yes, talking about our successes is important. But, talking about our challenges is even more important. If we don’t, we’ll never achieve success.
We know you have questions and comments. On Thursday, November 5, 2015 at 6:00pm PST, Drs. Conway and Jordan and Stephanie will be interviewed on the Pelvic Messenger Radioblog. There will be time for questions and answers during this 75 minutes segment.
You can find the link to the show here: http://www.blogtalkradio.com/pelvicmessenger
Finally, here a couple of video snippets from my IPPS lecture, “Interdisciplina
All my best,
Stephanie Prendergast, MPT
Stephanie A. Prendergast, MPT is the co-founder of the Pelvic Health and Rehabilitation Center, which has locations in San Francisco, Berkeley, Los Gatos, Los Angeles, and Boston. She currently treats patients in the Los Angeles location. Stephanie began serving on the International Pelvic Pain Society’s Board of Directors in 2002, served as their Vice-President and Scientific Program Chair in 2012, and in 2013 was the first physical therapist to serve as President. As an acknowledged leader in the field, she was invited to become on of the founding Board members of the Society for Pudendal Neuralgia in 2005 and subsequently co-developed and teaches “De-mystifying Pudendal Neuralgia,” a continuing education course attended by doctors, physical therapists, and other allied health professionals around the world. She served on the program committee for the World Congress on Abdominal and Pelvic Pain in 2013 and 2015 and is also Co-chair of the program committee for 2017. She is internationally recognized authority in the field of pelvic floor dysfunction, lectures regularly, and has numerous publications in medical textbooks, journals, and magazines. She co-authored the book Pelvic Pain Explained, to be released in January of 2016. You can find her on Twitter @pelvichealth, on Facebook at facebook/pelvicpainphysicaltherapy, and subscribe to PHRC’s weekly blog at pelvicpainrehab.com/blog.