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!