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 and Occupational 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:

 

1. 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.

 

2. 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.

 

3.  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)

 

4.  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.

 

5.  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.

 

6.  Sara: What are the side effects?

 

Dr. Prologo: We have not seen any side effects to date.

 

7.  Sara: Any long term issues?

 

Dr. Prologo: Not that we are aware of at this point.

 

8.  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.

 

9.  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.

 

10.  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.

 

11.  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.

 

12.  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.

 

13.  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).

 

14.  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.

 

15.  Sara:  Are you familiar with Interstitial Cystitis?

 

Dr. Prologo:  Yes.

 

16.  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.

 

17.  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.

 

18.  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 and occupational 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!

 

Image permission via Cosmopolitan

 

By Stephanie Prendergast

 

The Facts

21% of women undergoing vaginal delivery had levator ani avulsion¹

29% of women undergoing vaginal deliveries had pubic bone fractures²

 60% of postpartum women reported Stress Urinary Incontinence (SUI)³

64.3% of women reported sexual dysfunction in the first year following childbirth⁴

77% of women had low back pain that interfered with daily tasks⁵

 

Last month, Cosmo published an article titled “Millions of women are injured during childbirth, why aren’t doctors diagnosing them?”. The article had over 50,000 shares on Facebook and thousands of comments from suffering postpartum women grateful to hear that they were not alone. The article was unique and truthful, featuring mom and baby in diapers. The article refreshingly and openly discussed the staggering high prevalence of embarrassing problems that women silently deal with following childbirth.

 

As a pelvic floor physical and occupational therapists I am well aware of the musculoskeletal consequences of pregnancy and delivery. It is mind blowing to pelvic floor PTs that pelvic floor care for new moms is erroneously and ineffectively compartmentalized to ‘do your kegels’. I was interviewed for the Cosmo article and it was no surprise to me that there was confusion about the lack of postpartum medical care and why so many women were suffering.

 

Cosmo asked the question, WHY aren’t doctors diagnosing these problems? The short answer is musculoskeletal health is not technically the OBGYN’s responsibility. The standard of insurance-covered medical care in the United States includes one postpartum checkup at 6 weeks. This examination includes a depression screening, discussion around contraception and breast feeding, and checking the health of the cervix and uterus. This visit does not routinely include evaluation of musculoskeletal structures. Urinary, bowel and sexual function spans many medical disciplines, but a primary owner lies in the hands of a pelvic floor physical and occupational therapists who has undergone specific training to evaluate pelvic floor and girdle function and biomechanics. Since pelvic floor physical and occupational therapy is not automatically part of a women’s medical care in the US,  treatable impairments are often left unidentified and treated. As a result women suffer unnecessarily with incontinence, sexual dysfunction, and pain. The symptoms are not life-threatening.  However, one look at the comments on the recent media articles reflect the significant impact the symptoms have on the mother’s quality of life, relationships, and ability to care for her baby.

 

There is no need for women to suffer. A University of Michigan study described childbirth as  event more traumatic than the most aggressive combat sports. I do not think any sane person would disagree with this. Therefore, it should be no surprise that postpartum rehabilitation is a hell of a lot more sophisticated than doing a few kegels, and that every new mom needs it.

 

Since the current standard of maternal care does not automatically include a referral to a pelvic floor physical and occupational therapists, many women find us on their own. Once they do, they’re understandably upset that this type of service exists and that they were not told about it. We understand this frustration, but it is often misplaced on the physician. The insurance company and our broken healthcare system is the true problem. It is impossible for doctors to address all postpartum concerns in the limited time they have with their patients and this is as frustrating for them as it is for the patient. With that said, we want to share some information and tips to help you work with your OBGYN to get the postpartum care you need, and have it covered by your insurance.

 

1. At your 6-week postpartum visit or anytime thereafter, ask your OBGYN if he or she works with a pelvic floor physical and occupational therapists and if they can recommend someone for you. They may already be working with someone they trust that they can recommend.
2. Many states have direct access policies to physical and occupational therapy, which includes pelvic floor physical and occupational therapy. This means women can legally go to a pelvic floor physical and occupational therapists without a referral from a physician. If your OBGYN cannot recommend someone for you, women can use the ‘find a provider’ section on our blog homepage to find a qualified person in their local area.
3. While it is legal to see a physical and occupational therapists without a prescription, your insurance company may require a prescription to cover services to the physical and occupational therapists or to reimburse you for your expenses. In many cases, the physical and occupational therapy office you choose to go to will have systems in place to help you navigate the process of getting your care covered.
4. You may choose to ask your OBGYN or your primary care physician for a prescription for physical and occupational therapy to be evaluated and treated for pelvic floor dysfunction.

 

Once you find a pelvic floor physical and occupational therapists, you can expect that your unanswered questions and concerns will be addressed. Many women are embarrassed and worried about their symptoms, don’t be. As pelvic floor physical and occupational therapistss we have seen and heard it all and are here and ready to help!

 

For more information on what a postpartum physical and occupational therapy evaluation entails, please click here.

 

 

References

 

1. Van Delft et al. Levator ani muscle avulsion during childbirth: a risk prediction model. BJOG 2014 August; 121(9):1155-63.
2. Miller et al. Evaluating maternal recovery from labor and delivery: bone and levator ani injuries. AJOG 2015 August; 213:188e.1-11).
3. Mannion et al. The influence of back pain and urinary incontinence on daily tasks of mothers at 12 months postpartum. PLoS One 10(6):e0129615.
4. Kajehi M et al. Prevalence and risk factors of postpartum sexual dysfunction in Australian women. J Sex Med. 2015 Jun;12(6):1415-26. doi: 10.1111/jsm.12901. Epub 2015 May 11.
5. Mannion et al. The influence of back pain and urinary incontinence on daily tasks of mothers at 12 months postpartum. PLoS One 10(6):e0129615.

 

By Allison Wells, MD

 

Chronic pelvic pain is at a difficult intersection of anatomical pain generators and mood disorders like depression and anxiety that are coincident with or caused by the pain itself. To effectively relieve chronic pelvic pain you need a treatment that addresses the pain and the mood disorder issues. Ketamine infusions do both.

 

Ketamine has been used safely for anesthesia since the 1960s when it was first created. It has been a first choice for battlefield medicine and for the most critically ill patients in the operating room. Since the 1980s ketamine’s effect on chronic pain and on depression and other mood disorders has been studied and thousands of patients have obtained relief around the world through programs at academic medical centers and private ketamine infusion clinics alike. Ketamine possibly works on chronic pain through down regulating GABA-A or NMDA receptors that have been up regulated and become self-sustaining in the pain syndrome. This is in contrast to the opioid narcotics, like Oxycontin, which work on the mu receptors.

 

Ketamine works to calm the overexcited pathways that cause neuropathic pain. It stops the feedback loop from the revved up peripheral neurons and allows the peripheral pain nerves to return to a normal resting state. Ketamine is good for acute pain, but it really shines with chronic pain. It doesn’t just cover the pain, like opioids. It actually changes the neural pathways to get them to stop sending faulty signals.

 

Europe and Australia have ketamine as a standardized part of their chronic pain and depression guidelines that are written by the national health systems of both countries. In America, ketamine is not FDA approved for the treatment of pain and depression because there have been no large randomized controlled trials, although there have been many small trials with positive results. Since ketamine is an old, generic drug with FDA approval already for other uses, specific indications for depression and pain have not been sought.

 

It is really hard to randomize patients in a ketamine trial – they know immediately whether they were given the control or the active medication. Also, who is going to pay for such a trial when there is no readily apparent way to profit off a generic drug that can’t be patented? For this reason ketamine is considered “off-label”. However, some reports indicate that in America more than 80% of all doctors prescribe off-label medications and more than 21% of adult medications and up to 78.9% of children discharged from hospitals were on at least one off-label medication. We are beginning to see insurance companies recognize the depth and breadth of positive studies and they are beginning to cover ketamine treatments. BCBS and UHC are the insurers that we have begun to see routinely cover this care and Aetna and Humana have been slower to provide coverage, but each patient’s plan may be different.

 

Ketamine is typically used as an infusion in most treatment protocols. There are a few programs that administer the infusion as a continuous drip over up to 10 days in the ICU at levels that render the patient comatose. This is not a standard practice because of the huge cost and also because of the risks and side effects of being in an immobile, general anesthesia, intubated state for 10 days, namely: pneumonia, blood clots, and muscle wasting. The majority of ketamine infusion programs perform the infusion as an outpatient procedure over the course of a few hours each day of treatment and as deep sedation, where the patient is still able to talk and breathe on their own.

 

Other delivery methods, such as oral delivery, are generally less favorable for ketamine pain treatments. Ketamine is unpredictable when taken by mouth as it is first metabolized and broken down by the liver after absorption from the intestinal tract before it can have its effect on the nerves it’s meant to treat. Only about 16% of the active compound is available after oral administration to have an effect with the rest being metabolized into inactive or underactive metabolites. Also, most studies appear to indicate that ketamine concentrations need to reach a certain threshold and stay steadily above that threshold for a few hours to accomplish the resetting of the pain receptors.

 

I practice at Lone Star Infusion in Houston, Tx. A patient here receives a low-dose infusion of ketamine for up to 4 hours at a time in a quiet, relaxed setting. The patient then recovers for up to 2 hours before being released to go home. Infusions are administered by a board-certified anesthesiologist experienced with using ketamine and adjusting medications for safety and patient comfort, including the use of adjunct medicines as appropriate.

 

Most side effects of the ketamine are well-tolerated and last only as long as the infusion. Hallucinations and feelings of dissociation are generally mild and may be treated. Sleepiness is common. Nausea is common without pretreatment but rare if patients are given oral ondansetron first.

 

The beneficial effects of ketamine can last for weeks or months depending on the severity and chronicity of the pain and follow-up treatments with single infusions of ketamine can help maintain the effects over many years. Clinics around the world have now been working with pain and depression patients and have 10 years’ worth of data on ketamine’s safety and long-term efficacy.

 

In short, ketamine infusions may be an excellent option for patients with severe, intractable neuropathic pain. There are websites like Ketamine Advocacy Network (http://www.ketamineadvocacynetwork.org) that list ketamine providers by state and also by talking with local medical schools and pain fellowship programs patients can find information on a ketamine infusion center near them. Treatments can cost anywhere from just a co-pay to $1,450 per 4 hour infusion depending on insurance coverage.

 

Allison Wells, MD
Board Certified Anesthesiologist
Trained at Harvard and  Baylor College Of Medicine
I practice at Wells Medicine in Houston Tx

 

 

 

References

Ketamine Advocacy Network
http://www.ketamineadvocacynetwork.org

 

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Royal Cornwall Hospitals, NHS Trust, Clinical Guidelines for Nursing Care of Patient with Intravenous Ketamine Infusion, rcht.nhs.uk, accessed 3/10/2016

 

Scottish Palliative Care Guidelines, NHS Scotland, palliativecareguidelines.scot.nhs.uk, accessed 8/9/2016

 

Wittich, Christopher, Burkle, Christopher, Lanier, William. Mayo Clinic Proceedings, Ten Common Questions (and Their Answers) About Off-label Drug Use, P.11, ncbi.nlm.nih.gov, accessed 3/10/2016

 

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