Abstract
Purpose
Pudendal neuralgia (PN) is an extremely painful neuropathy of the pudendal nerve resulting in a negative impact on a patient's quality of life. The aim of this study is to evaluate the 2-year outcomes of repetitive doses of the transvaginal pudendal nerve injections (PNI), and to compare the success of the PNI concerning anatomical levels (endopelvic and extrapelvic portion) of the pudendal nerve pathology.
Methods
This retrospective longitudinal cohort study consists of patients with PN diagnosed with the first four essential Nantes criteria. Diagnostic PNI was performed on 67 patients to fulfill the fifth criteria of Nantes. A total of 56 patients who responded to the initial diagnostic PNI underwent therapeutic repeated transvaginal PNIs twice for 3 weeks apart. Mean pain intensity scores were measured using a visual analog scale at the 1st, 3rd, 6th, 12th, and 24th months after the therapeutic blocks were completed. Effectiveness of the PNIs’ was defined as ≥ 50% improvement of the initial pain, and relative improvement was defined as 30–50% improvement of the initial pain. Treatment failure was defined as the reduction of the initial pain by less than 30% or the return of the pain to its worst condition.
Results
The efficacy of the PNIs significantly declined over time. Pudendal nerve blocks provided a significant decrease in pain scores; however, this decrease lost its strength significantly in the 24th month. The intervention was more effective in entrapments of the pudendal nerve between sacrospinous and sacrotuberous ligaments or below (Level-2) when compared to the injuries in the endopelvic part (Level-1). More than 50% pain reduction continued in five patients with pathology at Level-1 and 24 patients with pathology at Level-2.
Conclusion
Repeated PNIs could provide a significant decrease in pain scores for both short- and long-term periods. However, the efficacy of the PNIs declined over 2 years. The success of PNIs may be affected by the anatomical level of the nerve injury; therefore, interligamentous pudendal nerve entrapment cases have more benefits than the cases of pudendal nerve entrapment in the endopelvic part. However, it is recommended to perform therapeutic nerve blocks even in patients with suspected endopelvic pudendal nerve pathology before the referral to surgery.
Similar content being viewed by others
References
Campbell JN, Meyer RA (2006) Mechanisms of neuropathic pain. Neuron 52:77–92
Bascom JU (1998) Pudendal canal syndrome and proctalgia fugax: a mechanism creating pain. Dis Colon Rectum 41:406
Ramsden CE, McDaniel MC, Harmon RL, Renney KM, Faure A (2003) Pudendal nerve entrapment as source of intractable perineal pain. Am J Phys Med Rehabil 82:479–484
Waldinger MD, Venema PL, van Gils APG, Schweitzer DH (2009) New insights into restless genital syndrome: static mechanical hyperesthesia and neuropathy of the nervus dorsalis clitoridis. J Sex Med 6:2778–2787
Benson JT, Griffis K (2005) Pudendal neuralgia, a severe pain syndrome. Am J Obstet Gynecol 192:1663–1668
Filler AG (2009) Diagnosis and treatment of pudendal nerve entrapment syndrome subtypes: imaging, injections, and minimal access surgery. Neurosurg Focus 26:E9
Bornstein J, Palzur E, Swash M, Petros P (2022) Vulvodynia: a neuroinflammatory pain syndrome originating in pelvic visceral nerve plexuses due to mechanical factors. Arch Gynecol Obstet. https://doi.org/10.1007/s00404-022-06424-4
Howard EJ (1985) Postherpetic pudendal neuralgia. JAMA 253:2196
Hruby S, Ebmer J, Dellon AL, Aszmann OC (2005) Anatomy of pudendal nerve at urogenital diaphragm—new critical site for nerve entrapment. Urology 66:949–952
Pereira A, Pérez-Medina T, Rodríguez-Tapia A, Chiverto Y, Lizarraga S (2018) Correlation between anatomical segments of the pudendal nerve and clinical findings of the patient with pudendal neuralgia. Gynecol Obstet Invest 83:593–599
Possover M, Forman A (2014) Neuropelveological assessment of neuropathic pelvic pain. Gynecol Surg 11:139–144
Possover M, Schneider T, Henle KP (2011) Laparoscopic therapy for endometriosis and vascular entrapment of sacral plexus. Fertil Steril 95:756–758
Kale A, Basol G, Usta T, Cam I (2019) Vascular entrapment of both the sciatic and pudendal nerve causing persistent sciatica and pudendal neuralgia. J Minim Invasive Gynecol 26:360–361
Vancaillie T, Eggermont J, Armstrong G, Jarvis S, Liu J, Beg N (2012) Response to pudendal nerve block in women with pudendal neuralgia. Pain Med 13:596–603
Weinschenk S, Hollmann MW, Strowitzki T (2016) New perineal injection technique for pudendal nerve infiltration in diagnostic and therapeutic procedures. Arch Gynecol Obstet 293:805–813
Kale A, Usta T, Basol G, Cam I, Yavuz M, Aytuluk HG (2019) Comparison of ultrasound-guided transgluteal and finger–guided transvaginal pudendal nerve block techniques: which one is more effective? Int Neurourol J 23:310–320
Prat-Pradal D, Metge L, Gagnard-Landra C, Mares P, Dauzat M, Godlewski G (2009) Anatomical basis of transgluteal pudendal nerve block. Surg Radiol Anat 31:289–293
Mamlouk MD, VanSonnenberg E, Dehkharghani S (2014) CT-guided nerve block for pudendal neuralgia: diagnostic and therapeutic implications. Am J Roentgenol 203:196–200
Schelhorn J, Habenicht U, Malessa R, Dannenberg C (2013) Magnetic resonance imaging-guided perineural therapy as a treatment option in young adults with pudendal nerve entrapment syndrome. Clin Neuroradiol 23:161–163
Peng PWH, Tumber PS (2008) Ultrasound-guided interventional procedures for patients with chronic pelvic pain—a description of techniques and review of literature. Pain Physician 11:215–224
Hagen NA (1993) Sharp, shooting neuropathic pain in the rectum or genitals: pudendal neuralgia. J Pain Symptom Manage 8:496–501
Labat JJ, Riant T, Robert R, Amarenco G, Lefaucheur JP, Rigaud J (2008) Diagnostic criteria for pudendal neuralgia by pudendal nerve entrapment (Nantes criteria). Neurourol Urodyn 27:306–310
Wadhwa V, Scott KM, Rozen S, Starr AJ, Chhabra A (2016) CT-guided perineural injections for chronic pelvic pain. Radio Graphics 36:1408–1425
Rofaeel A, Peng P, Louis I, Chan V (2008) Feasibility of real-time ultrasound for pudendal nerve block in patients with chronic perineal pain. Reg Anesth Pain Med 33:139–145
Abdi S, Shenouda P, Patel N, Saini B, Bharat Y, Calvillo O (2004) A novel technique for pudendal nerve block. Pain Physician 7:319–322
Boonstra AM, Preuper HRS, Balk GA, Stewart RE (2014) Cut-off points for mild, moderate, and severe pain on the visual analogue scale for pain in patients with chronic musculoskeletal pain. Pain 155:2545–2450
Tricard T, Saussine C, Munier P, Story F, Lang H (2019) The drug-resistant pudendal neuralgia management: a systematic review. Neurourol Urodyn 38:13–21
Faul F, Erdfelder E, Lang AG, Buchner A (2007) G * Power 3: a flexible statistical power analysis program for the social, behavioral, and biomedical sciences. Behav Res Methods 39:175–191
Lien KC, Morgan DM, Delancey JOL, Ashton-Miller JA (2005) Pudendal nerve stretch during vaginal birth: a 3D computer simulation. Am J Obstet Gynecol 192:1669–1676
Kastler A, Puget J, Tiberghien F, Pellat JM, Krainik A, Kastler B (2018) Dual site pudendal nerve infiltration: more than just a diagnostic test? Pain Physician 21:83–90
Fanucci E, Manenti G, Ursone A, Fusco N, Mylonakou I, D’Urso S et al (2009) Role of interventional radiology in pudendal neuralgia: a description of techniques and review of the literature. Radiol Med 114:425–436
Labat JJ, Riant T, Lassaux A, Rioult B, Rabischong B, Khalfallah M et al (2017) Adding corticosteroids to the pudendal nerve block for pudendal neuralgia: a randomized, double-blind, controlled trial. BJOG 124:251–260
Sermer C, Li ALK, Fernandes GL, Ribeiro AM, Polesello G, Tokechi D et al (2021) Intrapelvic entrapment of sacral nerve roots by abnormal bundles of the piriformis muscle: description of an extra-spinal cause of sciatica and pudendal neuralgia. J Hip Preserv Surg 8:132–138
Lemos N, Sermer C, Fernandes G, Morgado-Ribeiro A, Rossos A, Zhao ZY et al (2021) Laparoscopic approach to refractory extraspinal sciatica and pudendal pain caused by intrapelvic nerve entrapment. Sci Rep 11:10820
Usta T, Ozkaynak A, Kale A, Basol G (2019) Robot-assisted laparoscopic management of a vascular entrapment of the sacral nerve roots causing pelvic pain. J Obstet Gynaecol Res 45:1603–1607
Kale A, Basol G, Uzun DN, Usta T (2018) Sciatic nerve and sacral 2 nerve root decompression by aberrant hypogastric vein branch causing persistent sciatica. J Endometr Pelvic Pain Disord 10:224–226
Kale A, Basol G, Topcu AC, Gundogdu EC, Usta T, Demirhan R (2021) Intrapelvic nerve entrapment syndrome caused by a variation of the intrapelvic piriformis muscle and abnormal varicose vessels: a case report. Int Neurourol J 25:177–180
Possover M (2009) Laparoscopic management of endopelvic etiologies of pudendal pain in 134 consecutive patients. J Urol 181:1732–1736
Funding
The authors declare that no funds, grants, or other support were received during the preparation of this manuscript.
Author information
Authors and Affiliations
Contributions
GB: protocol development, data collection and management, and manuscript writing. AK: protocol development, data collection and management, and manuscript editing. HG: protocol development, manuscript writing and editing, and data analysis. ECG: data collection. KNB: data analysis. TU: protocol development and data collection.
Corresponding author
Ethics declarations
Conflict of interest
The authors declare that they have no conflict of interest.
Additional information
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Rights and permissions
About this article
Cite this article
Basol, G., Kale, A., Gurbuz, H. et al. Transvaginal pudendal nerve blocks in patients with pudendal neuralgia: 2-year follow-up results. Arch Gynecol Obstet 306, 1107–1116 (2022). https://doi.org/10.1007/s00404-022-06621-1
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00404-022-06621-1