Bolečine v križnici in zadnjici
Spoštovani,
Že 4 mesece imam bolečine v križnici in levo in desno v zadnjici prebližno 1 cm nižje od višini trtice.
Bila sem pri ortopedu , ki je podal naslednji izvid:
Anamneza:
Gospa prihaja zaradi bolečin , ki se pojavljajo v sakroilikalnih sklepih od oktobra lani. Bolečine so se začele najprej pri vsedanju in vstajanju iz stola. Če se na stolu nagne naprej , bolečina počasi pojenja.
Sedaj se bolečina pojavlja tudi vseskozi ko sedi, Pri hoji nima težav , razen ko vstane jo boli v desnem dimlju, tako ,da nekaj par metrov šepa , nato bolečina izveni. Velikokrat pri sedenju čuti bolečino globoku v rektumu, ki pri stoječi drži izgine.
Status: Lumbalna hrbtenica ni boleča, boleča sta oba SIS , nekoliko bolj desni kot levi, bolj v področju sakruma kot črevnic. Menel je obojestransko pozitiven, Lasequ negativen. Nevrološki status spodnjih okončin korekten.
MR LH , ki je bil opravljen je bp.Pri reviziji ugotavljam sklerolizacijo bolj na področju mase lateralis sakruma več desno kot levo v področju SIS, ki delujeta tudi nekoliko razširjena, kot bi šlo za kondenzantni sakroileitis, kar potrjuje tudi sam status oziroma klinična slika.
Bila pregledana proktološko, je bp, na pritisk sta boleča iztopišča pudendalnega živca.
Mnenje: Klinično gre za sakroilieitis. Napotim še ma MR SIS.
DG: Obojestranski verjetno kondenzantni cirkumskriptni sakroileitis
Verjetnost pudendalne bolečine
Terapija : Arcoxia 60 mg- 1x dnevno 30 dni
Pred nekaj dnevi sem opravila tudi MR SIS, ki se glasi:
Artikularne površine obeh sakroilikalnih sklepov so nekoliko iregularne, mestoma so nakazane posamične drobne erozije. Ni pa vidnega morebitnega subhondračnega edema kostnine, periartikularne maščovne infiltracije ali skleroze. Tudi sprememb v sklopu osteitis condenzans ilii ni videti.
Mnenje:
Blage degenerativne spremembe obeh sklepov sakroilnih sklepov.
Brez znakov morebitnega sakroiliitisa ali sprememb v sklopu osteitis condenzans ilii.
Glede na izvid naj bi bilo vse normalno, mene pa še vedno boli. Težko sedim , včasih je kakšen dan bolečina manjša potem zopet vse po starem.
Ker imam sedeče delo za računalnikom je včasih tako hudo ,da ne morem sedeti, čeprav sem si nabavila blazino z luknjo ,da bi razbremenila hrbtenico. Takrat počepnem in iz počepa delam na tipkovnici na mizi, ker enostavno ne morem več sedeti.
Arcoxio jemljem že 14 dni , nekih izboljšan ni, kontrolo imam pri ortopedu šele v začetku aprila. Kaj mi svetujete, kaj bi lahko bilo vzrok mojih težav , ker očitno ne gre za vnetje , saj tako piše v izvidu MR SIS.
Lp
Spoštovani,
glede na opis in mesto bolečine bi lahko šlo za draženje pudendalnega živca.
Priporočam, da opravite še slikanje medenice z magnetno resonanco in EMG medeničnega dna, nato pa, da pridete na pregled s vsemi posnetki ter izvidi.
Prosim.
Na MR medenice se lahko vidi morebitna utesnitev pudendalnega živca.
Zdravljenje je lahko neoperativno (fizioterapevtske metode, injekcije) ali operativno.
Spoštovani,
napotnico za slikanje vam lahko izdamo, vendar potrebujemo veljavno napotnico za ortopeda, kirurga ali travmatologa, katero vam lahko izda le izbrani osebni zdravnik. Cena prvega pregleda pri nas, ki traja 30 minut, je 120 EUR.
Spoštovani,
danes sem omenila zdravnici ,da me pošlje na MR medenice, pa pravi ,da ne ve kaj naj napiše na napotnico , kajti v medenici se lahko gleda več stvari in če ne napiše kaj točno naj gledajo , preiskava ni smiselna. Ali mi lahko napišete ,kaj naj zdravnica kot napotno diagnozo napiše glede na težave?
Upam,da jo prepričam ,da me pošlje na to preiskavo.
Še nekaj me zanima , v kolikor bi šolo za pudendalno draženje živcev ste napisali ,da pridejo v upoštev inekcije ter fizioterapija. Zanima me ali inekcije opravljate pri vas?
Kako pa je z fizioterapijo, ali ,mi lahko priporočate kakšne vaje , ki bi jih lahko opravljala?
V kolikor pa je potrebna operacija , kdo to opravlja oziroma kje ? Se oproščam za toliko vprašanj, vendar osebni zdravnik, kakor tudi ortoped pri katerem sem bila ne vesta več kam me naj pošljeta, saj MR SIS ter MR lumbosakralnega dela nista pokazala patologije.
Lep pozdrav
Spoštovani,
priporočam napotitev na MR nevrografijo pudendalnih živcev z močjo magneta 3 Tesla. Pripenjam pregledni članek.
Acta Radiol OnlineFirst, published on September 23, 2016 as doi:10.1177/0284185116668213
Pudendal nerve and branch neuropathy: magnetic resonance neurography evaluation
Vibhor Wadhwa1, Aws S Hamid2, Yogesh Kumar3, Kelly M Scott4 and Avneesh Chhabra2
Abstract
Acta Radiologica
0(0) 1–8
! The Foundation Acta Radiologica 2016
Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0284185116668213 acr.sagepub.com
Pudendal neuralgia is being increasingly recognized as a cause of chronic pelvic pain, which may be related to nerve injury or entrapment. Due to its complex anatomy and branching patterns, the pudendal nerve abnormalities are challenging to illustrate. High resolution 3 T magnetic resonance neurography is a promising technique for the evaluation of peripheral neuropathies. In this article, the authors discuss the normal pudendal nerve anatomy and its variations, technical con- siderations of pudendal nerve imaging, and highlight the normal and abnormal appearances of the pudendal nerve and its branches with illustrative case examples.
Keywords
Pudendal nerve, magnetic resonance imaging (MRI), magnetic resonance neurography, pelvic pain, pudendal neuralgia Date received: 25 March 2016; accepted: 8 August 2016
Introduction
The pudendal nerve is a mixed nerve composed of sen- sory, motor, and autonomic fibers. It innervates the female and male genitalia in addition to the perineum and rectum. Pudendal neuralgia is reported to have a prevalence of 6.6% among the general population and it is more commonly observed in women (1). It can be caused by a number of etiologies, such as entrapment, blunt or iatrogenic trauma, infection, or tumor com- pressing or infiltrating the nerve. These etiologies can affect the pudendal nerve or its branches in isolation or it can also involve the contributing sacral and pelvic nerves. Traditionally, the evaluation of pudendal neur- algia is based upon the clinical findings, since electro- diagnostic studies are limited in the evaluation of the pelvic neuropathies (2). Magnetic resonance neurogra- phy (MRN) is a high resolution non-invasive imaging technique dedicated to the evaluation of peripheral nerve pathologies and is being increasingly used in the setting of suspected pudendal neuropathy (3–6). It is imperative for the radiologist to become familiar with the normal and abnormal appearances of the pudendal nerve on MRN in the context of different pathologies affecting the sacral nerves, pudendal nerve, and its branches. In this article, the authors provide a review
of normal pudendal nerve anatomy, its branching var- iations, and technical considerations of MRN imaging for its optimal evaluation. Normal and abnormal appearances of the pudendal nerve and its branches are also presented with representative case examples along with pertinent review of the available literature.
Anatomy and variations
The pudendal nerve originates from the sacral nerve roots (S2–S4), and carries sensory, motor, and auto- nomic fibers. It courses laterally and inferiorly along the anterior border of the piriformis muscle. After it
1Department of Radiology, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
2Department of Radiology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
3Department of Radiology, Yale New Haven Health System at Bridgeport Hospital, Bridgeport, Connecticut, USA
4Department of Physical Medicine & Rehabilitation, University of Texas Southwestern Medical Center, Dallas, Texas, USA
Corresponding author:
Avneesh Chhabra, Department of Radiology & Orthopaedic Surgery, UT Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas,
TX 75390-9178, USA.
Email: [email protected]
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passes the antero-inferior margin of the piriformis muscle, it enters the gluteal region. At this level, it accompanies the pudendal artery and vein throughout the remainder of its course (7). It then runs inferiorly and laterally coursing between the sacrospinous liga- ment (anterior) and the sacrotuberous ligament (poster- ior). Distal to the inter-ligamentous space, it wraps around the inferior margin of the sacrospinous liga- ment and runs anteriorly and laterally to enter a con- fined space under the obturator internus fascia, known as Alcock’s canal (or the pudendal nerve canal) (3). The nerve is usually the posterior-most structure within the canal. Additionally, within the pudendal nerve canal or just before entering it, the pudendal nerve gives rise to inferior rectal branch, which travels horizontally towards the external anal sphincter muscle and distal rectum. The pudendal nerve terminates in the pudendal canal branching into the dorsal nerve of the penis/clit- oris and the perineal branches (8) (Fig. 1).
Recently, Furtmuller et al. reported a number of variations during surgical dissections of male and female cadavers (9). These included separate trunks traveling in the inter-ligamentous space or in Alcock’s canal, namely, common rectal-perineal trunk, dorsal- perineal nerve trunk, and rectal-dorsal trunk. In other variations, the inferior rectal nerve(s), perineal branch, or the dorsal nerve originated directly from the sacral plexus. Additionally, the dorsal nerve of penis or clit- oris may arise proximal to the inter-ligamentous space and pudendal canal, up to 13mm proximal to the ischial spine (10). The dorsal nerve then travels an aver- age of 30 mm superior to the plane of the ischial tuber- osity and 19 mm inferior to the tendinous arch of the levator ani. It exits by piercing through the inferior fascia of the urogenital diaphragm traversing between the inferior transverse pubic ligament and the pubic
arch, on an average 6 mm lateral to the pubic symphy- sis, to terminate on the dorsum of the penis/clitoris (9).
Causes of pudendal neuropathy
Pudendal neuralgia can be caused by a number of etiol- ogies. In a large series of 189 patients diagnosed with pudendal neuralgia, four locations of pudendal nerve entrapment were described (9), namely, the sciatic notch (2.1%), the ischial spine (4.8%), Alcock’s canal (79.9%), and distal branch neuropathy (13%). The etiologies can be further categorized based on location of the lesions along the course of the nerve (11–16):
. Pelvis or sacrum: a tumor or infection can involve sacral nerve or proximal pudendal nerve trunk(s);
. Inter-ligamentous space: nerve injury may be related
to fall or the nerve can get entrapped underneath the thickened falciform process of the sacrotuberous ligament;
. Entrance to Alcock’s canal: previous fall or pelvic surgery, e.g. hysterectomy or prior pelvic mesh sur- gery; under the thickened or tight obturator fascia; prominent varicosities;
. Ischiorectal space: prior hemorroidal surgery, ischiorectal abscess or proctocolectomy;
. Alcock’s canal: pubic bone fracture;
. Inside the pubic canal: birth trauma or cycling;
. Pubic symphysis area: trauma, penile fracture, or
surgery.
In addition to the above, Tarlov cysts may also com- press the nerve roots, or radiation therapy to the pelvis may affect the contributing sacral nerve roots or the nerve itself. In the authors’ experience, the most common cause of pudendal neuralgia appears to be
Fig. 1. Illustrations (a, b) showing normal pudendal nerve and its branches.
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Wadhwa et al.
3
unilateral or bilateral traction neuropathy rather than entrapment or injury. Underlying pelvic muscle spasm and/or pelvic instability and obliquity may be the con- tributing factors in such cases. Other neuropathic causes of pelvic pain that need to be considered in the setting of pudendal neuralgia include, genitofemoral neuralgia (often presents with anterior groin, scrotal, or labial pain), ilioinguinal neuralgia (groin pain, usu- ally not reaching the scrotum or labia), and perineal branch posterior femoral cutaneous neuropathy due to overlapping innervation with pudendal nerve in the posterior perineum (17).
Clinical findings
Pudendal neuralgia is a painful condition and the patients commonly present with genital numbness and erectile dysfunction (14,15). The pain is usually unilat- eral but quite commonly spreads bilaterally involving the deep pelvis, and there is often worsening of the pain during sexual intercourse (18). In a recent article by Prologo et al., patients with pudendal neuralgia described the pain in a variety of ways as burning, pull- ing, crushing, pressure, and throbbing (19).
On physical examination, the pudendal neuralgia may be elicited by direct pressure on the ischial spine and inferomedial to the sciatic notch (20). Tenderness can be elicited on direct palpation of the obturator internus muscle or by passive internal and external rotation of the hips (3). The Nantes criteria have been proposed for the diagnosis of pudendal neuralgia (2). The inclusion criteria consist of: pain in the area inner- vated by the pudendal nerve, extending from anus to clitoris (or penis); pain more severe when sitting; pain that does not awaken patient from sleep; pain with no objective sensory impairment; and pain relieved by diagnostic pudendal block. The exclusion criteria include: purely coccygeal, gluteal, or hypogastric pain; exclusively paroxysmal pain; exclusive pruritus; and presence of other non-pudendal imaging abnormalities able to explain the symptoms. To be diagnosed with pudendal neuralgia, a patient must exhibit all five inclu- sion criteria and also demonstrate absence of all exclu- sion criteria.
Diagnostic evaluation
Pudendal neuropathy may be overlooked due to many diagnostic confounders, such as pelvic floor dysfunc- tion, chronic prostatitis, interstitial cystitis, vulvodynia, coccydynia, hemorrhoids, ischial bursitis, and orchial- gia (18,21). To make an accurate diagnosis, the clin- ician requires a good clinical history, physical examination, and exclusion of other causes of pelvic pain. This is supplemented by use of different
diagnostic modalities, such as pudendal nerve terminal motor latency testing (PNTML), electromyography (EMG), and MRN (4,22,23). PNTML and EMG have questionable value in the diagnosis of pudendal neuropathy. EMGs are not specific for patients with pudendal neuralgia and may give abnormal results in the case of sacral radiculopathy or other upstream pathologies. The PNTML test examines only the motor function and cannot provide any direct evidence of sensory nerve damage (24).
MRN imaging: technical considerations
With the development of new advances in MRI dedi- cated to evaluation of peripheral nerves, also known as MRN, detailed assessment of anatomy and pathology of sacral nerves, pudendal nerve, and its branches is possible with superior resolution (25–27). MRN as opposed to conventional MRI affords superior reso- lution for delineation of fascicular detail and encom- passes pulse sequences that allow uniform fat suppression, vascular signal suppression, diffusion ima- ging and three-dimensional (3D) imaging (28–30). MRN can supplement the information gained from clinical and electrodiagnostic findings because it is able to detect the normal and abnormal appearance of the major nerves, as well as the surrounding soft tissue pathologies (31). The pudendal nerve is small and therefore, its evaluation is frequently limited due to poor spatial resolution and signal to noise ratio (SNR) on wide field-of-view imaging, inhomogeneous fat suppression, nerve branching variations, and sur- rounding vessels, especially in the setting of pelvis venous congestion. Prior imaging techniques were lim- ited to thick slice (5–6 mm with 10–20% interslice gap) T1-weighted (T1W), fat suppressed T2-weighted (T2W), and STIR (short tau inversion recovery pulse sequences) (3). Using MRN, the nerve can be displayed in superior resolution, in multiple planes, and in both anatomic and diffusion contrasts (4). The MRN proto- col dedicated to pudendal nerve evaluation in our insti- tute is highlighted in Table 1 (MR scanner: Achieva, Ingenia, Philips, Best, The Netherlands). Generally, 3T MRN provides better SNR as compared with the 1.5T machine and both two-dimensional and 3D imaging evaluation of the pudendal nerve and its branches is accomplished within approximately 25 min. The anter- ior torso XL coil, preferably multi-transmit coil, is used for imaging. Using 4 mm slice thickness and 10% gap with higher matrix (>256), one can assess the fascicular structure of the nerve. The fat saturation on T2W ima- ging is accomplished using spectral adiabatic inversion recovery (SPAIR) or modified (m) Dixon technique. T2 SPAIR imaging mitigates pulsation and breathing arti- facts, which are common with mDixon imaging.
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4 Acta Radiologica 0(0) Table 1. 3 Tesla MRN imaging parameters (MR scanner – Achieva, Ingenia, Philips, Best, Netherlands; Coil: XL Torso coil linked to
posterior spine elements).
Sequence
Axial T2 SPAIR (or STIR or T2 mDixon)
Axial T1W Axial DTI
Coronal 3D SPAIR TSE with MSDE pulse
TR (ms) 5320
710 7100
2000
TE (ms) 63
8.7 83
78
Slice (mm) 4.0
4.0 4.0
1.5
Matrix 320 256
320 256 128 128
1.5 mm isotropic voxel
FOV/Other
L5–S1 level to lesser trochanters
L5–S1 level to lesser trochanters L5–S1 level to lesser trochanters
B values 0, 600, 800; Directions 1⁄4 15
L2–3 to lesser trochanters
Time of acquisition
5min30s
5min10s 6min20s
8 min
3D, three-dimensional; b, diffusion moment; DTI, diffusion tensor imaging; FOV, field of view; MSDE, motion sensitive driven equilibrium; SPAIR, spectral adiabatic inversion recovery; STIR, short tau inversion recovery; TE, echo time; TR, repetition time.
However, the latter can provide multiple maps, such as in-phase, opposed phase, water, and fat maps (32). Keeping the echo time about 60–65ms for fat sup- pressed T2W imaging provides optimal SNR while enhancing the signal of endoneurial fluid in the nerve. Since many of these patients present with non-specific clinical findings and many also have lower back pain, in our institute, we perform complete lumbosacral plexus (LS) examination (total time 45–50 min) in most cases. The LS plexus MRN evaluation in addition includes lumbosacral spine evaluation with axial and sagittal T2W imaging, and axial T1W and T2 SPAIR in the upper abdomen. The 3D imaging field of view extends from the L2 level to the lesser trochanters and from the anterior to posterior skin, while keeping the isotropic resolution of 1.5mm. This evaluation aids in assess- ment of the LS spine, LS plexus nerves, sciatic, femoral, ilioinguinal, iliohypogastric, and genitofemoral nerves. Intravenous contrast administration is reserved for patients with an underlying history or suspicion of infection or malignancy.
Imaging evaluation
Axial T1W and T2 SPAIR (T2mDixon) images are evaluated together for the identification of anatomy and pathology (4). In the initial assessment, the reader should focus on the potential findings of injury or entrapment, such as focal scarring, thickened sacro- tuberous or sacrospinous ligaments, thickened obtur- ator fascia, perineal scarring, fracture deformity of the pubic rami or the sacrum, and any mass lesion. Thereafter, the major peripheral nerves of pelvis are evaluated on 3D imaging technique with thick slab maximum intensity projections (MIP) for signal and caliber symmetry. The normal sacral ganglia are twice as bright as the distal nerve root exiting the neural for- amina and the bilateral sacral nerves show symmetrical appearance in signal and size (33). The pudendal nerves
are best seen on axial images along the distal edge of piriformis muscle entering the interligamentous space at the ischial spine (4,5). The nerve is intermediate signal intensity at this point and shows a fascicular appearance, which helps in differentiation of the nerve from the adjacent vessels in the neurovascular bundle. The nerve usually starts branching distal to this point and can sometimes show different variations as described above.
Filler showed that the presence of pudendal nerve or rectal branch hyperintensity along the medial border of the obturator internus or proximal to its entrance to the Alcock’s canal is a useful indicator of neuropathy (34). In the authors’ experience, as the nerve enters Alcock’s canal under the obturator fascia, minimal hyperintensity on T2W images is not uncommon due to the magic angle artifact. The inferior rectal branch can be seen coursing in a curved manner in the ischiorectal fat plane with or without associated veins. When the axial images are evaluated with diffusion tensor imaging (DTI), the normal and abnormal nerve can be easily identified, as DTI suppresses the venous signal and isolates the nerve in difficult cases. The inferior rectal branch can arise before or after the pudendal nerve enters Alcock’s canal. Within Alcock’s canal, one or multiple nerve trunks can be identified. Distal perineal branches are difficult to identify due to their small size and frequent presence of pelvic venous congestion in affected cases (35). The intermediate signal dorsal nerve of the clitoris or penis is identified immediately under the pubic sym- physis on either side following the respective viscera (Fig. 2). 3D imaging is quite useful in evaluation of larger nerves in the lumbosacral plexus (26,36), although in the authors’ experience, it is limited for pudendal nerve evaluation due to small size and adjacent incom- plete venous signal suppression despite the use of motion sensitive driven equilibrium pulse. However, in a few cases, it can depict the course and caliber alterations associated with pudendal pathology.
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Wadhwa et al. 5
Fig. 2. Normal pudendal nerve anatomy. Axial T1W (a, d) and T2 SPAIR (b, c, e, f) images demonstrate the normal appearance of the pudendal nerve (arrows) at the ischial spine (a, b), Alcock’s canal (c, d) and its branches, i.e. inferior hemorrhoidal nerves (e) and perineal branches (f). Notice the intermediate signal of the normal nerves with the main trunks are best seen on T1W images and smaller branches are best seen on T2W images.
Combined evaluation on anatomic and diffusion- weighted imaging is useful in the detection of various pathologies related to pudendal neuralgia. Perineural scarring (strand-like hypointensities along the course of the nerve) can be differentiated from vessels, since vessels are bright on T2W images and are suppressed on high b values of DTI. One can differentiate the bright nerve from normally hyperintense vessel as the nerve shows a fascicular appearance and is intermediate in signal unless abnormal. Tortousity of vessels in the vicinity of the pudendal nerve or Alcock’s canal has been reported as an abnormal finding in patients with pudendal neuralgia (3). However, in the authors’ experience, it is quite common to find pelvis-venous congestion in pelvic pain patients and it is not clear whether this finding is related or unrelated to pudendal neuralgia. The pathologic findings of the pudendal and its branch neuropathy include alterations in signal or contour of the nerve, prominence of fascicles and/or encasement in scarring. Other suggestive findings include perineural pathology, such as thickened obtur- ator fascia, thickening of the sacrotuberous or sacros- pinous ligaments from prior injury, and prior intervention related perineural scar tissue and pubic fracture (37).
The sacral nerves and adjacent piriformis muscle should be evaluated when looking for pudendal nerve
Fig. 3. Sacral and pudendal neuropathy. A 40-year-old man presents with right pelvic and gluteal pain following a fall. Coronal (a) 3D IR TSE axial image shows abnormal asymmetrical thickening and hyperintensity of the right sacral nerve roots (long arrows) as compared to the left (small arrows). Axial T2 SPAIR images (b, c) show grade I strains in bilateral piriformis muscles (right > left, arrows). The right pudendal nerve is asymmetrically prominent and hyperintense as compared to the left (arrows).
abnormality. Increased signal or size of the sacral nerves is seen in lumbosacral plexopathy (usually bilat- eral), injury (bony fracture, trauma history, adjacent muscle strains), or perineural malignancy (nodular
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Acta Radiologica 0(0)
thickening and contrast enhancement), which may cause pudendal symptoms (Fig. 3). Since the most common cause is traction neuropathy, increased signal and prominence of the nerve is seen at the ischial spine (3). It is not uncommonly seen as a bilateral find- ing. DTI aids in finding the nerve signal alteration as it makes it conspicuous on the trace images due to sup- pression of the surrounding fat, muscle, and vascular signal. The downstream neuropathy changes could be seen extending into the pudendal canal (Fig. 4). The distal perineal or hemorrhoidal branches when entrapped in the pelvic floor scarring, become promin- ent and therefore, can be identified on the T2W and DTI images. The dorsal nerve of penis or clitoris can be seen as asymmetrically prominent or hyperintense due to genital inflammation or prior injury (Suppl. Figs. 1–4). These findings should be carefully correlated with the clinical picture and if concordant, image guided injections can be planned and performed to
help the patient (3,17). There is limited lit- erature describing imaging evaluation of these small branches of the pudendal nerve. If imaging con- firms the neuropathy, pudendal injection is performed as a confirmatory diagnostic test or for therapeutic benefit. If imaging shows a normal nerve, further diag- nostic injection can still be attempted if there is persist- ent strong clinical suspicion of neuropathy (38). However, if the diagnostic injection does not pro- vide the needed pain relief in the latter case, the diag- nosis of pudendal neuralgia should be abandoned (3). In such complicated situations (5.5% of patients), fur- ther diagnostic evaluation by ganglion impar injec- tion or epidural stimulator trial are suggested by Filler et al. (3).
Finally, MRN is helpful to find other confounding causes of pelvic pain, such as endometriosis, genitofe- moral neuropathy, ilioinguinal neuropathy, and other unsuspected pelvic mass lesions (19).
Fig. 4. Pudendal nerve re-entrapment neuropathy. A 34-year-old man with history of prior multiple surgeries for pudendal neur- opathy, complaining of persistent right sided pelvic pain and numbness. Axial T1W images (a, c) and axial T2 SPAIR (b, c) images show postoperative scarring from partial ligament resections on both sides (right > left) and increased signal of the pudendal nerves bilaterally with more prominence on the right (long arrows) as compared to the left (small arrows). The right pudendal nerve abnormality is conspicuous on DTI trace images (e, f; arrows, b value-600) with effective vascular and muscle signal suppression, correlating with patient’s symptoms.
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Wadhwa et al. Treatment
Pudendal neuralgia is a painful disease and timely treat- ment is essential before it worsens to peripheral, seg- mental, or central sensitization stages. Initial treatment is conservative and is primarily physiotherapy (including the use of biofeedback, myofascial release, manual connective tissue techniques, and vaginal dila- tors), and oral, rectal, and vaginal medications (39). A physician can also consider trigger point injections or botox injections as needed to help address pelvic floor muscular over-activity. Female pelvic pain shows a sig- nificant rate of spontaneous symptom remission in women over the years following presentation (40). Integrating physical and psychosocial treatments is likely to produce the best results for both men and women.
As a complement to conservative measures, nerve blocks can be performed as both a diagnostic and thera- peutic measure by injection of perineural local anes- thetic, hyaluronidase, and steroid (3). These can alleviate the symptoms temporarily and the patient may get enough pain relief to resume normal daily func- tioning. Image-guided pudendal blocks provide direct visualization of the nerve and can be used to target the nerve at various levels: as it passes between the sacros- pinous and sacrotuberous ligaments, at the ischial spine, and in Alcock’s canal (8,17). In recalcitrant cases or fading response to conservative treatment, surgery can be performed via transgluteal, perianal, laparoscopic, or transperineal approaches to decompress the nerve (24). Branch nerve resection is performed in the setting of neuroma while neurolysis with ligament resection is per- formed in the setting of entrapment or perineural scar- ring (41). Re-entrapment neuropathy can also occur following surgery and imaging plays an important role in the detection of iatrogenic nerve injury or entrapment related to perineural scarring (42,43). Pulsed radio fre- quency and cryotherapy has also been used as another option for intractable cases or following successful injec- tions as a long-term measure for pain relief (19,44).
In conclusion, pudendal neuralgia can be seen with numerous etiologies and the diagnosis is challenging. High-resolution MRN examination may be used to confirm the diagnosis of pudendal neuropathy, guide perineural injections, and exclude other confounding causes of pelvic pain syndrome.
Acknowledgements
The authors would like to thank Ms. Pam Curry, Department of Radiology, UT Southwestern Medical Center, for creating beautiful illustrations for this paper.
Declaration of conflicting interests
The authors declared the following potential conflicts of inter- est with respect to the research, authorship, and/or
7
publication of this article: Avneesh Chhabra serves as a MSK CAD consultant with Siemens Healthcare.
Funding
The author(s) disclosed receipt of the following financial sup- port for the research, authorship, and/or publication of this article: Avneesh Chhabra has received research grants from GE-AUR (GERRAF), Siemens Medical Solutions, Gatewood Fellowship Award and Integra Life Sciences unre- lated to this work. He also serves as a research consultant with Siemens CAD group. He also receives book royalties from Jaypee, Elsevier and Wolters.
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Zanima me ali inekcije opravljate pri vas? Da.
Kako pa je z fizioterapijo, ali mi lahko priporočate kakšne vaje , ki bi jih lahko opravljala?
Vaje ne, pač pa zdravljenje s Tecarjem (nova metoda diatermičnega zdravljenja).
V kolikor pa je potrebna operacija, kdo to opravlja oziroma kje? Imel sem eno pacientko, ki je bila na koncu operirana na Dunaju.
Spoštovani,
Najlepša hvala za vaš odgovor.
Napisali ste , da me naj zdravnik napoti na MR nevrografijo pudendalnih živcev. Ali je to preiskava MR medenice? Napotna diagnoza pa so pregled pudendalni živci. Ali prav razumem?
Še nekaj me zanima glede terapije oz. zdravljenje s Tecarjem. Ali to delate pri vas v Mariboru, koliko terapij je potrebnih in cena le te?
Lp
Spoštovani,
Napisali ste , da me naj zdravnik napoti na MR nevrografijo pudendalnih živcev. Ali je to preiskava MR medenice? Napotna diagnoza pa so pregled pudendalni živci. Ali prav razumem? Da, MR medenice – pripis pa: MR nevrografija pudendalnih živcev, diagnoza: Sum na vkleščenje pudendalnih živcev. Priporočam izvedbo v MDT&T, Lavričeva 1a, Maribor. Potrebno je pripisati: MR 3 Tesla. V MDT&T imajo 2 takšni napravi.
Še nekaj me zanima glede terapije oz. zdravljenje s Tecarjem. Ali to delate pri vas v Mariboru, koliko terapij je potrebnih in cena le te?
Terapije izvajamo le v Ljubljani. Potrebnih je 3 do 5 terapij. Cena ene terapije je 45 EUR.
Spoštovani,
hvala za vaš nasvet. Upam, da mi uspe pridobiti napotnico.
Glede terapije z Tacarjem se bom odločila, ker sem iz Koroške in mi je v Lj daleč.
Kako pogosto pa se dela ta terapija, a vsak dan zapored?
Kot terapijo ste omenjali tudi injekcije, ali je to isto kot blokada? Proktolog v centru Iatros mi je dejal da bi priporočal blokado v predel iztopiscu pudendalnih živcev.
Lp
Spoštovani,
prosim.
Terapija s Tecarjem se lahko izvaja tudi z večdnevnimi presledki.
Da, injekcija, ki sem jo navedel, je t.i. blokada.
Še enkrat najlepša hvala za vaše nasvete.
Upam, da mi uspe pridobiti še priporočene izvide, potem se slišimo.
Sem pa že bila na vezi z vašo fizioterapevtka v zvezi s terapijo tecar.
Mogoče samo še to, kako se aplicira ta injekcija-blokada, ali skozi danko, da zadene pudendalnega živce?
Kakšne so vaše izkušnje po aplikaciji blokade, ali blokada drži dlje časa oz a se mora ponavljati?
Zdravnica mi je svetovala zdravilo Lyrica, kaj menite o njemu? Glede na stranske učinke, odsotnost, zaspanost se ga bojim.
Sicer pa bi Rad odpravila vzrok, ne da jemljem zdravila, ki samo blažijo bolečine.
Še enkrat najlepša hvala za vaše nasvete in pomoč.
Lepe velikonočne praznike vam želim.
Lp
Prosim. Velja.
Mogoče samo še to, kako se aplicira ta injekcija-blokada, ali skozi danko, da zadene pudendalnega živce? Sam to apliciram pod ultrazvočnim nadzorom v okolici danke.
Kakšne so vaše izkušnje po aplikaciji blokade, ali blokada drži dlje časa oz a se mora ponavljati? Pogosto se mora po nekaj tednih ponoviti.
Zdravnica mi je svetovala zdravilo Lyrica, kaj menite o njemu? Glede na stranske učinke, odsotnost, zaspanost se ga bojim. Vsekakor priporočam poskusiti pred blokado.
Sicer pa bi Rad odpravila vzrok, ne da jemljem zdravila, ki samo blažijo bolečine. To je zanesljivo najbolj učinkovito zdravljenje.
Prosim.
Spoštovani,
Od splošne zdravnice mi je uspelo pridobiti napotnico za Mr medenice.
Sedaj čakam na slikanje.
Zanima me ali bi bila smiselna napotitev na fizioterapijo oziroma kakšno terapijo bi svetovali, ki jo je možno opraviti na napotnico v primeru mojih težav?
Seveda bi kasneje poskusila tudi s terapijo ta ar, če fizioterapija na napoteni o ne bi olajšala mojih težav.
Še nekaj me zanima, ali je možno priti k vam na pregled tudi z napotnico in če je to možno, kje se je možno naročiti?
Lp in najlepša hvala za vaš odgovor.
Spoštovani,
od fizioterapevtskih metod, ki so doosegljive v javnem zdravstvu, priporočam magnetoterapijo, UZ, diatermijo, TENS in/ali laser, odvisno od lokacije največje bolečnosti.
Preglede na napotnico imam v Medicinskem centru Ljubljana (MCL), praviloma prvi ponedeljek v mesecu.
Spoštovani,
najlepša hvala za vaš odgovor.
Napisali ste, da je možno na napotnico priti k vam na pregled v Medicinski center Ljubljana. Ali mi lahko zaupate stevilko na kateri se je možno naročiti in s katero napotnico je to možno (ortopedski pregled ali kaj drugega)?
Ali so vaši pregledi v Lj na napotnico v popoldanskem času?
Sem gledala na spletu MCL pa mi ni uspelo najti vaše ambulante.
Še enkrat hvala za vaše nasvete.
Lp
Spoštovani,
prosim.
Ambulanto imam običajno od 8.00 do 14.00. Za pregled se lahko naročite na telefonu 041 424 291 (Arbor mea d.o.o. – od 8.00 do 11.00) ali 041 737 033 (Kirurgija Bitenc d.o.o. – od 11.00 do 14.00).