2024-01-10 17:17:27
Definition: what is pudendal neuralgia?
Pudendal neuralgia (also called algie pudendale » or « pudendalgia ” or “ syndrome du canal d’Alcock “) is a neurological condition that affects the pudendal nerve. The latter is one of the most important nerves of the pelvis: “it is responsible for sensitivity and motor skills of the genital region and anus, as well as the pelvic floor muscles. Its function has long earned it the name of ‘pudendal nerve’. Pudendal in Latin meaning ‘genital parts'”, according to doctor François Guillibert, gynecologist.
In the event of neuralgia, the pudendal nerve can be irritated or compressed at different levels of its course such as at:
the ligamentous clamp (between the sacrotuberal ligament and the sacrospinous ligament); the entrance to the pudendal canal; the pudendal canal of Alcock (which is a splitting of the fibrous membrane of the internal obturator muscle).
Pudendal neuralgia causes pain in the pelvis area or at the level of genitals (between the anus and the penis or clitoris in women). The pain is worsened by sitting.
Symptoms can range from simple tingling (paresthesias) to very intense pain. If the diagnosis is confirmed, surgical intervention is often offered immediately. Dr François Guillibert, gynecologist
A rare and underdiagnosed disease
Pudendal neuralgia is rare since it affects 6 people out of 1,000. It is estimated that 3% of the population experiences an acute pain crisis (source 1). It is not uncommon for affected people to remain in thetherapeutic wandering. In fact, pudendal neuralgia has recently been taught in medical schools.
At first glance, the disease is often confused with gynecological pain in women. “Pudendal neuralgia is a pathology described since the beginning of the 20th century in reality. However, it is true that it has been ignored for a long time. Even today, the diagnosis can take a long time to obtain,” explains the practitioner.
What causes pudendal neuralgia?
Pudendal neuralgia is the consequence of compression or irritation of the pudendal nerve. This nerve passes through areas of narrowing in contact with the tendons of muscle insertion and ligaments which can sometimes compress or even hinder it, particularly in cases of microtrauma or certain diseases. In this type of circumstance, the formation of a scarred area can limit the mobility of the nerve in its sheath and induce signs of “suffering” of the nerve all along its route.
Pudendal nerve pain: who is at risk?
Some people are at greater risk for pudendal neuralgia, such as those who have experienced:
and trauma or injuries to the rpelvic region ;a pelvic surgery previous, including prostate or uterine surgery; pregnancy and childbirth; intense sporting activityin particular the running where the cycling ;a rapid weight loss or important ;of the musculoskeletal problems such as piriformis syndrome, which can compress the pudendal nerve.
Pudendal neuralgia can also be caused by certain illnesses such as diabetes, multiple sclerosis, Lyme disease, genital herpes or recurrent urinary infections.
The disease most often begins between 50 to 70 years oldwith a female predominance (6 women for 4 men).
Pudendal neuralgia following childbirth
Pudendal neuralgia is likely to be triggered following childbirth. In this case, it is the consequence repeated pushing efforts. It translates a pudendal nerve injury by stretching of the last. The pain may disappear following a few weeks. However, it happens that this condition becomes chronic.
What are the symptoms of pudendal neuralgia or Alcock’s canal syndrome?
The clinical picture of pudendal neuralgia is defined by the Nantes criteriarecognized internationally for the diagnosis of the disease (source 2).
It manifests itself by a permanent or intermittent chronic daytime pain in the pelvis and/or genitals (between the anus and the penis or clitoris in women). Patients do not complain of nighttime pain and the disease does not cause sleep disturbance.
The pain can be violent (intense burnsvice, twinges, numbness, foreign body sensation) and disabling. They are particularly evident in seated station. The latter is difficult, if not impossible, except on a toilet seat. Patients sometimes use buoysspecific anatomical cushions or even live upright.
Pudendal neuralgia is not associated with a sensory or motor deficit.
Pudendalgia: what are the consequences and complications?
The impact on quality of life is often severe, as with the majority of neuropathic pain.
Let us add that patients suffering from pudendal neuralgia very often have disorders associated with pain:
sexual disorders (decreased sexual sensations, painful intercourse…)urinary problems (frequent urination, urinary incontinence, false urge to urinate, etc.);troubles ano-rectaux (constipation, pain when passing stools);muscle aches (buttock painsciatic, pelvic irradiation, etc.).
“However, all of these disorders are far from being systematic. Pain is truly the main drawback of the disease,” according to the expert.
Diagnosis: how to detect pudendal neuralgia?
In case of signs suggestive of pudendal neuralgia, you should consult your doctor. The latter might direct you towards a urologistand neurologistand proctologue or even a gynecologist.
The diagnosis is essentially clinical. The doctor refers to the Nantes criteria following having eliminated all differential diagnoses (gynecological or anal pain for example).
Pudendal neuralgia is recognized by the location of painful areas which are very characteristic. Furthermore, the disease responds to anesthetic infiltrations which are therefore employed for diagnostic purposes. Dr François Guillibert,
And the gynecologist clarified: “Finally, it is possible to do certain confirmatory tests such as an electromyogram (EMG) and a Doppler ultrasound. An MRI helps eliminate differential diagnoses.”
Diagnostic criteria for pudendal neuralgia (Nantes criteria)
Pain of pudendal topography; triggered and/or aggravated by sitting; daytime, relieved at night; without sensory or motor deficit, responding to anesthetic infiltration (with lidocaine at 1%). The doctor therefore administers the infiltrations in order to confirm the diagnosis (infiltration test).
What treatment for pudendal neuralgia?
“Medication and physiotherapy are usually prescribed. However, when the diagnosis is confirmed, surgical intervention can be offered immediately. Radiofrequencies are an alternative to surgical intervention,” according to Doctor François Guillibert.
What medications for pudendal neuralgia?
First intentionthe doctor can prescribe antiepileptics (gabapentin, Neurontin®) or antidepressants (tricyclics or serotonin and norepinephrine reuptake inhibitors).
In the second line, combinations are possible: antidepressants + antiepileptics, antidepressants + tramadol or morphineantiepileptics + tramadol or morphine.
Stretching, physiotherapy, osteopathy: how to relieve yourself?
There are many techniques to relieve pudendalgia. The following are most often proposed: physiotherapy and theosteopathy with exercises, stretches and postures allowing the relaxation of the pudendal nerve.
The transcutaneous neurostimulation for analgesic purposes and alternative techniques (such as hypnosis, acupuncture, etc.) can also be effective.
Cushions to prevent pain when sitting
There are anatomical cushions to avoid pain when sitting in cases of pudendal neuralgia. These cushions can be taken anywhere, even to work. They have a hollow shape in their center.
Is there a surgical operation?
The surgical decompression can be performed. It consists of surgery in the deep region of the buttock which aims to free the nerve along its entire route in order to restore its mobility.
It is offered as a first-line treatment in the event of a positive infiltration test or following failure of drug treatment. Please note that infiltrations are only used for diagnostic purposes.
The radiofrequency destruction of the sensory fibers of the pudendal nerve is an alternative to surgery, but it is likely to have to be repeated due to the regeneration of the fibers and it can induce new, possibly painful, symptoms.
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