Pelvic Trust
Monday June 6, 2011
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When a patient presents with pain in the groin, a number of diagnoses may spring to mind. In women, it might be vulvodynia or interstitial cystitis. In men, prostatodynia, nonbacterial prostatitis or orchialgia might be suspected. In many cases, the actual cause is pudendal neuralgia, a condition that many patients suffer with for years because of its relative rarity.
The word “pudenda,” which refers to the external sexual organs, also is the Latin word for “shame.” But the real shame of PN is many patients are reluctant to seek help because of the area involved. Fortunately, there is much physical therapy can do to alleviate the pain and swelling caused by PN, although it calls for a high degree of sensitivity on the part of the therapist.
Possible Causes
Pudendal neuralgia usually is caused by one of four factors, says Stephanie Prendergast, MPT, a partner at the Pelvic Health and Rehab Center in San Francisco and Oakland, Calif. “It could be a compression issue from horseback riding or sitting,” she says. “Or it could be a tension problem related to labor and delivery or chronic constipation. There can be a visceral somatic etiology involving things like repetitive years of infections or UTIs. Or it can be caused by direct injury, such as acute surgical insult.”
PN is characterized by a sharp, shooting pain in the territory of the pudendal nerve — a symptom that can be caused by many other factors, says Prendergast. “These diagnoses do not have solid inclusion criteria, and conditions such as vulvodynia, interstitial cystitis and PN tend to have overlapping comorbidities that can lead to misdiagnosis,” she says.
Further clouding the issue is a condition called pudendal nerve entrapment, which means patients have “a clamping or squeezing of structures that cause compression of the nerve,” says Pamela Morrison, PT, DPT, BCB-PMD, IMTC, who owns a clinic in New York. “You’ll usually find it where the nerve traverses between ligaments, or through Alcock’s canal, which is made of connective tissue and part of a ligament. It can be caused by trauma, sacroiliac joint dysfunction, infections or even a stretch injury from sports.”
Determining What it Isn’t
Looking in the wrong place for a solution can arise from unfamiliarity with the area, Prendergast says. “Unfortunately, because many physicians and even PTs are not completely aware of the territory of the pudendal nerve, many general pelvic pain symptoms end up being called PN, particularly if a patient comes into the doctor and says ‘I have a pain when sitting,’” she says. “Well, that could be indicative of PN if the pain is of a neuralgic nature in the pudendal area. But if it’s a pain in, say, the posterior thigh, that’s not PN — but it can be labeled so because it hurts when they sit. That’s something we need to be very careful about.”
Pudendal neuralgia also can be mistaken for vulvar vestibulitis, a bowel or sexual dysfunction, or even a sports hernia, Morrison says. Much of the confusion arises because the pudendal nerve has three branches that innervate the skin of the perineum and the genitals, and the anal and urethral sphincters. “There are also some superficial muscles in the pelvic floor it innervates, and it has some function in sensory and autonomic function of the bladder and rectum,” she says.
There is a common misconception that PN is an injury specifically related to childbirth. In truth, Prendergast says, “of the patients we’ve seen with this diagnosis — some 700 in the past 10 years — less than 5% were childbirth-related.”
A pudendal nerve block, involving the injection of a local anesthetic into the pudendal canal, is often used as a diagnostic technique. However, the procedure does little to alleviate long-term pain, says Prendergast. “Patients are numb while the anesthetic is in effect, but when it wears off they’re right back where they started,” she says.
Another diagnostic tool used by neurologists is the pudendal nerve motor latency test, an electrophysiological procedure in which the speed of conduction in the pudendal nerve is determined. A new MRI technique developed by physicians Michael Hibner and Hollis Potter has enabled clinicians to observe swelling around the nerve, which may greatly aid them in diagnosing PN.
In cases of pudendal nerve entrapment, in which the nerve is compressed by intruding pelvic muscles or other structures, some physicians advise surgery. Three types of procedures are available for nerve decompression in PN patients: trans-perineal, trans-gluteal and trans-ischiorectal surgeries. However, Prendergast says, she does not recommend the controversial operation due to its generally poor outcomes. “We’ve seen a lot of failures with the patients we’ve sent for surgery, and since 2004 we have not been recommending that patients undergo this procedure,” she says.
How Physical Therapy Can Help
Patients with a PN diagnosis who don’t want surgery will be glad to know therapists can use many techniques to relieve the pain of PN and the pressure pelvic structures place on the nerve. “We work a lot on releasing the tissue that surrounds the pudendal nerve, so we use types of manual therapies, such as soft tissue mobilization, releasing the connective tissue and softening the musculature around the path of the nerve,” Morrison says. “We can do joint mobilization to help realign and normalize the mobility of the sacroiliac joints. And we certainly do pelvic floor muscle rehabilitation to normalize the tone of the muscle and take out any tension or trigger points.”
Morrison also says the soft tissue between the ischeal tuberosity and the coccyx can be another area of entrapment, which can cause tension and create pain. Helping to restore mobility to the sacrococcygeal joint and normalizing its function can alleviate discomfort in the area. She also recommends performing adverse neural tension techniques to help the patient regain nerve mobility.
Although PN still is a tricky diagnosis, Prendergast says things are improving. “For the first five years of my career, every man I saw and some women had been misdiagnosed with nonexistent infections,” she says. “Now I feel that people are getting in a lot faster and their conditions are not as bad as what I used to see. So it’s getting better, but there’s still a long way to go.” •
Mark Cantrell is a freelance writer.
The word “pudenda,” which refers to the external sexual organs, also is the Latin word for “shame.” But the real shame of PN is many patients are reluctant to seek help because of the area involved. Fortunately, there is much physical therapy can do to alleviate the pain and swelling caused by PN, although it calls for a high degree of sensitivity on the part of the therapist.
Possible Causes
Pudendal neuralgia usually is caused by one of four factors, says Stephanie Prendergast, MPT, a partner at the Pelvic Health and Rehab Center in San Francisco and Oakland, Calif. “It could be a compression issue from horseback riding or sitting,” she says. “Or it could be a tension problem related to labor and delivery or chronic constipation. There can be a visceral somatic etiology involving things like repetitive years of infections or UTIs. Or it can be caused by direct injury, such as acute surgical insult.”
PN is characterized by a sharp, shooting pain in the territory of the pudendal nerve — a symptom that can be caused by many other factors, says Prendergast. “These diagnoses do not have solid inclusion criteria, and conditions such as vulvodynia, interstitial cystitis and PN tend to have overlapping comorbidities that can lead to misdiagnosis,” she says.
Further clouding the issue is a condition called pudendal nerve entrapment, which means patients have “a clamping or squeezing of structures that cause compression of the nerve,” says Pamela Morrison, PT, DPT, BCB-PMD, IMTC, who owns a clinic in New York. “You’ll usually find it where the nerve traverses between ligaments, or through Alcock’s canal, which is made of connective tissue and part of a ligament. It can be caused by trauma, sacroiliac joint dysfunction, infections or even a stretch injury from sports.”
Determining What it Isn’t
Looking in the wrong place for a solution can arise from unfamiliarity with the area, Prendergast says. “Unfortunately, because many physicians and even PTs are not completely aware of the territory of the pudendal nerve, many general pelvic pain symptoms end up being called PN, particularly if a patient comes into the doctor and says ‘I have a pain when sitting,’” she says. “Well, that could be indicative of PN if the pain is of a neuralgic nature in the pudendal area. But if it’s a pain in, say, the posterior thigh, that’s not PN — but it can be labeled so because it hurts when they sit. That’s something we need to be very careful about.”
Pudendal neuralgia also can be mistaken for vulvar vestibulitis, a bowel or sexual dysfunction, or even a sports hernia, Morrison says. Much of the confusion arises because the pudendal nerve has three branches that innervate the skin of the perineum and the genitals, and the anal and urethral sphincters. “There are also some superficial muscles in the pelvic floor it innervates, and it has some function in sensory and autonomic function of the bladder and rectum,” she says.
There is a common misconception that PN is an injury specifically related to childbirth. In truth, Prendergast says, “of the patients we’ve seen with this diagnosis — some 700 in the past 10 years — less than 5% were childbirth-related.”
A pudendal nerve block, involving the injection of a local anesthetic into the pudendal canal, is often used as a diagnostic technique. However, the procedure does little to alleviate long-term pain, says Prendergast. “Patients are numb while the anesthetic is in effect, but when it wears off they’re right back where they started,” she says.
Another diagnostic tool used by neurologists is the pudendal nerve motor latency test, an electrophysiological procedure in which the speed of conduction in the pudendal nerve is determined. A new MRI technique developed by physicians Michael Hibner and Hollis Potter has enabled clinicians to observe swelling around the nerve, which may greatly aid them in diagnosing PN.
In cases of pudendal nerve entrapment, in which the nerve is compressed by intruding pelvic muscles or other structures, some physicians advise surgery. Three types of procedures are available for nerve decompression in PN patients: trans-perineal, trans-gluteal and trans-ischiorectal surgeries. However, Prendergast says, she does not recommend the controversial operation due to its generally poor outcomes. “We’ve seen a lot of failures with the patients we’ve sent for surgery, and since 2004 we have not been recommending that patients undergo this procedure,” she says.
How Physical Therapy Can Help
Patients with a PN diagnosis who don’t want surgery will be glad to know therapists can use many techniques to relieve the pain of PN and the pressure pelvic structures place on the nerve. “We work a lot on releasing the tissue that surrounds the pudendal nerve, so we use types of manual therapies, such as soft tissue mobilization, releasing the connective tissue and softening the musculature around the path of the nerve,” Morrison says. “We can do joint mobilization to help realign and normalize the mobility of the sacroiliac joints. And we certainly do pelvic floor muscle rehabilitation to normalize the tone of the muscle and take out any tension or trigger points.”
Morrison also says the soft tissue between the ischeal tuberosity and the coccyx can be another area of entrapment, which can cause tension and create pain. Helping to restore mobility to the sacrococcygeal joint and normalizing its function can alleviate discomfort in the area. She also recommends performing adverse neural tension techniques to help the patient regain nerve mobility.
Although PN still is a tricky diagnosis, Prendergast says things are improving. “For the first five years of my career, every man I saw and some women had been misdiagnosed with nonexistent infections,” she says. “Now I feel that people are getting in a lot faster and their conditions are not as bad as what I used to see. So it’s getting better, but there’s still a long way to go.” •
Mark Cantrell is a freelance writer.
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Monday June 6, 2011