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A 25-Year-Old Cyclist with Persistent Perineal Pain

  • David H. Kim
  • Arjun Ramesh
  • Adam C. YoungEmail author
Chapter
  • 39 Downloads

Abstract

Pudendal neuralgia is an uncommon, painful condition caused secondary to inflammation or entrapment of the pudendal nerve. The prevalence of pudendal neuralgia is reported at 1:100,000 but is often underdiagnosed. This pain is described as a pain along the perineum radiating to the genitals with associated numbness and in some cases erectile dysfunction. Diagnosis of this condition is one of exclusion with available diagnostic criteria and complementary diagnostic neurophysiologic testing or imaging. Diagnosis of pudendal neuralgia or entrapment is oftentimes delayed secondary to clinical signs which overlap with other conditions. Treatment options range from conservative medical management with anti-inflammatory or neuropathic pain medications, interventional pain therapies with pudendal nerve blocks and radiofrequency ablation, and ultimately surgical decompression. Adjunct therapies include stretching, cessation of exacerbating activity, and adjustments to cycling equipment.

Keywords

Perineal pain Pudendal neuralgia Pudendal nerve Pudendal canal Cyclist’s syndrome Alcock canal syndrome Perineal pain Pelvic pain 

References

  1. 1.
    Robert R, Labat JJ, Riant T, et al. The pudendal nerve: clinical and therapeutic morphogenesis, anatomy, and physiopathology. Neurochirurgie. 2009;55(4–5):463–9.PubMedGoogle Scholar
  2. 2.
    Filler AG. Diagnosis and treatment of pudendal nerve entrapment syndrome subtypes: imaging, injections, and minimal access surgery. Neurosurg Focus. 2009;26(2):E9.PubMedGoogle Scholar
  3. 3.
    Khoder W, Hale D. Pudendal Neuralgia. Obstet Gynecol Clin N Am. 2014;41(3):443–52.Google Scholar
  4. 4.
    Fisher HW, Lotze PM. Nerve injury locations during retropubic sling procedures. Int Urogynecol J. 2011;22(4):439–41.PubMedGoogle Scholar
  5. 5.
    Alevizon SJ, Finan MA. Sacrospinous colpopexy: management of postoperative pudendal nerve entrapment. Obstet Gynecol. 1996;88(4 Pt 2):713–5.PubMedGoogle Scholar
  6. 6.
    Lyon T, Koval KJ, Kummer F, Zuckerman JD. Pudendal nerve palsy induced by fracture table. Orthop Rev. 1993;22(5):521–5.PubMedGoogle Scholar
  7. 7.
    Báča V, Báčová T, Grill R, et al. Pudendal nerve in pelvic bone fractures. Injury. 2013;44(7):952–6.PubMedGoogle Scholar
  8. 8.
    Elahi F, Callahan D, Greenlee J, Dann TL. Pudendal entrapment neuropathy: a rare complication of pelvic radiation therapy. Pain Physician. 2013;16(6):E793–7.PubMedGoogle Scholar
  9. 9.
    Howard EJ. Postherpetic pudendal neuralgia. JAMA. 1985;253(15):2196.PubMedGoogle Scholar
  10. 10.
    Labat JJ, Riant T, Robert R, et al. Diagnostic criteria for pudendal neuralgia by pudendal nerve entrapment (Nantes criteria). Neurourol Urodyn. 2008;27(4):306–10.PubMedGoogle Scholar
  11. 11.
    Ploteau S, Cardaillac C, Perrouin-Verbe MA, et al. Pudendal neuralgia due to pudendal nerve entrapment: warning signs observed in two cases and review of the literature. Pain Physician. 2016;19(3):E449–54.PubMedGoogle Scholar
  12. 12.
    Durante JA, MacIntyre IG. Pudendal nerve entrapment in an Ironman athlete: a case report. J Can Chiropr Assoc. 2010;54(4):276–81.PubMedPubMedCentralGoogle Scholar
  13. 13.
    Masala S, Calabria E, Cuzzolino A, et al. CT-guided percutaneous pulse-dose radiofrequency for pudendal neuralgia. Cardiovasc Intervent Radiol. 2014;37(2):476–81.PubMedGoogle Scholar
  14. 14.
    Lefaucheur JP, Labat JJ, Amarenco G, et al. What is the place of electroneuromyogrpahic studies in the diagnosis and management of pudendal neuralgia related to entrapment syndrome? Neurophysiol Clin. 2007;37(4):223–8.PubMedGoogle Scholar
  15. 15.
    Benson JT, Griffis K. Pudendal neuralgia, a severe pain syndrome. Am J Obstet Gynecol. 2005;192(5):1663–8.PubMedGoogle Scholar
  16. 16.
    Carpes FP, Dagnese F, Kleinpaul JF, et al. Effects of workload on seat pressure while cycling with two different saddles. J Sex Med. 2009;6(10):2728–35.PubMedGoogle Scholar
  17. 17.
    Gemery JM, Nangia AK, Mamourian AC, Reid SK. Digital three-dimensional modelling of the male pelvis and bicycle seats: impact of riderposition and seat design on potential penile hypoxia and erectile dysfunction. BJU Int. 2007;99(1):135–40.PubMedGoogle Scholar
  18. 18.
    Hibner M, Desai N, Robertson LJ, Nour M. Pudendal neuralgia. J Minim Invasive Gynecol. 2010;17(2):148–53.PubMedGoogle Scholar
  19. 19.
    Pereira A, Pérez-Medina T, Rodríguez-Tapia A, et al. Chronic perineal pain: analyses of prognostic factors in pudendal neuralgia. Clin J Pain. 2014;30(7):577–82.PubMedGoogle Scholar
  20. 20.
    Elkins N, Hunt J, Scott KM. Neurogenic Pelvic Pain. Phys Med Rehabil Clin N Am. 2017;28(3):551–69.PubMedGoogle Scholar
  21. 21.
    Levesque A, Riant T, Labat JJ, Ploteau S. Use of high-concentration capsaicin patch for the treatment of pelvic pain: observational study of 60 inpatients. Pain Physician. 2017;20(1):E161–7.PubMedGoogle Scholar
  22. 22.
    Mamlouk MD, vanSonnenberg E, Dehkharghani S. CT-guided nerve block for pudendal neuralgia: diagnostic and therapeutic implications. AJR Am J Roentgenol. 2014;203(1):196–200.PubMedGoogle Scholar
  23. 23.
    Kastler A, Puget J, Tiberghien F, et al. Dual site pudendal nerve infiltration: more than just a diagnostic test? Pain Physician. 2018;21(1):83–90.PubMedGoogle Scholar
  24. 24.
    Labat JJ, Riant T, Lassaux A, et al. Adding corticosteroids to the pudendal nerve block for pudendal neuralgia: a randomized, double-blind, controlled trial. BJOG. 2017;124(2):251–60.PubMedGoogle Scholar
  25. 25.
    Buffenoir K, Rioult B, Hamel O, et al. Spinal cord stimulation of the conus medullaris for refractory pudendal neuralgia: a prospective study of 27 consecutive cases. Neurourol Urodyn. 2015;34(2):177–82.PubMedGoogle Scholar
  26. 26.
    Hunter CW, Yang A. Dorsal root ganglion stimulation for chronic pelvic pain: a case series and technical report on a novel lead configuration. Neuromodulation. 2019;22(1):87–95.Google Scholar
  27. 27.
    Valovska A, Peccora CD, Philip CN, et al. Sacral neuromodulation as a treatment for pudendal neuralgia. Pain Physician. 2014;17(5):E645–50.PubMedGoogle Scholar
  28. 28.
    Peters KM, Killinger KA, Jaeger C, Chen C. Pilot study exploring chronic pudendal neuromodulation as a treatment option for pain associated with pudendal neuralgia. Low Urin Tract Symptoms. 2015;7(3):138–42.PubMedGoogle Scholar
  29. 29.
    Robert R, Prat-Pradal D, Labat JJ, et al. Anatomic basis of chronic perineal pain: role of the pudendal nerve. Surg Radiol Anat. 1998;20(2):93–8.PubMedGoogle Scholar
  30. 30.
    Robert R, Labat JJ, Bensignor M, et al. Decompression and transposition of the pudendal nerve in pudendal neuralgia: a randomized controlled trial and long-term evaluation. Eur Urol. 2005;47(3):403–8.PubMedGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2020

Authors and Affiliations

  1. 1.Department of Anesthesiology and Pain MedicineKansas University Medical CenterKansas CityUSA
  2. 2.Department of AnesthesiologyRush UniversityChicagoUSA
  3. 3.Department of Anesthesiology and Pain ManagementIllinois Bone & Joint InstituteMorton GroveUSA

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