{"id":8241,"date":"2024-04-13T07:11:50","date_gmt":"2024-04-13T07:11:50","guid":{"rendered":"https:\/\/www.kauveryhospital.com\/ima-journal\/?p=8241"},"modified":"2025-04-09T10:50:09","modified_gmt":"2025-04-09T10:50:09","slug":"a-systematic-approach-to-pudendal-neuralgia-a-neuropathic-chronic-perineal-pain-syndrome","status":"publish","type":"post","link":"https:\/\/www.kauveryhospital.com\/ima-journal\/ima-journal-april-2024\/a-systematic-approach-to-pudendal-neuralgia-a-neuropathic-chronic-perineal-pain-syndrome\/","title":{"rendered":"A systematic approach to Pudendal Neuralgia- A neuropathic Chronic perineal pain syndrome"},"content":{"rendered":"

[vc_row][vc_column][vc_column_text]<\/p>\n

Introduction<\/strong><\/h2>\n

Chronic anal pain is difficult to diagnose and treat, especially with no obvious anorectal cause apparent on clinical examination. In chronic anal pain \u00a0there are \u00a03 main \u00a0categories, those are localized causes, \u00a0functional causes, and neuropathic pain. The most common category is local anorectal causes and includes a textbook list of anal conditions \u00a0and \u00a0chronicity of these conditions can also cause chronic anal pain. Neuropathic pain syndromes are rare but can be positively diagnosed to allow specific management. The diagnosis of pudendal neuralgia is primarily clinical and should be reviewed in the light of the course of the disease. Hence a thorough clinical knowledge and a systematic approach is essential.<\/p>\n

Case history<\/strong><\/h2>\n

A 17 yr boy who has been suffering from pain around the anus area \u00a0for 2 years. Initially this pain was aggravated by prolonged sitting and standing ( chronicity) and relived by lying down. But, at time progresses \u00a0the pain worsens during night time and also reproduced during micturition and defecation. Later on it radiating above upto sacral area , below \u00a0inner thigh region upto mid thigh area.. It was a constant dull aching in nature initially and \u00a0as the time progresses it disturbs \u00a0even during night time too. The boy was initially treated as hamstring muscle strain and treated with stretches and strengthening exercises elsewhere. The pain was minimally controlled, but reproduced \u00a0during sitting . Later patient was directed to do MRI ,it showed minor edema around second coccygeal bone. Then he was diagnosed as coccydynia and managed with neuropathic medicines and exercise and also advised to use donut pillow. Patient had some relief and managed the pain with all these measures. But the night pain was not subsided, hence he was instructed to do another MRI pelvis after 6 \u00a0months . The second MRI seems to be absolutely normal.<\/p>\n

Discussion<\/strong><\/h2>\n

This boy was referred for pain management, initially he was suspected to have coccydynia and prescribed neuropathic medicines. The pain was not settled and \u00a0moreover the \u00a0pain radiating to \u00a0inner thigh, further upto sacrum and \u00a0worsens with urination lights the suspicion of Pudendal neuralgia . In Clinical examination he \u00a0has been found to have left sided tenderness over the medial part of ischial tuberosity ( Tinel\u2019s sign). With all these clinical material we narrowed down to our diagnosis. In next visit we did \u00a0USG guided pudendal nerve block , which turn to be positive and he had good pain relief till date, which confirms the diagnosis of pudendal Neuralgia.<\/p>\n

The \u00a0Pudendal neuralgia refers to a chronic perineal pain syndrome due to entrapment between sacrotuberous and sacrospinous ligaments ,an entrapment neuropathy and this is diagnosed purely by clinical means only. The pain of pudendal neuralgia may be unilateral or bilateral and may radiate to the pelvis and thighs and cause deep pelvic discomfort. A burning sensation and numbness or paresthesia in the gluteal, perineal, and genital areas are commonly reported in association with the pain. Patients with pudendal neuralgia often suffer for several years before being diagnosed. Like any other\u00a0Neuropathic pain\u00a0the earlier the diagnosis \u00a0lights the way for easy management strategies.<\/p>\n

Four domains of diagnosis ,Nantes criteria have been defined, namely: (A) essential criteria, (B) complementary diagnostic criteria, (C) exclusion criteria, (D) associated signs not excluding the diagnosis. Pain should be relieved by anesthetic infiltration of the pudendal nerve. This is an essential criterion, but poorly specific.<\/p>\n

Pitfalls like localized causes may lead to a nonselective approach to diagnosis and to an extensive workup including endoscopy, anorectal physiologic testing, endoanal ultrasonography, or pelvic magnetic resonance imaging (MRI), with the goal of excluding other diagnoses. Thus, a selective approach is generally recommended based on suspicion from the patient\u2019s history and examination findings of past or present structural disease.<\/p>\n

Conclusion<\/strong><\/h2>\n

The key to diagnosis of chronic anal pain is to first exclude specific diseases and then to make a positive diagnosis, which will guide management. The clinicians who \u00a0armed with a relatively basic knowledge of possible diagnosis and treatments for chronic anal pain can make a specific diagnosis and initiate treatment even without a complex evaluation. The diagnosis of pudendal neuralgia is primarily clinical and should be reviewed in the light of the course of the disease. However once it diagnosed the pudendal neuralgia is treated by pudendal nerve block that is both diagnostic and therapeutically.<\/p>\n

References<\/strong><\/h2>\n

1.Chronic anal pain: A review of causes, diagnosis, and treatment Charles H. Knowles, PhD, FRCS, FACCRS (Hons) and Richard C. Cohen, MD, FRCS Cleveland Clinic Journal of Medicine June 2022, 89 (6) 336-343; DOI:
\n2.Pudendal Neuralgia -Rana AL-Jumah MD, Krishna B. Shah MD, in Interventional Management of Chronic Visceral Pain Syndromes, 2021
\n3.Anorectal pain -Giuseppe Chiarioni, Stefan-Lucian Popa, in Clinical and Basic Neurogastroenterology and Motility, 2020<\/p>\n

 <\/p>\n

\"\"V.Karthickraja MD,DA,FIPM<\/strong>
\nConsultant Anesthesiologist and Pain physician<\/em>
\nKauvery hospital, Chennai[\/vc_column_text][\/vc_column][\/vc_row]<\/p>\n","protected":false},"excerpt":{"rendered":"

[vc_row][vc_column][vc_column_text] Introduction Chronic anal pain is difficult to diagnose and treat, especially with no obvious anorectal cause apparent on clinical examination. In chronic anal pain \u00a0there are \u00a03 main \u00a0categories,<\/p>\n","protected":false},"author":2,"featured_media":8242,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[74],"tags":[],"class_list":["post-8241","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-ima-journal-april-2024"],"yoast_head":"\nA systematic approach to Pudendal Neuralgia- A neuropathic Chronic perineal pain syndrome<\/title>\n<meta name=\"description\" content=\"Chronic anal pain is difficult to diagnose and treat, especially with no obvious anorectal cause apparent on clinical examination. 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