Diagnosis, Rehabilitation and Preventive Strategies for Pudendal Neuropathy in Cyclists, A Systematic Review

This systematic review aims to provide an overview of the diagnostic methods, preventive strategies, and therapeutic approaches for cyclists suffering from pudendal neuropathy. The study defines a guide in delineating a diagnostic and therapeutic protocol using the best current strategies. Pubmed, EMBASE, the Cochrane Library, and Scopus Web of Science were searched for the terms: “Bicycling” OR “Bike” OR “Cyclists” AND “Neuropathy” OR “Pudendal Nerve” OR “Pudendal Neuralgia” OR “Perineum”. The database search identified 14,602 articles. After the titles and abstracts were screened, two independent reviewers analyzed 41 full texts. A total of 15 articles were considered eligible for inclusion. Methodology and results of the study were critically appraised in conformity with PRISMA guidelines and PICOS criteria. Fifteen articles were included in the systematic review and were used to describe the main methods used for measuring the severity of pudendal neuropathy and the preventive and therapeutic strategies for nerve impairment. Future research should determine the validity and the effectiveness of diagnostic and therapeutic strategies, their cost-effectiveness, and the adherences of the sportsmen to the treatment.

Role of 3 Tesla MR Neurography and CT-guided Injections for Pudendal Neuralgia: Analysis of Pain Response

Background: Magnetic resonance neurography (MRN) has an increasing role in the diagnosis and management of pudendal neuralgia, a neurogenic cause of chronic pelvic pain. Objective: The objective of this research was to determine the role of MRN in predicting improved pain outcomes following computed tomography (CT)-guided perineural injections in patients with pudendal neuralgia. Study Design: This study used a retrospective cross-sectional study design. Setting: The research was conducted at a large academic hospital. Methods: Patients: Ninety-one patients (139 injections) who received MRN and CT-guided pudendal blocks were analyzed. Intervention: A 3Tesla (T) scanner was used to evaluate the lumbosacral plexus for pudendal neuropathy. Prior to receiving a CT-guided pudendal perineural injection, patients were given pain logs and asked to record pain on a visual analog scale. Measurement: MRN findings for pudendal neuropathy were compared to the results of the CTguided pudendal nerve blocks. Injection pain responses were categorized into 3 groups – positive block, possible positive block, and negative block. Statistical Tests: A chi-square test was used to test any association, and a Cochran-Armitage trend test was used to test any trend. Significance level was set at .05. All analyses were done in SAS Version 9.4 (SAS Institute, Inc., Cary, NC). Results: Ninety-one patients (139 injections) who received MRN were analyzed. Of these 139 injections, 41 were considered positive (29.5%), 52 of 139 were possible positives (37.4%), and 46 of 139 were negative blocks (33.1%). Of the patients who had a positive pudendal block, no significant difference was found between the MRN result and the pudendal perineural injection response (P = .57). Women had better overall response to pudendal blocks, but this response was not associated with MRN findings (P = .34). However, positive MRN results were associated with better pain response in men (P = .005). Patients who reported bowel dysfunction also had a better response to pudendal perineural injection (P = .02). Limitations: Some limitations include subjectivity of pain reporting, reporting consistency, absence of a control group, and the retrospective nature of the chart review. Conclusion: Pudendal perineural injections improve pain in patients with pudendal neuralgia and positive MRN results are associated with better response in men. Key words: MRI, MRN, CT injection, pudendal neuralgia, pudendal nerve, pelvic pain, chronic pelvic pain, pudendal neuropathy

Chronic Pelvic Pain: The Neuropathic Pain Basis

Chronic pelvic pain (CPP) in both genders has been chiefly the province of surgical subspecialists. Morphologic end-organ processes have been studied for decades without significant advances in understanding the etiology of CPP or developing adequate therapeutic outcomes. The neurogenic basis of CPP has received little attention. Several peripheral nerves may be the source. The largest of these is a pudendal nerve and is the most important because it is a mixed nerve and affects sensory and motor symptoms in both the somatic and autonomic nervous systems. Nerve compression and stretch are the two most important etiologic factors. Practitioners can diagnose these painful neuropathies by a careful symptom history and physical examination. The most important diagnostic tool is sensory examination of the pudendal territory using pinprick. Various neurophysiologic tests can confirm pudendal neuropathy. The smaller peripheral nerves affect CPP. Because pudendal neuropathy is a tunnel syndrome related to cumulative, repetitive microtrauma, it can be treated accordingly. Treatment options include nerve protection, medications (analeptics, tricyclic amines), perineural infiltrations of local anesthetics with or without corticosteroids, and, in a significant minority, decompression of the pudendal nerves. The smaller nerves often respond to a program of postural correction and perineural anesthetic blockades. All patients require attention to central sensitization. Treatment success depends on the duration of symptoms, etiology, and severity of nerve damage. The last item can only be evaluated at surgery. Complete cures of CPP, treated using each modality, can be measured by validated symptom scores for as long as 13 years. To progress in the diagnosis and treatment of CPP, interspecialty studies are needed that distinctly separate neurogenic from nonneurogenic CPP. To date, this has not been done. Thus, diagnostic, etiologic, and treatment conclusions are quite limited. CPP provides a rich foundation for clinical research for neurologists. Key Words: abdominal cutaneous neuropathy, chronic pelvic pain, interstitial cystitis, irritable bowel syndrome, middle cluneal neuropathy, neurogenic pelvic pain, pudendal neuropathy, sexual dysfunction, thoracolumbar junction syndrome

Chronic Pelvic Pain: Neurogenic or Non-Neurogenic? Warm Detection Threshold Testing Supports a Diagnosis of Pudendal Neuropathy

Background: Chronic pelvic pain (CPP) in men is rarely considered to have a neurogenic (neuropathic) basis. Separation of neurogenic from non-neurogenic pain is possible using clinical examination and neurophysiologic tests. A definite diagnosis of neuropathic pain can be made. Objectives: We aim to demonstrate that definite pudendal neuropathic abnormalities can be supported by a quantitative sensory test (QST) called the warm temperature threshold detection (WDT) test in men with CPP. Study Design: This is a retrospective review of 25 consecutive, unrecruited men evaluated in a private clinical practice beginning on January 1, 2010. The techniques of examination and neurophysiological testing have been standard since 2003. Setting: A private practice that is a referral center because of its focus on CPP of a neuropathic basis. Methods: Pinprick sensation was evaluated at 6 sites in the pudendal nerve territory (3 branches on each side). A WDT was performed at each nerve branch using a Physitemp NTE-2C Thermoprobe and Controller. This used a stepping algorithm from a neutral baseline of 31.5°C. Quantitative and subjective “qualitative responses” were recorded. Our preferred symptom score to evaluate pain level at consultation is the National Institutes of Health Chronic Prostatitis Symptom Index (NIH-CPSI). The results become the benchmark for comparison of responses following future treatments (not discussed). When possible, microscopy was used to evaluate prostate secretions for inflammatory prostatitis except in 2 men with CPP who had undergone previous radical prostatectomy for cancer. Observations were made of the skin in the pudendal territory. Our specific evaluation for neuropathy also sought evidence of multiple additional neuropathic pelvic pain generators. Results: The WDT was abnormal in all men (88% quantitative), and pinprick sensation was abnormal in 92% of the men. The combination of tests provided a diagnosis of pudendal neuropathy in all patients, resulting in an accurate and timely explanation of the neurogenic basis of their CPP symptoms. The NIHCPSI scores ranged from 10 to 35 (median 25). Four of 15 men had inflammatory prostatitis in addition to pudendal neuropathy. Limitations: There is selection bias because the men were either self-referred, suspecting their diagnosis from internet searches, or were referred by physicians who were aware of the focus of this clinical practice. The warm temperature testing used established normal values for the men. The NIHCPSI does not evaluate sexual or bowel symptoms. Sensitivity or specificity values for the tests could not be obtained. Conclusions: A possible neuropathic basis for CPP in men can be suspected from symptoms and history of activities. A probable diagnosis of neuropathy can be determined using a pinprick sensory evaluation in the pudendal territory. A definite diagnosis of pudendal neuropathy can be made using WDT. The combination of these 2 examinations demonstrated pudendal neuropathy in 100% of this cohort. The institutional review board deemed this study met criteria for exemption. Key words: Chronic pelvic pain, pudendal neuropathy, quantitative sensory testing, warm temperature detection threshold test, neuropathic pelvic pain, definite diagnosis of neuropathy, chronic prostatitis