Pudendal nerve entrapment

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Pudendal nerve entrapment
Other namesAlcock canal syndrome
Specialty Neurology   OOjs UI icon edit-ltr-progressive.svg

Pudendal nerve entrapment (PNE), also known as Alcock canal syndrome, [1] [2] is an uncommon [1] [3] [4] source of chronic pain in which the pudendal nerve (located in the pelvis) is entrapped or compressed in Alcock's canal. There are several different types of PNE based on the site of entrapment anatomically (see Anatomy). [5] Pain is positional and is worsened by sitting. Other symptoms include genital numbness, fecal incontinence and urinary incontinence.

Contents

The term pudendal neuralgia (PN) is often used interchangeably with "pudendal nerve entrapment". This condition can greatly affect a person's quality of life. Pudendal neuralgia can be caused by many factors including inflammation, extreme cycling, and can be a "secondary condition to childbirth". [6] A 2009 review study found both that "prevalence of PN is unknown and it seems to be a rare event" and that "there is no evidence to support equating the presence of this syndrome with a diagnosis of pudendal nerve entrapment," meaning that it could be possible to have all the symptoms of pudendal nerve entrapment (otherwise known as pudendal neuralgia) based on the criteria specified at Nantes in 2006, without having an entrapped pudendal nerve. [7]

A 2015 study of 13 normal female cadavers found that the pudendal nerve was attached or fixed to the sacrospinous ligament (therefore "entrapped") in all cadavers studied, suggesting that the diagnosis of pudendal nerve entrapment may be overestimated. [8]

Symptoms

There are no specific clinical signs or complementary test results for this condition. [9]

Genito-anal numbness and fecal or urinary incontinence can occur. [10] [11] [12] People may also experience a burning pain in perianal or genital areas. [13]

In male competitive cyclists, it is often called "cyclist syndrome", [4] in which cyclists rarely develop recurrent numbness of the penis and scrotum after prolonged cycling, or an altered sensation of ejaculation, with disturbance of micturition (urination) and reduced awareness of defecation. [14] [15] Nerve entrapment syndromes, presenting as genitalia numbness, are amongst the most common bicycling associated urogenital problems. [16]

Pain, if present, is positional and typically caused by sitting and relieved by standing, lying down or sitting on a toilet seat. [17] If the perineal pain is positional (changes with a person's position, for example sitting or standing), this suggests a tunnel syndrome. [18] Anesthesiologist John S. McDonald of UCLA reports that sitting pain relieved by standing or sitting on a toilet seat is the most reliable diagnostic parameter. [19]

A systematic review study found that PN may be implicated in various sexual dysfunctions such as persistent genital arousal disorder (PGAD), erectile dysfunction, premature ejaculation, and vestibulodynia. [20] Additionally, another review that looked at cycling-related sexual dysfunction suggested that cycling may indirectly cause sexual dysfunction by disturbing the testosterone signaling aspect of the hypothalamic-pituitary-gonadal axis of the body. [21]

Anatomy

Anatomy of the pudendal nerve from the spinal nerve roots to the terminal branches in an adult male. Pudendal nerve.svg
Anatomy of the pudendal nerve from the spinal nerve roots to the terminal branches in an adult male.

The pudendal nerve carries both motor and sensory axons. It stems from the spinal nerves S2–S4 of the sacral plexus. [22] [23] The nerve progresses between the piriformis and coccygeus muscles and exits the pelvis by passing through the greater sciatic foramen. [22] The pudendal nerve then re-enters the pelvic cavity by passing through the lesser sciatic foramen. After re-entering the pelvis, it breaks off into three branches known as the inferior rectal nerve, the perineal nerve, and the dorsal sensory nerve of the penis or clitoris. [22] These three nerves are also referred to as the terminal branches, and they are more susceptible to injuries due to their locations.

There are also four levels of pudendal nerve entrapment compressions:

Although there has been no evidence for a direct functional connection between the pudendal nerve and sacrotuberous ligament, many clinical studies have pointed at the sacrotuberous ligament as a potential cause of PNE. [24] Around the ischial level of the spine, pudendal nerve runs between the sacrotuberous ligament and the sacrospinous ligament (posteriorly and anteriorly, respectively), giving way for potential compression of the pudendal nerve. [13]

Causes

PNE is said to be caused by genitoanal surgical scarring and mishaps in the pelvic region, trauma to the pelvis, pregnancy, childbirth, bicycling and anatomic abnormalities. [25] Vaginal birth may lead to pudendal nerve damage from the stretch during delivery and the likelihood increases when delivering larger-than-average babies. As the pudendal nerve lies in the pelvic region, surgical procedures that involve this area, such as a caesarean section, can cause nerve injury. [23]

PNE can present in cyclists, likely due to both the compression and stretching of the pudendal nerve for prolonged time. [26] Heavy and prolonged bicycling, especially if an inappropriately shaped or incorrectly positioned bicycle seat is used, may eventually thicken the sacrotuberous and/or sacrospinous ligaments and trap the nerve between them, resulting in PNE.

Anatomic abnormalities can result in PNE due to the pudendal nerve being fused to different parts of the anatomy, or trapped between the sacrotuberous and sacrospinalis ligaments.

Pathophysiology

Prolonged pressure on the pudendal nerve and chronic traction injuries interrupt the normal microvasculature of the pudendal nerve triggering a cascade of physiological changes. The sequence of physiologic changes are a breakdown of the blood-nerve barrier, followed by edema and connective tissue changes, followed by diffuse demyelination, and finally Wallerian degeneration. In the acute form, a metabolic block by an impaired blood supply will interrupt normal function of the pudendal nerve. In the chronic form, neuropraxia and axonmetesis (Sunderland type 1 and 2) injuries will create positive symptoms (e.g. pain and paresthesias) and negative symptoms (loss of sensation). [27] [28] [29]

Diagnosis

Labat et al state that "there are no specific clinical signs or complementary test results of this disease". [9] Kaur et al confirm that there are no specific and consistent radiological findings in patients with PNE. [22]

Diagnostic tests that can be performed to suggest PNE are:

Diagnoses are made through neurophysiological testing rather than imaging. However, MRI and CT imaging may be used to exclude other diagnoses. [22]

Similar to a Tinel's sign digital palpation of the ischial spine may produce pain. In contrast, people may report temporary relief with a diagnostic pudendal nerve block (see Injections), typically infiltrated near the ischial spine. [9] It is important to note that the duration of pain relief from pudendal nerve block is different per person. [31]

Imaging studies using MR neurography may be useful. In people with unilateral pudendal entrapment in the Alcock's canal, it is typical to see asymmetric swelling and hyperintensity affecting the pudendal neurovascular bundle. [32]

Nantes Criteria

Pudendal nerve entrapment is difficult to diagnose and there are no specific examinations that can clearly confirm the diagnosis. A multidisciplinary group in Nantes, France developed a set of diagnostic criteria (the "Nantes Criteria") to serve as a guide to physicians in diagnosing PNE. [33] It consists of inclusions, exclusions, and complementary characteristics of the syndrome. [22] Some sources discourage the use of this guide due to errors found in the criteria.[ citation needed ]

Inclusion criteria are: [22]

  1. The involved area corresponds to the area of supplied by the pudendal nerve (anus to the clitoris or penis). [33]
  2. Pain worsened by sitting, because of increased pressure on the nerve. [33]
  3. The patient is not awoken by pain during sleep. [33]
  4. No objective loss of sensation on clinical examination. Loss of superficial sensation in the perineal area is more indicative of a lesion at the root of the sacral nerves. [33]
  5. Pain relieved by an anesthetic block of the pudendal nerve. [33]

Exclusion criteria are: [22]

Complementary criteria are: [22]

A systematic review by Indraccolo et al analyzed PN due to pudendal entrapment and PN without pudendal entrapment in women with chronic pelvic-perianal pain. The review classified the Nantes' criteria as the gold standard for diagnosing PN secondary to PNE. [34] Because of this, the authors of the systematic review additionally suggest that the criteria may be useful in assessing the efficacy and effectiveness of the pudendal nerve entrapment treatments that people may undergo.

Differential diagnosis

Differential diagnosis should consider the far commoner conditions chronic prostatitis/chronic pelvic pain syndrome and interstitial cystitis. [17] Other causes for similar symptoms of pudendal nerve entrapment include compression from a tumor, prostatitis in males, uterine diseases in females, complex regional pain syndrome (CRPS), superficial skin infections, and other neuropathies that share the same region as the pudendal nerve. [22]

Treatment

Treatments include behavioral modifications, physical therapy, analgesics and other medications, pudendal nerve block, and surgical nerve decompression. [7] A newer form of treatment is pulsed radiofrequency. [35] Most medical treatments are intended for symptomatic relief, such as pain. If symptoms are not managed through this standard of care, surgery is considered. [10]

Nerve protection

This is a form of self treatment to keep pressure off the pudendal nerve. It involves avoiding any activities that may increase pain in the pelvic area. [22] A seat cushion with the center area removed may be used to provide relief and prevent further pain. [30] A 2021 systematic review of preventative and therapeutic strategies found that cyclists who take precautions in maintaining proper posture may prevent the development of a more severe disorder. [36] It is also suggested that using a wider seat when cycling could prevent damage to the nerve, but more evidence is necessary to show long-term benefit. [26]

Ergonomics

Various ergonomic devices can be used to allow an individual to sit while helping to take pressure off of the nerve. A few recommendations to decrease nerve compression while cycling include having soft, wide seat in a horizontal position and setting the handlebar height lower than the seat. [36] There are also bicycle seats designed to prevent pudendal nerve compression, these seats usually have a narrow channel in the middle of them. Additionally, other recommendations include wearing padded bike shorts, standing on pedals periodically, shifting to higher gears, and taking frequent breaks. [36] For sitting on hard surfaces, a cushion or coccyx cushion can be used to take pressure off the nerves.

Physical therapy

Mobilization of the nerves and muscles in the pelvic region is a proposed way to treat symptoms associated with a nerve entrapment. An example of this is neural mobilization. The goal of neural mobilization is to restore the functionality of the nerve and muscles through a variety of exercises involving the lower extremities. Exercises to specifically target the pudendal nerve would be determined based on the anatomical layout of the nerve. It is important to note that evidence is limited to show support for this therapy. [37]

Another possible treatment for nerve entrapments in the pelvic region would be stretching and strengthening exercises. A treatment plan would be determined by a physical therapist to specifically manipulate the pudendal nerve through a variety of stretches. Strengthening exercises may also be recommended to relieve the excessive pressure caused by the entrapment, but there is currently limited evidence to support this choice of therapy. [37]

Medications

There are numerous pharmaceutical treatments for neuropathic pain associated with pudendal neuralgia. Drugs used include anti-epileptics (like gabapentin [35] ), antidepressants (like amitriptyline [17] ), and palmitoylethanolamide. [38] Often times polypharmacy is used with consideration of medication history and side effects. [30]

Injections

Illustration of imaging from a CT-guided injection of the pudendal nerve at the pudendal canal. CT image guided injection pudendal nerve.png
Illustration of imaging from a CT-guided injection of the pudendal nerve at the pudendal canal.

One way to identify and alleviate pain associated with the pudendal nerve is a "CT-guided nerve block." [39] During this procedure, "a long-acting local anesthetic (bupivacaine hydrochloride) and a corticosteroid (e.g. methylprednisolone) are injected to provide immediate pudendal anesthesia." [17] A pudendal nerve block can be inserted from several different anatomical locations including: transvaginal, transperitoneal, and perirectal. A reduction in pain following this injection is typically felt quickly. The most common side effect of a pudendal nerve block is injection site irritation. [31] Relief from chronic pain may be achieved through this procedure due to the reduced inflammation from the steroid medication, and "steroid-induced fat necrosis" which "can reduce inflammation in the region around the nerve" to lessen strain on the pudendal nerve. This treatment may alleviate symptoms for up to 73% of people. [17] Treatment of pudendal nerve entrapment by nerve block is not often prescribed due to "discomfort associated with the local injections as well as the risk of injuring critical structures." [31]

Pulsed radiofrequency

This can be used instead of pudendal nerve perineural injections. [30] In recent years, Pulsed radiofrequency (PRF) is starting to become more common for managing chronic pain, and has shown to have long-term benefits and low problem occurrences. [40] Pulsed radiofrequency has also been successful in treating a refractory case of pudendal neuralgia, but additional research is needed to study the effectiveness of pulsed radiofrequency on treating pudendal nerve entrapment. [35] Pudendal Nerve Stimulation (PNS) was found to significantly decrease subjective pain levels in people with pudendal neuralgia. A majority of people who underwent PNS reported "significant" or "remarkable" pain relief at 2 weeks after treatment. [41]

Surgical

Decompression surgery is a "last resort", according to surgeons who perform the operation. [18] It is highly controversial.

According to supporters of the theory of PNE, surgery is indicated when severe symptoms are present after exhausting all other forms of treatment. The surgery is also another option to confirm the diagnosis of pudendal nerve entrapment. [30]

The surgery is performed by a small number of surgeons in a limited number of countries. The validity of decompression surgery as a treatment and the existence of entrapment as a cause of pelvic pain are highly controversial. [42] [43] While a few doctors will prescribe decompression surgery, most will not.

There are several different approaches in order to perform a decompression surgery on the pudendal nerve. The different access areas include: superior transgluteal, superior retrosciatic, inferior retrosciatic, medial transgluteal, inferior transgluteal and transischial entry. [5] The transgluteal entry involves "neurolysis of the PN at the infrapiriform canal and transection of the sacrospinal ligament." Another point of entry which is described as a "perineal para-anal pathway", "follows the inferior rectal nerve to the Alcock's canal." [10]

If nerve damage is discovered, other surgery options may be considered like a "neurectomy" or "neuromodulation". [10]

History

Pudendal neuralgia was first described in cyclists in 1987. [44]

See also

Related Research Articles

Vulvodynia is a chronic pain condition that affects the vulvar area and occurs without an identifiable cause. Symptoms typically include a feeling of burning or irritation. It has been established by the ISSVD that for the diagnosis to be made symptoms must last at least three months.

<span class="mw-page-title-main">Pudendal nerve</span> Main nerve of the perineum

The pudendal nerve is the main nerve of the perineum. It is a mixed nerve and also conveys sympathetic autonomic fibers. It carries sensation from the external genitalia of both sexes and the skin around the anus and perineum, as well as the motor supply to various pelvic muscles, including the male or female external urethral sphincter and the external anal sphincter.

<span class="mw-page-title-main">Sciatica</span> Lower back pain that extends down leg

Sciatica is pain going down the leg from the lower back. This pain may go down the back, outside, or front of the leg. Onset is often sudden following activities like heavy lifting, though gradual onset may also occur. The pain is often described as shooting. Typically, symptoms are only on one side of the body. Certain causes, however, may result in pain on both sides. Lower back pain is sometimes present. Weakness or numbness may occur in various parts of the affected leg and foot.

Meralgia paresthetica or meralgia paraesthetica is pain or abnormal sensations in the outer thigh not caused by injury to the thigh, but by injury to a nerve which provides sensation to the lateral thigh.

<span class="mw-page-title-main">Sacrotuberous ligament</span> Ligament of the pelvis

The sacrotuberous ligament is situated at the lower and back part of the pelvis. It is flat, and triangular in form; narrower in the middle than at the ends.

<span class="mw-page-title-main">Sacrospinous ligament</span> Ligament of the pelvis

The sacrospinous ligament is a thin, triangular ligament in the human pelvis. The base of the ligament is attached to the outer edge of the sacrum and coccyx, and the tip of the ligament attaches to the spine of the ischium, a bony protuberance on the human pelvis. Its fibres are intermingled with the sacrotuberous ligament.

<span class="mw-page-title-main">Internal pudendal veins</span> Set of veins in the pelvis enclosed by pudendal canal

The internal pudendal veins are a set of veins in the pelvis. They are the venae comitantes of the internal pudendal artery. Internal pudendal veins are enclosed by pudendal canal, with internal pudendal artery and pudendal nerve.

<span class="mw-page-title-main">Pelvic pain</span> Medical condition

Pelvic pain is pain in the area of the pelvis. Acute pain is more common than chronic pain. If the pain lasts for more than six months, it is deemed to be chronic pelvic pain. It can affect both the male and female pelvis.

A neurectomy, or nerve resection is a neurosurgical procedure in which a peripheral nerve is cut or removed to alleviate neuropathic pain or permanently disable some function of a nerve. The nerve is not intended to grow back. For chronic pain it may be an alternative to a failed nerve decompression when the target nerve has no motor function and numbness is acceptable. Neurectomies have also been used to permanently block autonomic function, and special sensory function not related to pain.

<span class="mw-page-title-main">Anal triangle</span> Posterior part of the perineum

The anal triangle is the posterior part of the perineum. It contains the anus in mammals.

Vulvar vestibulitis syndrome (VVS), vestibulodynia, or simply vulvar vestibulitis, is vulvodynia localized to the vulvar vestibule. It tends to be associated with a highly localized "burning" or "cutting" type of pain. Until recently, "vulvar vestibulitis" was the term used for localized vulvar pain: the suffix "-itis" would normally imply inflammation, but in fact there is little evidence to support an inflammatory process in the condition. "Vestibulodynia" is the term now recognized by the International Society for the Study of Vulvovaginal Disease.

<span class="mw-page-title-main">Superior cluneal nerves</span>

The superior cluneal nerves are pure sensory nerves that innervate the skin of the upper part of the buttocks. They are the terminal ends of the L1-L3 spinal nerve dorsal rami lateral branches. They are one of three different types of cluneal nerves. They travel inferiorly through multiple layers of muscles, then traverse osteofibrous tunnels between the thoracolumbar fascia and iliac crest.

Anterior interosseous syndrome is a medical condition in which damage to the anterior interosseous nerve (AIN), a distal motor and sensory branch of the median nerve, classically with severe weakness of the pincer movement of the thumb and index finger, and can cause transient pain in the wrist.

<span class="mw-page-title-main">Nerve compression syndrome</span> Symptoms resulting from chronic, direct pressure on a peripheral nerve

Nerve compression syndrome, or compression neuropathy, or nerve entrapment syndrome, is a medical condition caused by chronic, direct pressure on a peripheral nerve. It is known colloquially as a trapped nerve, though this may also refer to nerve root compression. Its symptoms include pain, tingling, numbness and muscle weakness. The symptoms affect just one particular part of the body, depending on which nerve is affected. The diagnosis is largely clinical and can be confirmed with diagnostic nerve blocks. Occasionally imaging and electrophysiology studies aid in the diagnosis. Timely diagnosis is important as untreated chronic nerve compression may cause permanent damage. A surgical nerve decompression can relieve pressure on the nerve but cannot always reverse the physiological changes that occurred before treatment. Nerve injury by a single episode of physical trauma is in one sense an acute compression neuropathy but is not usually included under this heading, as chronic compression takes a unique pathophysiological course.

<span class="mw-page-title-main">Spinal stenosis</span> Disease of the bony spine that results in narrowing of the spinal canal

Spinal stenosis is an abnormal narrowing of the spinal canal or neural foramen that results in pressure on the spinal cord or nerve roots. Symptoms may include pain, numbness, or weakness in the arms or legs. Symptoms are typically gradual in onset and improve with leaning forward. Severe symptoms may include loss of bladder control, loss of bowel control, or sexual dysfunction.

<span class="mw-page-title-main">Sacroiliac joint dysfunction</span> Abnormal motion in the sacroiliac joint of the pelvis

The term sacroiliac joint dysfunction refers to abnormal motion in the sacroiliac joint, either too much motion or too little motion, that causes pain in this region.

<span class="mw-page-title-main">Vaginal support structures</span> Structures that maintain the position of the vagina within the pelvic cavity

The vaginal support structures are those muscles, bones, ligaments, tendons, membranes and fascia, of the pelvic floor that maintain the position of the vagina within the pelvic cavity and allow the normal functioning of the vagina and other reproductive structures in the female. Defects or injuries to these support structures in the pelvic floor leads to pelvic organ prolapse. Anatomical and congenital variations of vaginal support structures can predispose a woman to further dysfunction and prolapse later in life. The urethra is part of the anterior wall of the vagina and damage to the support structures there can lead to incontinence and urinary retention.

A nerve decompression is a neurosurgical procedure to relieve chronic, direct pressure on a nerve to treat nerve entrapment, a pain syndrome characterized by severe chronic pain and muscle weakness. In this way a nerve decompression targets the underlying pathophysiology of the syndrome and is considered a first-line surgical treatment option for peripheral nerve pain. Despite treating the underlying cause of the disease, the symptoms may not be fully reversible as delays in diagnosis can allow permanent damage to occur to the nerve and surrounding microvasculature. Traditionally only nerves accessible with open surgery have been good candidates, however innovations in laparoscopy and nerve-sparing techniques made nearly all nerves in the body good candidates, as surgical access is no longer a barrier.

<span class="mw-page-title-main">Deep gluteal syndrome</span> Medical condition

Deep gluteal syndrome describes the non-discogenic extrapelvic entrapment of the sciatic nerve in the deep gluteal space. In simpler terms this is sciatica due to nerve irritation in the buttocks rather than the spine or pelvis. It is an extension of non-discogenic sciatic nerve entrapment beyond the traditional model of piriformis syndrome. Where sciatic nerve irritation in the buttocks was once thought of as only piriformis muscle, it is now recognized that there are many other causes. Symptoms are pain or dysthesias in the buttocks, hip, and posterior thigh with or without radiating leg pain. Patients often report pain when sitting. The two most common causes are piriformis syndrome and fibrovascular bands, but many other causes exist. Diagnosis is usually done through physical examination, magnetic resonance imaging, magnetic resonance neurography, and diagnostic nerve blocks. Surgical treatment is an endoscopic sciatic nerve decompression where tissue around the sciatic nerve is removed to relieve pressure.

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