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Pudendal neuropathy symptoms and treatment. Pinched pudendal nerve symptoms treatment methods

Pudendal neuropathy is a pinching of the pudendal nerve located in the pelvic area. The element takes part in the emptying of the intestines and urination, sends impulses to the nerves passing through the male and female genitals. Neuralgia causes intense pain.

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Manifestations

A pinched pudendal nerve is expressed in the following symptoms:

Inability to control the processes of defecation and emptying of the bladder (complete and incomplete in the form of kalomazaniya, drip urine);
Feeling of a foreign object in the anus;
Painful sensations in the perineum and the area of the internal genital organs, which resemble a strong burning sensation;
Sexual Disorders: impotence in men, inability to achieve orgasm;
Increased sensitivity of tissues in the affected area, manifested when touched.

In neuralgia, the pain is especially severe when sitting; its intensity decreases when the patient lies down. The syndrome occurs during bowel movements, emptying the bladder, during sex.

Pudendal neuralgia

The described nerve fiber originates in the spinal cord. It is located in the pelvic cavity, leaving it through the sciatic opening and returning through the piriformis, located under the piriformis muscle. The latter can cause pinching of the fiber.

The disease develops due to:

Traumatization during delivery. They talk about obstetric neuropathy.
Chronic injuries caused by cycling or horse riding due to fractures of the pelvic bones.
Increased tone of the piriformis muscle.
Prolonged sitting in a sitting position.
Genital herpes.
Development of tumor neoplasms in the pelvic area, which squeeze nerve fibers.

Diagnosis of pathology includes:

Collecting anamnesis;
Physical examination;
Ultrasound of the Alcock canal (the genital canal, which is formed by the fascia of the internal obturator muscle).

Another way to determine pinching is blockade. If the injected anesthetic acts for 12 or more hours, then this confirms the presence of pudendal neuropathy.

Treatment of pathology includes:

Administration of hormones and anesthetics;
Reception or administration of muscle relaxants to reduce muscle tone;
Taking antiepileptic drugs to reduce the severity of pain;
Physiotherapy procedures (electrophoresis, phonophoresis);
Physical therapy (exercises aimed at strengthening the muscles of the pelvic floor and other pelvic muscles).

Sometimes therapy requires the work of a psychologist or psychotherapist with the patient.

Psychotherapist help

A doctor of this profile will help patients if, against the background of sharp pains caused by a pinched inguinal nerve, they have sexual dysfunctions. In men, this is psychological impotence due to fear of pain, in women - a decrease in libido and anorgasmia on the same basis.

Pinching does not bother at night. If discomfort occurs at this time of day, then you need to urgently undergo an examination, this symptom may indicate compression by a tumor neoplasm.

Neuropathy - what is it, causes of appearance, forms and symptoms

Neuropathy is a non-inflammatory damage to nerve fibers, not always accompanied by pain. Patients usually talk about tingling, numbness, problems with the sensitivity of a certain area, and a decrease in the degree of limb mobility.

Some forms of pathology are associated with dysfunctional changes in the genitourinary system, gastrointestinal tract organs.

The reason is that the affected nerves cause a malnutrition of the muscles, limit their functions. The muscles cease to contract normally, the nerves transmit impulses incorrectly, as a result, the degree of sensitivity of a particular zone falls.

The progression of neuropathy takes a long time, during which symptoms of the disease may be absent. The provoking factors for the development of pathological changes will be stress, alcohol consumption, exacerbation of chronic diseases.

Forms of neuropathy:

Chronic sensorimotor - it is characterized by positive symptoms of a neurological nature, which manifests itself or intensifies at night, at rest. Seriously ill patients face negative symptoms. In advanced stages, a characteristic deformation of the feet and digital phalanges develops, accompanied by a limitation of articular mobility.
Acute sensory - the form is accompanied by pronounced sensory symptoms, different types of sensitivity, basic reflexes may persist. The pain is severe, the patient often loses weight sharply, nervous disorders and depressive disorders can develop. With an in-depth study, altered indicators of the glycemic index are diagnosed (glycemic control may worsen or improve). The pathogenetic basis is the formation of arteriovenous shunts with the formation of replacement vascular structures within the intraneural blood flow.
Hyperglycemic - causes reversible neurological changes quickly, the main ones include moderate symptoms of the sensory type, a violation of the normal speed of propagation of nervous excitement along the fibers. The form manifests itself in persons with a newly diagnosed disease, prone to a deterioration in the function of glycemic control. Normalization of the current indicators of glycemia leads to an improvement in the severity of neurological symptoms.
Autonomous is one of the most common forms of diabetic neuropathy. It can have different manifestations, taking into account the severity of the course.
Multifocal and focal are tunnel forms of neuropathy that develop in elderly people (there are exceptions, but rarely). The most famous form is a tunnel, localized in the carpal canal, caused by compression of the median nerve by the transverse carpal ligament.
Cranial is a rare species, usually diagnosed in old people, patients who have had diabetes for a long time.
Diabetic amyotrophy - occurs after the age of 50-60 years, accompanied by atrophy of the thigh muscles, severe symptoms, patients complain of severe pain.
Chronic inflammatory - develops as a result of the rapid progression of polyneuropathy. Long-term immunomodulatory treatment, involves the use of azathioprine, plasmapheresis, corticosteroids, intravenous infusion of immunoglobulins.

The main risk factor and cause for the development of neuropathy is diabetes mellitus. He, like intoxication, traumatic effects, causes damage to nerve fibers. First of all, those nerves that are responsible for the transmission of impulses in the limbs are affected - hence the numbness of the toes, hands, pain, impaired sensitivity.

Autonomic neuropathy is always accompanied by malfunctions of internal organs and systems, problems with genitourinary, excretory, and digestive functions.

A patient diagnosed with diabetes should monitor blood glucose levels - if they are elevated, the supply of blood to the muscles will be disrupted. Over time, they atrophy, the structure of the skin will change, and their restoration is long and difficult.

It is necessary to avoid the use of toxic substances: mainly alcohol and its substitutes, arsenic, heavy metals, aggressive drugs. Toxic neuropathy mainly causes damage to the nerves of the extremities; with alcoholism, everyone has it, but complaints do not always arise.

Traumatic neuropathies are the consequences of compression of the nerves as a result of bone fractures, improper formation of scar tissue, injury to the nerve by a growing neoplasm.

How is any type of neuropathy diagnosed?

The procedure for diagnosing neuropathy:

Collecting a clinical history, analyzing complaints.
Examination of the legs, assessment of their condition.
Assessment of established symptoms.
Application of electrophysiological examination methods.
Other diagnostic techniques: nerve biopsy, skin punch biopsy, non-invasive techniques.

First, the doctor should interview the patient about the main complaints, ask him leading questions, ask about the sensations caused by progressive pathology.

Typical symptoms of neuropathy: paresthesia, tingling, burning sensation, lumbago at rest, severe pain even in the absence of stimulus. It is necessary to find out when the symptoms appeared, what are they associated with, whether they worsen at night or in the evening.

Examination of the feet and other parts of the limbs is mandatory, it will show the presence of keratosis (calluses) in areas with excessive pressure, pay attention to increased dryness of the skin, the presence of ulceration, obvious deformities of the feet.

For the analysis of subjective and objective symptoms, appropriate scales and questionnaires are used. Regardless of the scale used, a visual analysis of the condition of the limbs is carried out. To determine tactile sensitivity, it is convenient to use a monofilament apparatus.

Electrophysiological methods (eg, stimulation electroneuromyography) complement the results of general clinical diagnosis.

They are:

Non-invasive - objective and reliable;
Assessing the severity, dynamics, nature of the progression of pathology;
Carrying information about the function of nerve fibers, their structural features;
Conducting differential diagnosis of neuropathies.

The disadvantage of electrophysiological diagnostics is that it is quite painful.

Exercise therapy, gymnastics for neuropathy

With polyneuropathy, regardless of its type, form, reasons for development, gymnastics is effective. A special exercise therapy complex will restore muscle work, improve blood supply to the lower extremities.

Massage of the extremities is useful - it will restore blood supply, start regenerative processes, and stimulate nerve fibers to work. Contact a chiropractor, over time, the actions can be performed independently (that is, do self-massage sessions).

Features of nutrition in pathology

When this disease is detected, it is necessary to begin its treatment and adjust the diet, depending on the cause of the functional disorder of the legs.

The patient's diet should be correct and balanced. Contain the necessary trace elements, vitamins, healthy fats, carbohydrates and proteins to maintain the entire body in working order, and the ability to resist this disease.

Try to eliminate harmful foods from your diet and aggravate the condition of this disease. For example, these are very spicy, smoked-salty or salty dishes, various canned food, mayonnaise, ketchup, store sauces.

Limit consumption of sausages and confectionery to a minimum. Do not drink alcohol, carbonated drinks, or smoke cigarettes. Any food with dyes should also be excluded from the diet.

Pathology develops in both men and women of different ages. Despite the prevalence of this problem, neuropathy is rarely diagnosed. This is due to the fact that only a small percentage of patients pay attention to the symptoms of the disease and seek medical help.

Genital neuropathy can affect various nerve fibers surrounding the genitals (femoral genital, ilio-inguinal nerve).

The reasons for the development of the disease

The main etiological factor provoking genital neuropathy is the pinching of the pudendal nerve, which occurs in the Alcock canal. In connection with the affected area, the disease is also called "Alcock's canal syndrome".

This kind of pathology, such as femoral genital neuropathy, progresses as a result of injury to the groin area or the formation of a hernia. The defeat of the ilio-inguinal nerve is the result of the formation of muscle scars that appear after surgery or injury.

Pudendal neuropathy also develops for the following reasons:

labor activity (obstetric neuropathy);
hypertonicity of the piriformis muscle;
spasm of the muscles of the anus;
tension of the internal obturator muscle;
fracture of the pelvic bones;
malignant formations in the pelvic cavity;
herpes virus;
nerve damage caused by horse riding or cycling.

The main symptoms

Pudendal neuropathy is manifested by multiple, but mild symptoms. It is in connection with the blurring of symptoms that this disease is difficult to diagnose. Patients complain about the following phenomena:

aching pain in the perineum, anus and genitals;
burning and tingling sensation in the groin;
discomfort in the anus;
a feeling of the presence of a foreign body in the rectum, urethra or vagina (in women);
dysfunctions of the genital organs;
urinary incontinence;
hypersensitivity of the skin in the pubic area.

In women, the development of pathology is accompanied by itching and burning in the clitoris, labia, and vagina. The unpleasant sensations become more intense while sitting.

Often, patients are worried about the feeling of numbness of the genitals, problems with defecation (constipation), discomfort during urination, pain during sexual intercourse.

Diagnostics and treatment

When referring to patients with complaints of the symptoms of pudendal neuropathy, the specialist makes a diagnosis based on the compiled anamnesis, which contains the symptoms characteristic of the disease (pain, burning, sensory impairment). Also, patients are prescribed to undergo an ultrasound Doppler scan, during which a slowdown in the velocity of blood flow in the genital artery can be detected, indicating a possible pinching of this vessel. And since this artery passes along with the pudendal nerve through the Alcock canal, it can be concluded that the cause of the violation is compression processes. The method of diagnosing the disease is also a pudendal nerve blockade. If, after its implementation, the pain syndrome weakens, then this indicates the development of neuropathy.

Treatment of pathology is based on the use of such medications:

Pregabalin;
vaginal suppositories with diazepam;
injection of glucocorticoids with local anesthetics.

If the pinched nerve is difficult enough and does not respond to pharmacological therapy, then the patients may be prescribed surgical treatment.

All about stress and depression

Infringement of the pudendal or femoral-genital nerve

There are many nerve pathways in the human body, each of which innervates its own specific area. Among them, one can distinguish the pudendal nerve, which is called the genital nerve in medicine. It is responsible for the innervation of the pelvic floor muscles, and when this bundle is pinched, people experience chronic pain in the pelvic region. This is usually due to compression neuropathy. It is compression (nerve entrapment). In men, this problem occurs 2-3 times more often than in women due to anatomical features.

Features of the anatomy of the pudendal nerve

The pudendal nerve path begins much higher than the innervated zones, therefore doctors often call it the femoral-genital nerve. It passes through the muscles of the lower back and over the ureter, and then reaches the groin area. At this point, it divides into 2 branches:

The femoral genital nerve, passing into the inguinal branch, has 2 options for continuation, depending on the sex of the person:

Male. It leaves through the canal together with the spermatic cord and follows into the scrotum;
Female. In the case of the weaker sex, the pudendal nerve leaves the canal together with the round ligament of the uterus and smoothly passes into the skin of the labia majora.

The inguinal nerve in women and men innervates the following tissues:

Muscle tissue of the anus;
The outer skin of the anus and genitals;
Anal sphincter;
Musculature of the perineum;
Female clitoris;
Male cavernous bodies of the penis;
Sphincter of the bladder.

The pudendal nerve pathway is responsible not only for the sensations experienced during intercourse, but also directly for defecation and urination.

It performs the last two functions thanks to the vegetative fibers in its composition. It is the autonomous (vegetative) part of the nervous system that is responsible for many systems beyond the control of human consciousness, for example, pupillary constriction, heart rhythm, etc.

Damage to this nerve is caused by entrapment by the piriformis muscle, ligaments, etc. Sometimes the reason for this compression lies in the injury received, as a result of which the pelvic bones were crushed or the ligaments were torn. Usually, this type of neuralgia is accompanied by a feeling of tension and inflammation.

Inflammation causes

Traction-compression neuropathy of the left or right nerve pathway occurs in the Alcock canal. Therefore, a pinched pudendal nerve that occurs in this area is called Alcock's syndrome. Among other types of neuropathy inherent in this nerve pathway, the femoral-genital form can be distinguished. It manifests itself mainly due to a groin injury or the development of an inguinal hernia. Ilio-groin neuropathy also belongs to this group. It occurs due to the appearance of scars on the muscle tissue, which are the result of surgery.

Infringement of the pudendal nerve occurs mainly due to the following factors:

Injury during childbirth;
Spasm of the muscle tissue of the anus;
Fracture of the pelvis;
Development of malignant oncological diseases;
High tone of the piriformis muscle;
Complications of herpes;
Spasm of the internal obturator muscle;
Compression of the joint path due to riding a horse or bicycle.

Symptoms

Compression neuropathy of the pudendal nerve is characterized by many symptoms, but their severity is rather weak. For this reason, it is extremely difficult to diagnose pathology. Among the main manifestations of the disease are the following:

Painful sensations of a aching nature in the pelvic region;
Genital dysfunction;
A constant feeling of discomfort in the anal area;
Involuntary urination;
False sensation of a foreign object in the groin;
A burning sensation and a slight tingling sensation in the groin area;
Too high sensitivity of the skin in the groin area.

In females, severe itching and burning in the genital area can be added to the main symptoms of neuropathy. In a seated position, these signs are significantly enhanced.

In more rare cases, the following symptoms are observed:

Stool disorder (constipation);
Numbness of the genitals;
Pain during intercourse and when urinating.

Diagnostics

The doctor identifies the presence of a problem, focusing on the symptoms that appear and the results of an ultrasound scan. With neuropathy, it will indicate impaired blood flow in the genital artery, which goes through the Alcock canal. From this, we can conclude that with it there was a squeezing of the shameless nerve pathway.

An effective diagnostic method is the blockade of the pudendal nerve pathway. If the discomfort disappears, then all the fault lies with neuropathy. Usually, in such a situation, a course of therapy is prescribed, which includes glucocorticoid injections, vaginal suppositories and other methods of restoring strangled nerve fibers.

The course of therapy

Treatment of neuropathy should consist of a set of measures aimed at eliminating inflammation, relieving pain and restoring nerve conduction. It usually includes the following methods of therapy:

Elimination of pain with the help of anticonvulsants (Gebapentin);
The use of physiotherapeutic procedures (phonopharesis, electropharesis, etc.);
Blocking the nerve pathway with a solution of hormones and anesthetics;
The use of muscle relaxants (Mydocalm);
The use of vitamin complexes (Neuromultivitis).

Vitamins Neuromultivit and their analogs can be taken both as a component of the blockade solution and in the form of tablets. If the discomfort is strong, then suppositories for rectal or vaginal use based on Diazepam and special exercise complexes are used. The essence of physiotherapy exercises for neuropathy of the pudendal nerve is to compress and relax the muscles of the perineum.

If there is no point in continuing to treat medically damaged nerve tissues due to the lack of results, then surgical intervention will be required to decompress the compressed nerve. Such operations are extremely effective, but have a long recovery period.

With prolonged absence of treatment, the development of the consequences of pathology is possible. The disease can become chronic and some of the symptoms can be extremely difficult to eliminate. There have been cases of impotence and decreased libido, as well as increased frequency of involuntary urination and defecation.

Pudendal neuropathy is unpleasant, but some people live with it for years. This is usually associated with vague symptoms and a chronic type of course. You can avoid such discomfort, but for this you will have to undergo an examination and follow all the doctor's recommendations.

The information on the site is provided solely for popular informational purposes, does not claim to be reference and medical accuracy, and is not a guide to action. Do not self-medicate. Please consult your healthcare professional.

Pinched pudendal nerve in men and women

The "pudendal" or pudendal nerve (n. Pudendus) is very often the cause of chronic pelvic pain found in adults. The most common cause of this is compression neuropathy. Moreover, the "pinching" of the pudendal nerve in men is three times less common than in women.

A bit of anatomy

The pudendal nerve is small in length, but a very important nerve of the latter, if you go from the brain, the sacral plexus. It lies in the pelvic cavity, bends around the ischial bone along the way. Further, it is divided into three branches - the rectal, perineal and dorsal nerve of the penis (clitoris). Its functions are varied:

they innervate the muscle that lifts the anus;

innervates the anal sphincter;

sphincter

gives branches to the muscles of the perineum;

innervates the genitals: the cavernous bodies of the penis in men, the clitoris in women;

gives the sensitivity of the skin of the external genital organs and the anus;

innervates the sphincter of the urethra.

As you can see, this nerve plays an important role not only in the intimate life of a person, but also in urination and defecation. The pudendal nerve contains a large number of autonomic fibers that provide the "unconscious work" of the sphincters. After all, a person never thinks, does not control and deliberately does not squeeze muscles, so as not to accidentally defecate or urinate in broad daylight. This is done by autonomic nerve fibers that enter the lumen of the pudendal nerve.

The pudendal nerve in the male body (yellow)

This nerve can be pinched both by the piriformis muscle, which is located in the pelvic cavity, or be squeezed between the two ligaments.

In addition, the nerve can be damaged, for example, due to a road accident, falls from a great height, in which the pelvic bones are fractured. A fairly common cause of chronic pelvic pain is nerve damage during childbirth, as well as the involvement of the nerve trunk in the growth of a malignant neoplasm.

In addition, activities such as horseback riding or cycling can also lead to compression neuropathy of the pudendal nerve over time.

Symptoms of pudendal neuropathy

What with any neuropathic lesions, all symptoms consist of pain, sensory disturbances, autonomic disorders and muscle weakness. A pinched pudendal nerve is manifested by the following symptoms:

painful sensations in the perineum;

discomfort in the anus and genitals;

burning shade of pain;

decreased skin sensitivity in these areas, "creeping";

an unpleasant sensation of sensation of a foreign body in the urethra and anus;

fecal and urinary incontinence. It may be incomplete, and manifest itself in the form of kalomaziya or drip urinary incontinence;

sexual disorders: impotence, anorgasmia.

Pinched pudendal nerve in women causes the above symptoms also in the lower third of the vagina.

Pinched pudendal nerve in men, in addition to the above, can cause pain during intercourse.

The very nature of the pain becomes burning, touching the skin becomes excruciatingly unpleasant. There is a sensation of electric shock, sensation of either a hot or cold foreign body, problems with urination and defecation, and other various and unpleasant symptoms.

About the diagnosis of neuropathy

With such unpleasant and painful sensations, a person is not inclined to endure for a long time, as, for example, with pain in an arm or leg. Therefore, most often he turns to a neurologist, or a proctologist, in the event that violations of the anal sphincter are expressed and there are problems with the retention of urine and feces.

Less often, the patient turns to a sex therapist, but a competent specialist should, using elementary questioning, identify organic disorders and refer the patient to a specialist. Pudendal neuropathy is diagnosed on the basis of the following complaints and studies;

patient complaints, which were detailed above;

the nature of the pain, which indicates neuropathic changes (burning, crawling "goose bumps", all kinds of itching, trouble when touched);

a trial therapeutic and diagnostic novocaine blockade of this nerve reliably reduces the severity of symptoms, or completely relieves the patient of suffering for the duration of novocaine - from 12 hours to 3 days;

when performing ultrasound of the perineum and small pelvis with Doppler ultrasound, almost always with compression - ischemic neuropathy of the pudendal nerve, there is a decrease in the volumetric blood flow velocity in the adjacent genital artery. This happens "for company": the genital artery passes along with the nerve in the same canals, and its narrowing indirectly confirms the compression of the pudendal nerve;

an important diagnostic criterion is increased pain if a person is sitting and a decrease in pain if a person lies on their back. Also, for neuropathy of the pudendal nerve, unilateral lesion is characteristic. On the same side, frustrations arise;

patients often note that if cold is applied to the perineum, it causes relief, and burning pains decrease. This symptom indicates the neuropathic nature of the nerve damage.

In addition to these diagnostic criteria, palpation of the perineum can reveal characteristic pain points that reflect a spasm in the piriformis muscle.

It is important that the pathology of this nerve has a deep connection with the progression of myofascial syndrome. This syndrome is more difficult to treat because the muscles are deeply located.

In addition, pudendal neuropathy exacerbates depression, anxiety and makes people more susceptible to negative events.

Treating neuropathy

As in all other cases, the therapy for this disease must be comprehensive. The basic principles of treatment are as follows:

impact on the neuropathic nature of pain with gabapentin (Tebantin, Lyrica);

carrying out regular nerve blocks with anesthetics and hormones;

physiotherapeutic effect: phonophoresis, Amplipulse - therapy, electrophoresis;

muscle relaxants of central action (Mydocalm). Allows you to relax muscles, including reducing the tone of the piriformis muscle;

B vitamins, which are part of the blockade, as well as tablet forms.

Sometimes the treatment requires the support of a psychologist, corrective therapy is performed, and antidepressants are prescribed. Sometimes it is required to prescribe rectal or vaginal suppositories with diazepam, as well as perform special exercises. Their meaning lies in gradual relaxation - compression of the muscles of the perineum.

You should find out what exercises you need to do when the pudendal nerve is pinched

In the event that conservative treatment is ineffective, then decompression surgery is performed, which is performed in centers for the treatment of chronic pelvic pain.

It should be remembered that the treatment of pudendal neuropathy is a long process, and all the prescriptions of specialists must be followed for at least 6 months.

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QUESTIONS TO THE DOCTOR

About the site

This site contains information about such a difficult and fairly common disease like neuralgia. All articles on the site are written by qualified and active doctors, neurologists - those who face this disease every day in their practice.

Pinching and neuropathy of the pudendal nerve in women and men

Is the pudendal (genital) nerve and its damage different from similar pathology in other "regions" of the body?

Yes, the nature of the pathology is already different in that the pudendal nerve serves the pudendal area - the genital area, the structure of which is different for men and women. The words of one very concentrated boy from the movie "Kindergarten Policeman" immediately come to mind, with which he stopped everyone who entered the door of the kindergarten: boys have a penis, girls have a vagina.

In men, the concept of external genitalia includes much more structures in terms of quantity, volume, and occupied area, therefore, the pudendal nerve has a more complex and branched structure, while in women, due to the greater "compactness" of the external genitals, its length is much shorter.

The pudendal nerve is a paired structure formed on both sides of the body also by paired branches of the sacral spinal (spinal) nerves, provides innervation to the organs available in both sexes: the perineum, the sphincters of the bladder and rectum, as well as the levator anus muscle, and then begin differences in structure: in women, it provides sensitivity and vegetation of the labia majora and small labia and the clitoris, in men - the same functions in relation to the cavernous bodies of the penis and scrotum.

In the photo, the same painful area in women is highlighted in yellow

About the causes and symptoms of functional disorders

For the etiology of damage, the proximity to the sciatic bone, which the nerve bends around, entering the pelvic cavity, is important, as well as the relatively shallow depth of the terminal branches under the surface of the skin and mucous membranes of the pelvic organs. Therefore, a disorder of functions can occur as a result of:

trauma to the perineal region;

Perineal trauma can lead to more serious consequences.

The provoking factors can be:

horseback riding or cycling (quite frequent or professional);
protracted labor;
fracture of the pelvic bones (when falling from a height, in a car or plane crash).

Disorders of the functions of the organs located in the pelvis allow to understand that something is wrong with the femoral-genital nerve. These can be sensitivity disorders or vegetative disorders.

Deviations in vegetation are expressed by disorders in the functioning of glands and other structures containing smooth muscle fibers, in particular, disorders of the mechanism of blood filling in the cavernous bodies of the penis or clitoris.

Disorders of the trophism of the skin of the perineum, scrotum and perianal zone can also be a sign of disorders.

In addition to physical factors of influence, the cause of pathology can also be general somatic diseases:

tuberculosis;
collagenoses;
disorders of blood supply due to endocrine disorders and vascular catastrophes or for another reason.

Infringement of rights, or about neuralgia

It has long been noticed that those who have been infringed on their rights either loudly scream about this fact, or grumble about it in an undertone, while no one hears.

Provoking factors

The same is the case if the pudendal nerve is pinched in the canal containing it. A canal with a narrowed diameter for some reason (due to bony growths, bone fractures or for another reason) presses on the nerve, which leads to predominantly painful sensations of varying intensity.

Compression of the nerve can result from its "swelling", accompanied by an increase in diameter, which causes it to be inconsistent with the diameter of the enclosing canal.

But the structure of the affected pudendal nerve does not change with neuralgia. Movement disorders do not occur in the same way as loss of sensitivity.

Therefore, neuralgia is exclusively pain of a different nature and intensity.

And an infringement of the pudendal nerve can occur in the inguinal canal:

with varicose veins of the spermatic cord in men;
due to the pathology of the round ligament of the uterus in women;
due to inguinal hernia or scarring after hernia repair.

Pelvic neuralgia, often accompanying pinching of the pudendal nerve, can also occur due to:

childbirth injuries;
muscle spasm in the anal area, hypertonicity of the piriformis muscle or internal obturator muscle;
the development of oncopathology in the pelvic organs;
the onset of complications of herpes.

Features of symptoms

Symptoms of this form of neuralgia are chronic pain in the pelvic region, which have the character:

whining;
burning and itching sensations, especially strong in women and especially in a sitting position;
excessively high sensitivity of the skin of the groin and perineum;
feelings of constant discomfort in the area of the natural openings of the body;
false-obsessive sensation of a foreign body in the genital area.

Against the background of chronic stress from long-term sensations, the following may appear:

disorders of urination (involuntary act) or pain when urinating;
dysfunction of the genitals (pain during coitus);
stool disorders (constipation).

Diagnostic criteria and treatment

For diagnosis, symptoms are important - the patient's sensations, as well as the absence of external manifestations of pathology.

The use of the following helps to identify the disease:

In the first case, a violation of blood flow through the genital artery is revealed, in the second - the disappearance of the phenomena of discomfort after manipulation.

In treatment, the main goals are: pain relief, elimination of inflammation and restoration of nerve conduction.

Therefore, it is advisable to use:

anticonvulsants (gabapentin) that provide pain relief;
muscle relaxants (Mydocalm), used to relax the muscles;
blockade of the pudendal nerve with a combination of anesthetic solutions and hormones;
vitamin complexes (Neuromultivitis class);
physiotherapy techniques (electro-, phonophoresis and the like).

To reduce the symptoms of discomfort, vaginal or rectal suppositories with Diazepam and exercise therapy (to massage the muscles of the perineum) are used.

If the therapeutic methods are ineffective, surgical decompression is used, eliminating infringement and symptoms.

Surgical decompression is sometimes the only option

If there is no limit to indignation, or about neuropathy

In addition to neuralgia, the genital nerve can also become the arena of the inflammatory process, then they talk about neuropathy (neuropathy), or pudendal neuritis (a rarely used term now).

Neuropathy differs from neuralgia in the presence of structural changes in the pudendal nerve, as well as movement disorders and the possibility of loss of sensitivity, which serves as a reason for indignation and grief of the patient, because we are talking neither more nor less about the genitals.

What could be the cause?

The cause of the pathology (also called pudendoneuropathy) is the implementation of two mechanisms:

compression-squeezing of the trunk of the nerve in the "scissors" sacrospinal ligament-piriformis muscle;
traction due to overstretching of the nerve in the zone of its transfer over the sciatic spine.

The first is illustrated by the consequences of long-term or unsuccessful horse riding or cycling (compression with a rigid saddle), and the second - the consequences of surgical intervention - so when traction of the thigh with the use of a perineal fixator, the nerve is pulled against the pubic region.

Features of symptoms

The clinic may consist of lesions of the main nerve trunk or signs of involvement of various branches of the pudendal nerve.

When a surgical fixator is used in the perineal area, an isolated damage to the dorsal nerve of the penis occurs with anesthesia of the penis and a complete breakdown of a previously normal erection.

Full restoration of sensitivity can occur within 6 to 18 months after the operation, while the restoration of an erection can be only partial.

When compressed by a rigid saddle, disorders are felt as transient numbness or the appearance of paresthesias in the genital area.

Both unilateral and bilateral sensory loss can be observed, not delineated by the penis area, but continuing to manifest itself also in the scrotum area.

Neuropathies of the pudendal nerve are able to signal themselves with pain in the lower buttock and in the anus, a short-term delay in urination or a disorder of the imperatives to it, accompanied by sharp pain when palpating in the projection of the sciatic bone.

In men, the inflamed pudendal nerve denotes itself with characteristic symptoms - paresthesia or hypesthesia and pain in the anal region, in the area of the penis and scrotum.

Diagnostics and treatment methods

The main diagnostic criterion is the pulling of the knee to the opposite shoulder causes pain in the buttock (due to the stretching of the sacrospinous ligament).

A simple diagnostic method is to pull the knee up to the shoulder

The clinic is confirmed by electromyography, stating the lengthening of the anal reflex, which is closed on the pudendal nerve trunk, as well as a test blockade with the introduction of a solution of novocaine into the zone of the ischial spine.

The choice of treatment method depends on whether the process is running or is in an acute stage.

So, all symptoms disappeared in a group of cyclists on their own, after the consent of those to refrain from cycling for a month. In the chronic course of neuropathy, long-term restorative therapy is required.

In a chronic course, the methods of medication are applicable in combination with rational exercise therapy and physiotherapy.

Drug therapy includes the use of anti-inflammatory drugs (glucocorticoids Prednisolone, Triamcinolone, Hydrocortisone) in combination with anesthetics (Novocaine 0.5 or 1%) in the form of blockades. A case of pain, noted for 14 years, after a course of perineural administration of Triamcinolone is described.

Blockade is an effective method, the point of injection is indicated with a finger

Pure novocaine blockades are usually less effective.

In order to relieve pain, suppositories of a combined formulation with anesthetics, sedative and antispastic compositions, both rectal and vaginal, are applicable.

Vitamin therapy (the introduction of vitamin C and group B in adequate doses) is especially effective in combination with physiotherapy (various methods of thermal therapy), while exercise therapy allows you to increase the possibilities of muscles spasmodic with pain and helps to raise the general tone of the body.

Surgical intervention is applicable in the absence of the effect of treatment with therapeutic methods.

You should be extremely careful in the case of neuropathy of oncogenic etiology.

Preventive measures

When riding a bicycle or horse professionally, you should take precautions and follow a break-time routine.

The implementation of traction in a hip fracture requires the use of a perineal fixator with an adequate support area (up to 9 cm) with a mandatory softening pad.

Intramuscular administration of a solution of Magnesium sulfate in large doses requires caution to prevent the occurrence of ischemic necrosis of the gluteal muscles.

With the appearance, and even more so - an increase in painful sensations in the pelvis, perineum and genitals, you should immediately seek help from a neuropathologist.

This section was created to take care of those who need a qualified specialist, without disturbing the usual rhythm of their own life.

Pudendal nerve neuropathy

Pudendal neuralgia, Pudendal neuralgia, Pudendal nerve canal syndrome, Alcock's canal syndrome, Pudendal nerve compression syndrome, Tunnel pudendopathy is a fairly common but rarely diagnosed disease.

Symptoms: pain in the perineum, genitals, anus. Like all types of neuropathic pain, this pain is characterized by a burning sensation, tingling sensation, and "goose bumps". A foreign body sensation in the rectum, vagina and / or urethra is quite common. In addition to these symptoms, there may be urinary or fecal incontinence, sexual dysfunctions. The pain is worse while sitting. In women, the symptoms of pudendal neuralgia include pain (burning, itching, tingling) in the clitoris, pubis, vulva, lower 1/3 of the vagina and labia. The skin in these areas can be hypersensitive to touch and pressure (hyperesthesia and allodynia).

Possible symptoms also include burning, numbness, tenderness, electric shock or knife sensation, aching pains, sensation of a lump or foreign body in the vagina or rectum, twisting or constriction feeling, abnormal temperature sensations, hot poker feeling, constipation, pain, and difficulty defecating, difficulty or burning when urinating, pain during intercourse, and sexual dysfunction - loss of sensation in the clitoris and / or anterior third of the vagina.

Diagnostic criteria for pudendal neuropathy:

Pain (burning, itching) in the area of the three branches of the pudendal nerve (clitoris, anus, vaginal vestibule)
The neuropathic nature of the pain (burning, itching, tingling, goosebumps, hypersensitivity or loss of sensation)
The effect of a pudendal nerve block (pain relief at the start)
A decrease in the velocity of blood flow in the genital artery, which is determined during an ultrasound Doppler scan. Since the pudendal artery passes along with the pudendal (pudendal) nerve in the Alcock canal, the processes leading to compression of the pudendal nerve also lead to compression of the pudendal artery.

The pudendal (pudendal) nerve leaves the spinal cord at the level of the 2,3,4th sacral vertebrae (S2-S4), leaves the pelvic cavity through the sciatic foramen magnum, and then returns to the pelvis through the piriform foramen, under the piriformis muscle. The piriformis muscle can cause compression (compression) of the pudendal (pudendal) nerve in myofascial syndrome (piriformis syndrome).

In the pelvic cavity, the pudendal nerve passes through the Alcock canal, where it can also be compressed by the sacrospinal ligament.

That is why the symptoms of pudendal neuropathy appear in the anus, perineum and external genitalia.

Causes of pudendal neuropathy:

Obstetric neuropathy - damage to the pudendal nerve during childbirth, sometimes the obturator nerve suffers with it
Myofascial syndromes - hypertonicity of the piriformis muscle can cause compression of the pudendal nerve in the foramen infrapiriformis. In addition, compression of the pudendal nerve can be caused by a spasm of the internal obturator muscle or the levator ani muscle.
Traumatic neuropathy - caused by a chronic injury (cycling or horse riding) or a fracture of the pelvic bones.
Compression of the pudendal nerve in the Alcock canal

Diagnostics of the neuropathy of the pudendal nerve:

The diagnosis is made on the basis of the so-called diagnostic criteria (Aix-en-Provence diagnostic criteria):

Localization of pain (one or more branches of the pudendal nerve - more often on one side)
The nature of the pain (burning sensation, "goose bumps", tingling sensation, sensation of "electric shock")
Increased pain while sitting
Reducing pain when lying down
Unilateral nature of pain
The positive effects of cold
Injection of anesthetic into the pudendal nerve area reduces pain by 12 or more hours
Ultrasound examination of the Alcock canal with the determination of the blood flow velocity in the genital artery allows one to suspect compression of the pudendal nerve with a decrease in the blood flow velocity in the artery - since they pass together in this canal.

Treatment must be comprehensive:

Drugs affecting neuropathic and chronic pain (Lyrica, Tebantin)
Physiotherapy
Genital nerve block with anesthetics and glucocorticoids
Surgery - Pudendal Nerve Decompression
Neuromodulation

Remember that the duration of treatment is at least 6 months.

In the field of diagnosis and treatment of pudendal neuralgia neuropathy, we work closely with prof. Eric Botran, one of the world's leading specialists in the treatment of chronic pelvic pain, who regularly consults at our clinic. Professor Botran's next visit will take place in December 2014.

In our clinic we use all modern methods of treatment.

We are the only clinic in Russia where pudendal (pudendal) nerve decompression operations are performed.

Please contact us and we will do our best to help you.

Patients from other cities believe that the treatment in our clinic is long and therefore it is difficult for them to come to us! Sometimes this is true, but in most cases one day is enough for diagnosis. The next day, an injection of botulinum toxin, cryoneurolysis of the pudendal nerve, decompression of the pudendal nerve, TVT surgery are performed - in general, the most effective manipulations for the treatment of chronic pelvic pain syndrome and urinary disorders. Patients can continue their treatment at home - under our close supervision via Skype, e-mail, etc. We provide all the necessary medications and (if necessary) devices for home physiotherapy.

Make an appointment by calling 14 17

What exactly is this pathology manifested in?

There can be many options.

Psychologist, Business coach Coach RPT therapist

Who faced pudendal neuropathy?

And who made the diagnosis?

And yes, it will be easier.

How long has this been going on?

Go see a neurologist.

Faced neuropathy of various nerves.

And yes, it will be easier.

What are the objective methods that have been verified?

How long has this been going on?

Is the onset gradual or rapid?

What happened the day before (week, month, 1/2 year)?: Physical and / or psychological trauma?

Psychologist, Group leader

for a long time they could not make a diagnosis.

Psychologist, Group leader

on the eve there was NOT ANYTHING, it came out of nowhere. started about 3 months ago, gradually increasing. for a long time they could not make a diagnosis.

in the same place, viral diseases, and drug treatment and other things can disrupt chemical processes - injure nerve endings. Didn't you get sick with anything? Have not been treated?

Oh! I sympathize. This is really very difficult. I remember the neuropathy of the sciatic nerve after childbirth for the rest of my life. Horror. Due to breastfeeding (and heroic stubbornness), she was not treated with anything. Now I think in vain, but my doctors were somehow passive in this regard - they did not offer anything but anesthetic and rest. Within three months, everything went away completely. But sometimes at a certain position of the body (if I sit for a long time in a certain position, for example) - I feel pain.

But I had traumatic neuropathy. Have you established a physiological cause?

How did you prove ds?

Psychologist, Group leader

Strength to you and support of loved ones!

The diagnosis is made only on the basis of patient complaints

- ultrasound of the pelvic organs;

"Standard examination of patients with CPP includes the following laboratory and instrumental methods:

- laboratory research (including for herpes infection);

- ultrasound of the pelvic organs;

- X-ray examination of the lumbosacral spine and pelvic bones;

- densitometry to exclude osteoporosis;

- X-ray (irrigoscopy) or endoscopic (sigmoidoscopy, colonoscopy, cystoscopy) examination of the gastrointestinal tract and bladder;

HTB is cron. pelvic pain

The pudendal nerve itself is inaccessible to direct palpation

Where was the maximum pain when feeling: in the perineum or in the buttock area?

Guys, who faced this terrible sore? Do you have any experience?

I understand that the site is "psychological", but psychology and psychosomatics are not of interest.

now I'm not going to argue with you

Are there osteopaths in your city?

Psychologist, Kpn individual family

As an explanation: special osteopathic techniques can relieve tension in the pelvic ligaments or piriformis muscle, which most often injure the nerve.

Psychotherapist, Cognitive Behavioral Therapy

such a diagnosis is made only on the basis of the patient's complaints, palpation of this nerve, if cold and blockade help

I have hand neuropathy. For neurological pain, conventional pain relievers do not help. Use gabapentin and antidepressants. It only helped me, and before that 7 years of torment, going to doctors, many hospitals and painkillers.

Treatment is long-term, at least half a year of constant medication. Already 10 years have passed, but attacks sometimes occur after physical exertion, but not so painful and prolonged. Surveys are done. I had an EMG and showed nerve damage.

Neuropathy is nerve damage. There must be genesis, that is, the reason for the defeat.

He himself did not suffer, but there were patients with neuropathy. Depending on the genesis, the duration and success of treatment is different.

In addition to eliminating the main cause and symptomatic therapy (anti-inflammatory, vitamin B12), psychotherapeutic techniques are also used to increase resistance (resistance, tolerance) to pain.

Find a good yoga coach.

Psychotherapist, Gestalt therapist

they have no muscles and, in principle, they cannot strain.

Pay attention to collagen morphology

In addition, it is advisable to remember the purpose of the ligamentous apparatus and the places of its fixation.

The answer may appear by itself (awareness)

As for the usual painkillers, I am aware that this is horror, nothing helps. I am taking the drugs you are talking about. should relieve 50 percent of the pain - but nothing, already at the maximum dosage. Here's an EMG I did not do, no one said (If you still have pain, why is this? Is there something left?

I also took it at the maximum dosage. How long do you take? Nerves, if damaged, recover very slowly, maybe more than one year, depending on the degree.

Why do I sometimes show up for so long: there are organic reasons. We still need to consult, and this is all the money. Free is useless.

What drug are you taking? I took neurohormone and tibantin. Talk about hell. I am taking Velaxin. Outwardly, I did compression from novocaine, orthoferrite and something else.

Firstly, it is contraindicated for me to sit, and secondly, I have little idea of doing yoga in a hospital bed.

Lyrics, it's like Tibantin

All in 1 tbsp. mix the gauze to wet. cellophane and insulation on top for an hour.

I wrote from the phone, so the errors in the previous message.

but on the mucous membrane, I think this is not possible.

Psychologist, Humanistic Psychotherapy

I have no experience, I will not tell you about the case, but I want to support and wish you to find adequate treatment and recover as soon as possible!

exactly. and Lyrica was prescribed by 3 doctors. Tibantin, on the contrary, was fooled. Well, I'll drink it. True, my appetite greatly increases (at first I walked like a drunk, my lips and tongue went numb, but this is nonsense of course. Here the doctor recommends laser therapy for me.

my appetite did not increase. and the side effects were unpleasant, but bearable, I even drove a car with them. They then pass. my dosage was 300 mg 3 times a day. At the expense of the laser, no, they did not say. The first time I hear it. And what does it do?

and who fooled tibantin?

Don't listen to them. I am writing to you as a practitioner)

I had hellish pains, I climbed up the wall, so I understand like no one else.

finding an understanding person is important. Yesterday the doctor told me to "complete treatment", but the center is located in another city, they found one. Can you find out? "Effective laser treatment:

Nivritis, neuralgia (intercostal neuralgia, trigeminal neuralgia, migraine neuralgia, shingles) ", my list is not on the list, since it is a rather rare infection, but they said on the phone that they were being treated. Thioctacid was not prescribed.

Delivers severe pain and interferes with a full life. That is why it is important to recognize the disease in time and start treating it.

In this article, we'll talk about pelvic neuralgia (inflammation of the inguinal, pudendal, pudendal nerve) in men and women, its symptoms, treatment of hip joint pathology.

Pelvic neuralgia is a pinched nerve in the hip joint... In this condition, the nerve is pinched, which is located between the bones, ligaments and tendons, which gives rise to severe pain syndrome.

Sometimes the pain lasts for only a few minutes, and sometimes it lasts for 2-3 days. Pathology develops in both men and women... The danger lies in the fact that other ailments can be disguised under this disease. Therefore, the treatment is carried out incorrectly.

Disease code according to ICD-10: M79.2. Anorectal neuralgia is also referred to as pelvic neuralgia. This is an inflammation of the nerves in the coccyx and anus, as well as in the perineum. The inflammatory process is accompanied by acute pain. Also, a type of pelvic neuralgia is pudendal neuralgia.

Etiology

Pain in the area of the inflamed nerve may decrease and become worse. It all depends on the degree of stress.

Possible causes of pelvic neuralgia:

In women, during pregnancy, the uterus increases in size, because of this, it puts pressure on the sacral plexus, from which the nerve endings come out. Such processes lead to a pinched nerve and the occurrence of severe pain. In some cases, the symptomatology of the disease manifests itself after childbirth - this occurs with an incorrect presentation of the fetus or difficult childbirth (more about neuralgia during pregnancy).

Also, the reasons for the appearance of pelvic neuralgia include excess weight, diabetes mellitus of any type, and in some cases - shingles, if it is localized in the lumbar region. In children, the development of pelvic neuralgia is most often caused by injuries.

Clinical picture

Many people confuse this type of neuralgia with. The symptoms are indeed similar, the difference lies in localization. Pelvic neuralgia is most often caused by pinching of the hip nerve.

This process is characterized by severe pain while walking and running.... Also, the disease is manifested by burning and numbness of the lower extremities. If the external thigh nerve is pinched, then the pain syndrome will be present at rest, even during sleep.

A feature of pain in pelvic neuralgia is the fact that it does not have a specific localization - unpleasant sensations can appear in different places. Sometimes the pain is completely absent, but at the same time there is a burning sensation, numbness of the affected area, as well as restriction of movement.

Symptoms in men

In addition to all of the above signs of the disease, men experience pain during urination and ejaculation, a burning sensation and pain in the urethra, as well as blood spots in the semen. These symptoms are typical for other ailments, therefore, the diagnosis must be carried out especially carefully.

Symptoms in women

Women may confuse signs of pelvic neuralgia with a genital infection, PMS, and dysmenorrhea. The characteristic symptoms of the disease can be considered:

disturbed menstrual cycle;
pathological discharge;
papillomatosis;
infertility.

Signs of anorectal pathology

Additional signs of rectal neuralgia are pain in the anus, pale skin, and increased sweating. Sometimes they are joined by heaviness in the lower abdomen and a burning sensation in the tailbone.

Pudendal

Symptoms of this are constant pain in the pelvic area, which is aching in nature.

Additional signs also appear:

burning sensation, especially when sitting;
increased sensitivity of the skin in the genital area;
sensations of a foreign body in the genitals;
disorders of urination (in some they occur involuntarily, while in others, on the contrary, with acute pain).

Patient complaints

Patients complain of pain in the perineum and coccyx... At the same time, discomfort during walking increases, due to which the gait can change - it becomes shuffling, patients move in small steps.

Diagnostics

Confusing symptoms with "female" and "male" diseases, patients mistakenly go to see a gynecologist or urologist who do not see any abnormalities and cannot make any diagnosis.

It is impossible to wait until the pain goes away by itself, since the unpleasant sensations will only intensify.

Experienced gynecologists and urologists, seeing the picture of the disease, immediately refer their patients to a neurologist. Since the most important symptom is pain, the doctor must study all of its characteristics: duration, nature, frequency, reasons that cause it. After that, the neurologist prescribes additional therapy to determine the inflamed nerve.

The main types of diagnostics are:

radiography;
electroneuromyography;
Doppleography ultrasound.

Treatment

Drug therapy

Medicines are used to relieve pain... Usually a painful attack lasts 2-5 minutes. But because of its intensity, it seems to the patient that its duration is much longer.

If the pain is caused by the pressure of muscle tissue on the nerve endings, then it is advisable to take antispasmodics. NSAIDs - this group of drugs is used to relieve swelling, inflammation and pain relief. The course is short - 3-5 days.

Medicines with a diuretic effect are prescribed to relieve puffiness. Reparants - prescribed to improve and accelerate the recovery of nerve fibers... Even after relieving pain, you need to consult a doctor and find out its cause.

Physiotherapy

Physiotherapy is necessary to warm up the joints and tendons. The following procedures are most often used:

electro- and phonophoresis;
magnesium therapy;
hot baths;
wraps;
splint overlay;
applications.

Massage is a separate item of physiotherapy. It is most often prescribed for. The procedure is aimed at relieving pinching and reducing inflammation.

However, please note that all procedures should be carried out only under the supervision of the attending doctor.

Gymnastics for inflammation of the pudendal (genital) nerve

Exercise aims to improve blood flow in the inflamed area. They start with a regular walk. Often, in the first days of walking, pain can be felt, but you need to overcome it and walk at least 10-15 minutes at a slow pace.

As soon as the patient's condition improves, you need to move on to gymnastics. Basic exercises:

Radical methods

Doctors try to treat the disease in conservative ways. However, in some cases, surgery is necessary, which most often involves destroying the affected nerve or neutralizing pressure on the nerve.

Apply radical methods in the following cases:

lack of positive results after conservative treatment;
rapid progression of the disease;
the presence of severe motor and sensitive contractures;
the appearance of tumors.

Folk recipes

Effective recipes:

Take a medium-sized onion, peel, chop finely and boil in a glass of milk for 5 minutes. Strain the finished broth and drink a glass of milk three times. The course of treatment is seven days.
Take 50 g of thyme and boil it in a glass of water. Cool the broth and soak a gauze bandage in it. Apply to the affected area and insulate. Leave the compress overnight.
Grate 100 g of horseradish on a fine grater, squeeze the juice from it, soak cheesecloth in the juice and reapply to the inflamed area. Insulate and leave for at least 5-6 hours, and preferably overnight.

This method of treatment cannot be independent; it is combined with traditional therapy. Before using any, you need to consult a doctor.

Forecast and prevention

To avoid the recurrence of nerve inflammation, you need to move more, but not overload the body, and also eat as many healthy foods as possible.

You also need to treat infectious diseases in a timely manner and avoid hypothermia, fully rest.

With proper and timely treatment, the prognosis for recovery is favorable. But, if you start the situation, the following complications are possible:

limitation of limb mobility;
degradation of the myelin sheath of the nerve;
pain attacks that cannot be dealt with with the use of painkillers.

At the moment, there is no way to restore the damaged nerve, but it is possible to reduce the manifestation of inflammation and stop the further development of the disease. To do this, you need to contact a doctor at the first sign for qualified help.

A bit of anatomy

they innervate the muscle that lifts the anus;

innervates the anal sphincter;

gives branches to the muscles of the perineum;

innervates the genitals: the cavernous bodies of the penis in men, the clitoris in women;

gives the sensitivity of the skin of the external genital organs and the anus;

innervates the sphincter of the urethra.

The pudendal nerve in the male body (yellow)

This nerve can be pinched both by the piriformis muscle, which is located in the pelvic cavity, or be squeezed between the two ligaments.

In addition, activities such as horseback riding or cycling can also lead to compression neuropathy of the pudendal nerve over time.

Symptoms of pudendal neuropathy

What with any neuropathic lesions, all symptoms consist of pain, sensory disturbances, autonomic disorders and muscle weakness. A pinched pudendal nerve is manifested by the following symptoms:

painful sensations in the perineum;

discomfort in the anus and genitals;

burning shade of pain;

decreased skin sensitivity in these areas, "creeping";

an unpleasant sensation of sensation of a foreign body in the urethra and anus;

fecal and urinary incontinence. It may be incomplete, and manifest itself in the form of kalomaziya or drip urinary incontinence;

sexual disorders: impotence, anorgasmia.

Pinched pudendal nerve in women causes the above symptoms also in the lower third of the vagina.

Pinched pudendal nerve in men, in addition to the above, can cause pain during intercourse.

About the diagnosis of neuropathy

With such unpleasant and painful sensations, a person is not inclined to endure for a long time, as, for example, with pain in an arm or leg. Therefore, most often he turns to, or a proctologist, in the event that violations of the anal sphincter are expressed and there are problems with the retention of urine and feces.

patient complaints, which were detailed above;

the nature of the pain, which indicates neuropathic changes (burning, crawling "goose bumps", all kinds of itching, trouble when touched);

a trial therapeutic and diagnostic novocaine blockade of this nerve reliably reduces the severity of symptoms, or completely relieves the patient of suffering for the duration of novocaine - from 12 hours to 3 days;

when performing ultrasound of the perineum and small pelvis with Doppler ultrasound, almost always with compression - ischemic neuropathy of the pudendal nerve, there is a decrease in the volumetric blood flow velocity in the adjacent genital artery. This happens "for company": the genital artery passes along with the nerve in the same canals, and its narrowing indirectly confirms the compression of the pudendal nerve;

an important diagnostic criterion is increased pain if a person is sitting and a decrease in pain if a person lies on their back. Also, for neuropathy of the pudendal nerve, unilateral lesion is characteristic. On the same side, frustrations arise;

patients often note that if cold is applied to the perineum, it causes relief, and burning pains decrease. This symptom indicates the neuropathic nature of the nerve damage.

In addition to these diagnostic criteria, palpation of the perineum can reveal characteristic pain points that reflect a spasm in the piriformis muscle.

It is important that the pathology of this nerve has a deep connection with the progression of myofascial syndrome. This syndrome is more difficult to treat because the muscles are deeply located.

In addition, pudendal neuropathy exacerbates depression, anxiety and makes people more susceptible to negative events.

Treating neuropathy

As in all other cases, the therapy for this disease must be comprehensive. The basic principles of treatment are as follows:

impact on the neuropathic nature of pain with gabapentin (Tebantin, Lyrica);

carrying out regular nerve blocks with anesthetics and hormones;

physiotherapeutic effect: phonophoresis, Amplipulse - therapy, electrophoresis;

muscle relaxants of central action (Mydocalm). Allows you to relax muscles, including reducing the tone of the piriformis muscle;

B vitamins, which are part of the blockade, as well as tablet forms.

You should find out what exercises you need to do when the pudendal nerve is pinched

In the event that conservative treatment is ineffective, then decompression surgery is performed, which is performed in centers for the treatment of chronic pelvic pain.

It should be remembered that the treatment of pudendal neuropathy is a long process, and all the prescriptions of specialists must be followed for at least 6 months.

Recently, especially in French and Spanish-speaking medical circles, the approach to the pathogenesis, diagnosis and treatment of diseases of the pelvic organs has changed significantly.
First of all, it has become complex or, as they say in Europe, "multimodal", since the pelvic organs are closely interconnected, often have a common efferent and efferent innervation, blood circulation, musculo-ligamentous apparatus. Thus, the defeat of one organ often involves others in the pathological process.
An example is the occurrence of painful bladder syndrome (not interstitial cystitis - these are different things, below will be explained why), in patients with adenomyosis or IBS.
This is due to the phenomenon of the so-called. cross sensitization. Most of the pelvic organs receive sensory and motor innervation through the n.pudendus. In addition, in some cases, these organs are represented in the same or neighboring centers of the brain. This issue will also be discussed in more detail below.
Secondly, the point of view of a decrease in the role of inflammatory diseases in the pathogenesis of chronic pelvic pain syndrome is increasingly prevalent. Currently, the main role, according to French colleagues, is played by myofascial (spastic) syndromes of the pelvic floor muscles and neuropathy of the pudendal nerve, which is informally called the king of perineum - "the king of the perineum." Third, the terminology has changed: more and more often, instead of the term "chronic pelvic pain syndrome", the term "chronic perineal-pelvic pain and dysfunction syndrome" is used.
We hope that at the 1st International Congress on Pelvic Pain and Dysfunction, which will be held in Amsterdam, a common terminology will be adopted.

Within the framework of this article, it is not possible to consider all pain syndromes and dysfunctions of the pelvic organs, therefore, we propose to pay attention to the syndromes of the female pelvic organs that are relevant to practice, that is, to urogynecological syndromes.

Pain syndromes:

painful bladder syndrome;
pudendal neuropathy;
myofascial syndromes.

Disorders of the accumulative and evacuation function of the bladder:

overactive bladder with detrusor hyperactivity;
overactive bladder with increased bladder sensitivity;
and men in tension.

As for the painful bladder syndrome, according to G. Amarenco, this is a condition caused precisely by cross-sensitization of the bladder, due to damage to neighboring organs, for example, the colon (IBS) or the uterus with adenomyosis. In this case, the number of C-fiber receptors also increases, central sensitization occurs - but this is a consequence of a pathological process in another organ. Pathological changes in the lamina propria of the urothelium can cause damage to the umbrella cells, similar to IC - but in this case it will be secondary.

Clinical case

A 38-year-old female patient who has not given birth. She applied for a long-term (3 years) dysuria, pollakiuria, nocturia, pain syndrome localized in the urethra, irradiation to the right lower limb. Were carried out repeated courses of antibiotic therapy for U. urealitycum. Urine cultures are sterile, general urine tests are unchanged. The performed cystoscopy revealed visual signs of leukoplakia in the area of the Lieto triangle.
Pathological examination: no evidence of leukoplakia was found.
The patient underwent TURP of the altered area in the area of the Lieto triangle. After the operation, the condition improved somewhat, but after a month he returned to the situation that preceded the intervention. At the time of examination, filling out the urination diary showed 41 micrations per day, the average urination volume was 37 ml.
The patient was examined together with Professor E. Botran (L'Avancee Perinneal-Pain Clinic, Aixen-Provence).
The examination revealed adenomyosis, increased tone of the right internal obturator muscle, pain at the trigger point m. obturatorius int.

According to the expert opinion of Professor Botran, in this case there is a painful bladder syndrome caused by cross-sensitization due to adenomyosis and aggravated by the myofascial reaction of the right internal obturator muscle. In addition, due to neurogenic inflammation in the lamina propria of the urothelium caused by cross-sensitization, the patient has a urothelium injury.
The pathogenesis of this condition can be as follows. Adenomyosis, like any other condition that causes chronic pain syndrome, leads to a decrease in the pain threshold. This is well demonstrated in a rat experiment called the pressure paw vocalization test.
Its essence is as follows: two groups of rats were taken, in one of them chronic pain syndrome was caused by the introduction of a chemical reagent under the skin of the back, the other group remained intact. A month later, the test was carried out by squeezing the paws of the rats of both groups with a special device. The vocalization threshold was determined, i.e. when the rats started to squeak. So, before the start of the study, the threshold in rats of both groups was the same. But after a month, in the group of rats with chronic pain, vocalization occurred with much weaker pressure on the paw, compared with intact rats. This seems quite logical. Pain is a signal of tissue damage. If the pain has become chronic, it means that the brain has not taken action sufficient to eliminate the cause of the pain. Therefore, it is necessary to lower the pain threshold in order to motivate the central nervous system for more active actions.

The next stage is peripheral sensitization. In the affected organ, the production of nerve growth factor (NGF) increases. This leads to an increase in the number of receptors associated with demyelinated C-fibers. The main role of C-fibers is the transmission of chronic pain impulses. Accordingly, an increase in their number leads to an increase in pain in the affected organ. However, as we have already discussed, the pelvic organs have cross innervation, and in this case, the number of receptors for C-fibers increases not only in the endo- and myometrium, but also in the urothelium.
In addition, this patient was diagnosed with myofascial reaction m. obturatorius int. dext. Muscle contraction is a normal response to pain. However, long-term pain leads to spastic contractions, which, in turn, cause pain due to the accumulation of lactate in the muscle and compression of nerve fibers. As an example, you can give piriformis-syndrome, when m. piriformis causes compression of n. pudendus.

Returning to the examined patient - for the treatment of adenomyosis, she was referred to. In addition, for the purpose of treating painful bladder syndrome, it has been recommended:

katadolon 200 mg - in order to relieve pain and central sensitization;
pregabalin - 75 mg 2 times a day with gradual dose titration - to eliminate peripheral sensitization;
injection of 100 units of botulinum toxin into the right obturator muscle under electromyographic (EMG) control;
intravesical electrophoresis 200 U of botulinum toxin;
intravesical administration of sodium hyaluronate (URO-HYAL) in order to restore the urothelium.

Attention should be paid to the effectiveness, albeit short-term, of the TUR of the Lieto triangle. As you know, the main afferent innervation of the urinary bladder is localized in the area of the Lieto triangle - apparently TUR temporarily disabled the endings of the afferent fibers.

Pudendal neuropathy

The main symptom of pudendal neuropathy is pain in one or more areas innervated by n. pudendus or its branches.
These are the areas of the rectum, anus, urethra, perineum and genitals. One of the typical symptoms is an increase in pain while sitting and progression throughout the day.
The causes of neuropathy are still discussed, but the most famous is the compression of the pudendal nerve in the Alcock's canal.
Other causes are: piriformis-syndrome, damage to the pudendal nerve during childbirth, pelvic trauma, and malignant neoplasms. Therefore, an MRI scan is desirable for any chronic pelvic pain.
The role of the herpes virus is also being actively discussed - indirect evidence is the effectiveness of acyclovir and valacyclovir in some cases of PN.

There are so-called. The Nantes PN criteria, which were developed by J.J. Labat, R. Robert, G. Amarenco. Five main criteria are highlighted:

pain in the area innervated by the pudendal nerve;
predominant pain in the "sitting" position;
pain does not cause sleep disturbance (i.e., does not cause the patient to wake up at night);
pain does not cause serious sensory disturbances;
a pudendal nerve block relieves pain.

Patients generally describe PN pain as neuropathic, i.e. burning, paresthesia. Most often, the pain is localized on one side. The sensation of a foreign body in the rectum is very characteristic.
A few words about anatomy n. pudendus. The pudendal nerve contains both afferent and efferent fibers, which causes sensory and motor disorders of the corresponding organs.
The pudendal nerve enters the pelvis at the S2-S4 level, passes through f. piriformis, then through the Alcock canal and divides into 3 branches.
It is assumed that dysfunction of the pudendal nerve can lead to symptoms of an overactive bladder, predominantly of sensory origin, due to an increase in the number of C-fibers in the bladder, as well as due to cross-sensitization, which we have already mentioned, in organs receiving the same innervation due to convergence of sensory pathways in the small pelvis.
Diagnosis of PN is based on the above Nantes criteria, in addition, it is necessary to palpate the trigger points m. piriformis and m. obturatorius for the diagnosis of myofascial syndromes.
In the diagnosis of compression of the pudendal nerve in the Alcock canal, transvaginal ultrasound with an assessment of blood flow in a. pudenda and v. pudenda, because when the nerve is compressed, these vessels are also compressed and the blood flow velocity on the affected side decreases.

Treatment of pudendal neuropathy

Medication usually includes pregabalin, starting at 75 mg twice daily, titrated up to 600 mg / day. To relax the muscles, use vaginal suppositories with diazepam, injections of local anesthetics with glucocorticoids into the muscles concerned. In case of a positive effect, botulinum toxin is injected under EMG control.
For diagnosis and treatment, a pudendal nerve blockade is used under X-ray or ultrasound control. Usually 5 ml of 0.5% bupivacaine is injected with 80 mg of triamcinolone - 3 injections.
Surgical treatment is carried out only with proven compression of the pudendal nerve that is resistant to drug therapy. Significant improvement is achieved only in 44% of cases. Other authors report 62% effectiveness (E. Botran), 70% (R. Robert).
Indications for decompression of the pudendal nerve, its technique require further discussion and study.

Pelvic myofascial syndromes

Myofascial syndromes or chronic myofascial pain are chronic pain syndromes and dysfunctions caused by chronic spasm of the pelvic ligamentous apparatus.
These syndromes are quite widespread, but they are rarely diagnosed in urological practice. For example, Skootsky S. reports about 30% of patients with chronic pelvic pain who were diagnosed with myofascial syndromes in specialized pain clinics, while Bartoletti R. published data on 5,540 patients with CPPS examined in 28 Italian urological clinics - myofascial syndromes were detected only in 13.8% of cases.
Therefore, it is necessary to more carefully examine patients with chronic cystitis, chronic prostatitis, urethritis, etc. in order to identify neuropathic and myofascial syndromes.

Types of Iofascial Pelvic Syndromes:

levator syndrome;
internal obturator muscle syndrome;
piriformis syndrome;
bulbocavernous syndrome.

Levator syndrome

Localization of pain:

pain in the anorectal region;
pain in the vagina;
pain in hypogastrium;
pollakiuria and imperative urge to miction;
increased pain while sitting.

According to J. Rigaud, this syndrome occurs in 100% of cases in patients with CPPS of both sexes.

Internal obturator muscle syndrome:

feeling of a foreign body in the rectum;
pain in the urethra;
pain in the vulva.

Piriformis syndrome:

back pain;
pain in the perineum;
dyspareunia;
erectile dysfunction;
pain in the buttock and hip joint;
pain during bowel movements.

Bulbocavernosal syndrome:

pain in the perineum;
dyspareunia;
syndrome of sexual arousal without sexual stimulation;
erectile dysfunction;
pain at the base of the penis.

analgesics (katadolon);
gabapentins;
benzodiazepines (if possible, vaginal suppositories);
antidepressants (trazodone);
transcutaneous electrical stimulation (TENS);
injections of anesthetics and glucocorticoids into the involved muscles (naropin 0.5% + diprospan);
injections of botulinum toxin under EMG control (Porta M.A, Grabovskiy C.);
sacral neuromodulation.

Overactive bladder with detrusor hyperactivity

Enough has been written about this type of OAB, and effective methods of diagnosis and treatment have been developed.
The drugs of choice are M-anticholinergics, however, cases of insufficient effectiveness of these drugs are quite common. Perhaps this is due to the combination of OAB with DO and OAB with increased sensitivity of the bladder, which will be discussed below.

Overactive bladder with increased bladder sensitivity

Clinically, this type of OAB (which is sometimes called "OAB without OAB") is manifested by a frequent or even constant sensation of the urge to urinate, but without urgent urges and episodes of urgency, as in women. M-anticholinergics are usually ineffective.

Urodynamic manifestations:

a decrease in the volume of the first sensation of filling the bladder;
decrease in the volume of the first urge to urinate;
decrease in the maximum cystometric capacity;
absence of detrusor hyperactivity and episodes of urinary incontinence;
positive test with cold water;
positive test with lidocaine.

Etiology:

pudendal neuropathy;
myofascial syndromes;
cross-sensitization of the urothelium with adenomyosis, IBS, ad-eksitis;
damage to the GAG-layer of the urothelium.

Pathogenesis

Just as in painful bladder syndrome, there is an increase in the number of C-fibers and receptors affiliated with them. Moreover, sometimes the clinical and urodynamic manifestations of both conditions are identical. Perhaps these are manifestations of the same process, different in severity.
Central sensitization also plays an important role. That is why the use of tibial neuromodulation is effective - the tibial nerve and the pudendal nerve have the same representation in the central nervous system.

pregabalin;
intravesical use of anesthetics, oxybutynin;
intravesical electrophoresis of anesthetics, glucocorticoids, botulinum toxin;
intravesical use of vanilloids (resiniferatoxin, capsaicin);
transcutaneous electrical stimulation (TENS) with electrode placement at the S2-S4 level, (for example, Neurotrack Pelvitone, 10 Hz mode, 200 ms, 30 - 40 minutes per day);
sacral neuromodulation;
tibial neuromodulation;
treatment of pudendal neuropathy and myofascial syndromes;
laser or electroablation of the Lieto triangle (A.I. Neimark, V. Gomberg);
hydro-stimulation of the bladder.

Stress Incontinence (Stress Incontinence)

Pathology deserves consideration in a separate article, so we will only touch on its relationship with pelvic dysfunctions and pain syndromes.
We are talking about the complications of implantation of synthetic slings by transobturator access. Quite often (2-8%) after this procedure, pain syndrome occurs, associated with the placement and persistence of the implant in the obturator muscle, with compression of the branches of the obturator nerve and the occurrence of myofascial obturator syndrome. Sometimes, in addition to pain, symptoms of OAB occur, which are very difficult to stop.

A possible solution to the problem seems to be the use of new types of slings:

mini-slings of the new generation (“JUST-SWING”) - they are fixed with a titanium anchor in the obturator membrane, without involving the muscle;
biodegradable mini-slings (for example, a matrix of polylactic acid obtained by electrospinning technology), impregnated with fibroblast growth factors.

For the treatment of pain syndromes after TVT-O surgery, it is possible to inject mixtures of anesthetics and glucocorticoids into the obturator muscle. If ineffective, removal of the implant.

Conclusion

The diagnosis and treatment of pelvic pain syndromes and dysfunctions seems to be a very relevant and promising area in urology. The active introduction of a modern approach to the tactics of managing patients with such syndromes will improve the quality of medical care and reduce the cost of treatment.
You should also consider the possibility of organizing specialized offices or departments within the leading urological treatment institutions.

I.A. Apolikhin, Ya.B. Mirkin, D.A. Bedretdinova, I.A. Eisenach, O. Yu. Malinina.
Scientific Center for Obstetrics and Perinatology. Academician V.I. Kulakova, Research Institute of Urology, Ministry of Health and Social Development of the Russian Federation, Moscow, NMTC International, New Medical Technologies LLC.

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