Publication Abstract - A Must Read!

[nyt]

I am going to play devil's advocate for a minute. I looked very closely at the images posted, I am assuming from the paper because I have not gotten a copy of the paper. Yes, this is connective tissue but it is not scar tissue. This is like the connective tissue you peel away when you purchase ribs or a whole tenderloin that you cut up yourself for steaks. Our bodies are full of connective tissue. They do not even use the word scar tissue in their figure legend and they use the words "appears fixed" they do not definitively state that is fixed. Before I went out on disability I had performed hundreds of surgeries on animals. I have operated on animals that had prior surgeries and I know what scar tissue looks like compared to connective tissue. This is not scar tissue. I can tell you from personal experience it is a difficult to carefully dissect muscle and nerves from scar tissue but not connective tissue. Maybe what they should be saying is that because of the connective tissue it makes this region more likely to form scar tissue when injured. If you look at an earlier post of mine in this thread I gave some links and discussed scar tissue and connective tissue.

[cpps-admin]

The problem that needs to be addressed is that the PNE surgeons have not yet acknowledged that adhesions of the pudendal nerve are normal. For instance, here is Filler claiming adhesions are pathological:

The term “entrapment” is used to convey any number of problems occurring at a particular point along a nerve, according to Dr. Filler. “The nerve becomes irritated—pinched, squeezed, narrowed, or stuck on something, a condition called an adhesion.” Nerves may slide freely between soft, fatty tissues along most of their course but become pinched or squeezed through tight spots, according to Dr. Filler. Swelling can occur in these areas, increasing compression of the nerve.

This is clearly wrong, and calls the whole field of PNE surgery into doubt.

[nyt]

I think some of the problem is understanding what the medical term for adhesions means: "Adhesions are fibrous bands of scar tissue that form between internal organs and tissues, joining them together abnormally." http://medical-dictionary.thefreedictio ... /Adhesions

That is the medical term Dr. Filler is referring to, not normal connective tissue. In the images those are NOT fibrous bands of scar tissues it is normal connective tissue.

[cpps-admin]

Then why is Filler saying that the nerve should slide freely, and if it does not, it's pathological? It just does not add up.

What you're saying sounds like the last refuge of the true believer, nyt. The credo goes like this:

If you have pelvic pain, then the pudendal nerve is attached and not sliding freely and must be freed by surgery

Then, when it is shown by new research that all pudendal nerves are "stuck on something" (attached) and do not slide freely, the mantra becomes:

If you have pelvic pain, then the pudendal nerve is most probably attached not by normal connective tissue but by fibrotic connective tissue (scar tissue) and even though it never slides freely, it must be freed by surgery

You're going further and further out on a limb.

A good start would be to get the PNE surgeons to agree that the nerve is always attached or "entrapped", and then get them to show that the attachments are fibrotic in PNE patients (since that is speculation at this stage).

[nyt]

cpps-admin, you have drawn conclusions that I have not stated. Unless I misunderstand part of our conversation it seems to me that you believe adhesions and connective tissues are the same thing and behave the same way in the body. I'm trying to make the point that even though scar tissue, which are adhesions, are derived from some of the cells of connective tissue do not behave in the same manner inside the body. Adhesions are thick bands of fibrotic tissue and connective tissue is a fine smooth sheath.

Our muscles our covered in connective tissue yet they are able to contract and relax and move freely. In cadaver research you absolutely CANNOT tell if a nerve is sliding freely or not.

At this point, cpps-admin, I think we must agree to disagree. I believe this paper raises important considerations for patients and physicians. If I didn't think this was an important subject I never would have put the abstract up on this forum. However, I do not believe this paper proofs that the pudendal nerve is entrapped and unable to move freely. The authors raise this possibility but they have absolutely NO proof.

[cpps-admin]

cpps-admin, you have drawn conclusions that I have not stated. Unless I misunderstand part of our conversation it seems to me that you believe adhesions and connective tissues are the same thing and behave the same way in the body. I'm trying to make the point that even though scar tissue, which are adhesions, are derived from some of the cells of connective tissue do not behave in the same manner inside the body. Adhesions are thick bands of fibrotic tissue and connective tissue is a fine smooth sheath.

Adhesions are connective tissue. "Adhesions are made up of blood vessels and fibroblasts—connective tissue cells" (Medical Dictionary).

Surgeons mostly talk about adhesions when they occur in places they should not, e.g. between abdominal organs. I'm a hunter and I've slaughtered many animals. The organs inside the abdominal cavity move freely in relation to one another. They "slosh around" in a soup, as it were. The word "adhesion" is most commonly used when such an organ becomes fixed to an adjacent structure. Adhesions may be thought of as internal scar tissue that connects tissues not normally connected.
https://www.youtube.com/watch?v=LVP6JngpgEE

Well known areas of adhesion are the shoulder (frozen shoulder), abdominal adhesions (or intra-abdominal adhesions, most commonly caused by abdominal surgical procedures), pelvic adhesions (a form of abdominal adhesions in the pelvis, typically in women affecting reproductive organs — endometriosis and pelvic inflammatory disease are typical causes), pericardial adhesions (forming after cardiac surgery between the heart and the sternum), peridural adhesions (may occur after spinal surgery), and peritendinous adhesions (occurring around tendons after hand surgery).

I have yet to see the word adhesions applied to structures that are closely bound by connective tissue, such as the pudendal nerve and the sacrospinous ligament.

Our muscles our covered in connective tissue yet they are able to contract and relax and move freely.

Quite so, but the muscles are not connected to each other along their lengths by connective tissue, for if they were we would not be able to move!

See how muscles are not adhered to each other:
https://youtu.be/qiRT_LJ9c3U?t=11m12s

In cadaver research you absolutely CANNOT tell if a nerve is sliding freely or not.

Er, why not? If you dissect out a nerve and find it attached at certain points, in all cadavers, you can safely say that the situation is not pathological.

I do not believe this paper proofs that the pudendal nerve is entrapped and unable to move freely. The authors raise this possibility but they have absolutely NO proof.

The paper does prove that the nerve is attached to the SSL by connective tissue, and therefore obviously cannot slide around freely. I don't know what you mean by "no proof". Reminds me of the old joke: "Who are you going to believe, Dr Filler or your lying eyes?"

[Violet M]

Do we know the lifestyle of the 13 cadavers who were used in this study? I was fine until I started exercising heavily so I think that the amount of movement/repetitive motion may be partly what caused an injury to the nerve. If I had lived a sedentary lifestyle I might have been fine. So just because they found 13 cadavers with the nerve attached to the SSL doesn't prove anything to me. I might have lived 40 plus years with the SSL attached to the ligament but it wasn't until I started an intense weightlifting program that I ran into problems. Often there is something that triggers the symptoms of PNE.

Violet

[sage721]

So Violet,

All the weightlifters, football players, etc or a whole lot of them should have PNE according to your logic. However, it is almost unheard of. I doubt you have done more intense exercise then these olympians, professional athletes, etc...

[Violet M]

So Violet,

All the weightlifters, football players, etc or a whole lot of them should have PNE according to your logic. However, it is almost unheard of. I doubt you have done more intense exercise then these olympians, professional athletes, etc...

Totally agree with you Sage except that exercise isn't the only variable. For most people with PNE, there seems to be more than one factor involved.

I believe (and so does Dr. Bautrant) that there can be a genetic component that causes some people to get PNE, which makes sense in my case because it does run in my family. I might have had a musculoskeletal predisposition to PNE that was triggered by exercise but that doesn't mean everyone has a musculoskeletal predisposition. Some people can exercise and they are just fine. I was told by my gyn that I most likely have a genetic collagen deficiency because I have other ligament problems including pelvic instability.

Other people may not necessarily have a musculoskeletal predisposition but they might have an accident or pelvic surgery that triggers PNE. But just because one person develops PNE due to a pelvic surgery or an accident, doesn't mean everyone is going to. Just because one athlete develops PNE doesn't mean everyone who exercises is going to. People develop different diseases for different reasons. We all have different risk factors, body builds, and genetics, etc. Just because those 13 cadavers didn't have symptoms of PNE, doesn't mean there would never be a cadaver who did have symptoms of PNE during their lifetime. Having the nerve attached to the SSL isn't the only possible variable.

Violet

[cpps-admin]

Sigh. Violet, now it's a collagen disorder, or a "belief" in a genetic component (no proof required!), or a predisposition "triggered by exercise" (again no proof but hey, sounds plausible, right?).

And now nerve attachment —long the key finding to justify a PNE diagnosis, the gold standard— is discarded as "not the only possible variable". In other words, that didn't pan out so drop it and find another justification.

So out with the old reasoning, and in with the new, only this time there is no attempt to provide proof. Now it's right in your face claims of unprovable (or disprovable) conditions, like genetic predispositions.

This is a classic case of denial and of rationalizing away findings that show the whole PNE diagnosis is deeply suspect.

May I humbly suggest that the management of this site should seriously consider closing down this forum, given than many people have already had major surgeries, usually unsuccessfully, on the strength of some of the clearly false (in hindsight) claims made here about nerve entrapment and attachment?

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