Health Organization for Pudendal Education

Dear Dr. Jason, what are your thoughts on trans vaginal nerve blocks? I went to see an obgyn at Emory in ATL. He is familiar with Pudendal Neuralgia enough to know what it is but doesnt have patients with it Hes done many of the vaginal blocks on pregnant women and wants to do it on me bc its the same method. Im very hesitant about this. Im concerned doing it trans vaginally will cause more vaginal or woesening vaginal issues,along with my many other issues. He has admitted to me thar tgere is no risk (which we know is not true) and it can possiblty rewire and stop the problem.

Dr. Attaman,
Thank you so much for your clear explanation of the ultrasound guided bilateral nerve block.

I think many on this forum are leery of nerve blocks because there are reports on this forum of lack of improvement or even worsening of symptoms.
It is very hard for many of us to justify proceeding with nerve blocks with the possible cost of increased pain. Would you be willing to share how often you feel patients have received improvement in pain from pudendal nerve blocks (past the initial anesthetic stage)? Or is it really viewed only as a diagnostic?

Also, considering that steroids have been used in many areas of the body for resolution of pain, do you have opinions on why pudendal nerve blocks in particular could cause increased pain?

Thank you,
solarmom

Hello Dr. Attaman!

I have been off the forum for some time, and it's nice to know we on the West Coast have a "new", knowledgeable doctor to try. My wife has family in your area and has been trying to get me up there.

I was struck when I read "I do every form of pain injection there is, and pudendal nerve blocks with ultrasound were some of the most challenging for the first hundred or so."

PNE being a fairly uncommon diagnosis, the fact that you have done over 100 of them blows me away. You look like a fairly young man - but then everyone looks young to me these days.

I fall into this category: "If a patient gets great anesthetic phase pain relief, but no or poor steroid phase relief, that is also good, because we can then determine that the problem is indeed the pudendal nerve! Typically I will try the injection at least one more time and if similar results, may need to try more advanced procedures or treatments to get long term relief in this case."

I am about to have my fourth pudendal block, all at the ischial spine. The first one failed, costing me a testicle. The second worked, but for only 2 hours. The third also failed. These were all from different doctors. I am returning to the second doctor for a repeat block soon.

If your second block works on a patient, then what do you recommend be done once you know it's the PN?

Also, I have read there is a second location where a block can be tried. I believe at the Alcock Canal. How is that block performed and what might be learned by trying that after a successful block at the ischial spine?

The second block also helped, but I wish I hadn't used sedation so I was more aware of the effect. Not ready to have Hibner cut my buttock open. What else can be done?

Steroids were also injected, but that had no effect last time, so I am not optimistic.

Jon,

Have you thought about pulsed radio frequency ablation of the PN? It seems about half the people who try it get good pain reduction for 6 months or so after, then the procedure needs to be redone. It is done similar to a nerve block. There are several doctors in the U.S. doing the procedure, I believe Dr. Attaman may do it on the west coast but if you live other places there are others too. I know of one in Maryland, Massachusetts, and I believe one in Denver, CO.

Sincerely,
Stephanies

Thank you for the suggestion! Always open to trying ANYTHING that might help. I'm up to 9 surgeries and countless blocks of every kind - flying all over the country trying to get my life back!

How would ablation work on the PN? Ablation is used to destroy tissue. I've have the perineal branch cut already but was told the PN itself is too large to cut, and that it would cause urinary and fecal incontinence.

Still hoping that Dr. Attaman also responds to my post.

I have not had PRF, but I believe that it destroys the myelin sheath of the nerve (not the nerve itself) which interrupts the pain signals. Again, it does not work for everyone but some do very well with the treatment. You can search for PRF on here and read some of the experiences others have had with it or even use Google to search pudendal nerve and PRF. If you are thinking of seeing Dr. Attaman in Seattle, you could call his office and confirm he does the procedure and get more information. I know it is done on the east coast in a couple places and maybe Dr. Hibner in AZ as well.

stephanies wrote:I have not had PRF, but I believe that it destroys the myelin sheath of the nerve (not the nerve itself) which interrupts the pain signals. Again, it does not work for everyone but some do very well with the treatment. You can search for PRF on here and read some of the experiences others have had with it or even use Google to search pudendal nerve and PRF. If you are thinking of seeing Dr. Attaman in Seattle, you could call his office and confirm he does the procedure and get more information. I know it is done on the east coast in a couple places and maybe Dr. Hibner in AZ as well.

I do indeed perform Pulsed Radiofrequency Treatment (PRF) of all peripheral nerves in the body, including the pudendal nerve. To clarify, pulsed radiofrequency treatment does NOT destroy any important part of the nerve, other than a few cell layers that is not clinically significant (in other words, the few cells that are destroyed are microscopic and have no effect on the nerve itself). One can pulse the pudendal nerve anywhere along its course, or pulse it at its origin at the S2-S4 dorsal root ganglia.

In contrast, continuous or "thermal" radiofrequency ablation does indeed destroy the nerve.