confused about what to do with mri results/scar tissue?

[meg1155]

I recently had the 3 Tesla MRI done and I am posting it to get some assistance in deciphering it and what to do about it. I appreciate any feedback. Thank you.


MRI of the Pelvis

MRI of the pelvis was performed utilizing coronal and oblique axial inversion recovery, followed by coronal, sagittal axial oblique axial fast spin echo techniques. Clinical concern is pudendal nerve entrapment and the patient reports right and left sided vulvar pain, left anal pain and suprapubic discomfort, but denies clitoral or vaginal pain.

There is anterior angulation of the coccyx, which is minimally deviated to the right. The anococcygeal ligament appear symmetric as is the coccygeous muscle. The sacrospinous and sacrotuberous ligaments appear symmetric and there is no scar entrapment of the pudendal nerves adjacent to the ligaments. Hamstring tendinosis is seen without ischial bursitis. The pudendal nerves in the posterior margin of Alcock’s canal appear unremarkable. There is scar on the left surrounding the superficial perineal muscles at the vestibule, extending to the lateral side wall of the Alcock’s canal and abutting some of the anterior inferior perineal branches of the pudendal nerves that extend to the anterior margin of the anus. This is noted on series 6, images 17 through 21. This is also present but to a much lesser extent on the right. The posterior inferior perineal branches appear unremarkable. The levator ani muscles appear symmetric. The obturator internus muscles also appear unremarkable. The obturator nerves throughout the obturator canals appear symmetiric. There is some resorption of the inferior margin of the pubic symphysis, with a projection of bone off the posterior margin of the right pubis, seen on series 6 images 38 and 39, abutting small branch vessels but not directly abutting the dorsal nerve to the clitoris. Dorsal nerves to the clitoris appear fairly symmetric. No pelvic adenopathy is seen. There is some prominence of the pericervical venous plexus but without features to suggest marked pelvic venous congestion syndrome. Varices do extend into the anteroinferior margin of Alcock’s canal, more prominent on the right than the left.

There is no occult fracture or osteonecrosis. There is thickening of the greater trochanteric bursae but no bulky bursitis. Images obtained anteriorly demonstrate no appreciable scarring around the genital branches of the genitofemoral or the ilioinguinal nerves.

No regional adenopathy is seen. Small foci of diminished signal intensity are seen in the uterus compatible with small degenerative leiomyomata.

Impression
MRI of the pelvis demonstrates scarring of the pelvic floor localized around the superficial perineal muscles, extending to the left lateral margin of Alcock's canal adjacent to the pudendal nerve, as well as around the anterior inferior perineal branches to the anus. There are slightly prominent veins in the Alcock's canal inferiorly without evidence of extensive pelvic venous congestion syndrome. The nerves more posteriorly adjacent to the sacrotuberous ligaments appear unremarkable.

[Violet M]

Meg, that's the $6 million question around here. I wish there was an easy answer but there isn't. It can be removed surgically but surgery in itself can cause additional scar tissue. Were you able to speak with the doctor who read the report so they could elaborate more on what they mean by scarring of the pelvic floor as opposed to nerves being entrapped by scar tissue?

[meg1155]

She sent me a reply but I am still confused! She said to try a nerve block? What causes scar tissue, I thought it was from injections? I don't want even more injections!! Based on my report, I don't think that my pudendal nerve is entrapped?

[AliPasha1]

Hi Meg,
What are your exact symptoms.You have some issues at the Alcock's Canal as well at the rectal branch of the Pudendal Nerve.

I am not in favor of PN blocks myself,but a PN block at the Alcock's Canal isn't a bad idea.It's a tough decision.Where are you exactly located.

Kind Regards,
Ali

[Charlie]

She sent me a reply but I am still confused! She said to try a nerve block? What causes scar tissue, I thought it was from injections? I don't want even more injections!! Based on my report, I don't think that my pudendal nerve is entrapped?

Firstly while the 3T is a very interesting development I don't think you should base your decisions solely on it. I think it is fantastic that people have publicized the scan on forums but we need to remember that there are no studies as of yet that can prove that this is a useful diagnostic tool. That is not to say it is not worthwhile but I would be weary making plans based soley on it.

Also you ask a really good question Meg

What causes scar tissue?

I want to know the answer to this question as well.

When this scan sees scar tissue I am not too sure what it is seeing? Why would there be scar tissue on a nerve? When I ask this I am not saying the 3T is wrong I just genuinely don't know why there would be scar tissue on a nerve. If you have had previous surgery there I can understand why there might be some scar tissue but if you have not why would there be scar tissue there? I don't see how a nerve block is going to create scar tissue. The body can withstand a needle.

I thought PNE was caused by a compression of the nerve. This compression could be caused by muscle ,the ligaments or by a narrow alcocks canal sometimes caused by the obturater internus becoming fibrotic. The nerve is compressed and then it starts firing pain signals. For instance there is this diagram used at a conferance last year. It does not say anything about scar tissue



Perhaps when the nerve is compressed scar tissue starts to develop? I am not trying to be argumentative asking this question I genuinely want to know the answer. If someone has the explanation of why there is scar tissue on a nerve it would be great if they could post it up. I have already asked my Dr and he does not know why there is scar tissue on the nerve.

[AliPasha1]

Hi Charlie,
The scar with the passage of time becomes scelorsis(hardening of the tissue) around the nerve which in time restricts the movement of the nerve thus causing pressure and eventually damage to the mylim sheath or even the axons to that extent.The scarring could be into the narrowing of the ligaments or the Alcock's Canal or the dorsal nerve.

I believe that you are a patient of Dr. Filler.Did you have the 1.5 Tesla MRN with him?Did he actually show you the PN and the muslces around it.Dr. Potter will actually show the scarring of the tissues or the entrapment of the Pudendal Nerve.Imagine,that about a year ago,no one could even see the PN along it's whole path or the pathology around it.And don't forget that we have had two or three surgical confirmations from Dr. Potter's MRI.Although,I would agree that the data sample is small when it comes to surgical verifications, but it is proving to be better than any diagnostoc tool before.
And again remember it is symptoms which are important and they have to correlate with the MRI findings.Secondly,if Dr. Potter MRI's were not there,we would have never found that the dorsal nerve entrapment or any of it branches can be entrapped other than the PN itself.I guess it has opened "Pandaro's box",because it amazing that none of the PNE surgeons ever paid any attention the respective branches.To be frank the pain can be referred from the branches itself if they are entrapped in scar issure or have some sort of pathology.
That's why the PNE surgery have had such poor results because not all the points of entrapment were explored.Sometimes you have to think outside the box to solve the Enigma.

As far as the studies are concerned,Dr. Hibner is going to publish the findings with Dr. Potter in the coming months.

Regards,
Ali

[HerMajesty]

I think most females have "battle scars" in their pelvis. Unlike males our pelvic cavity is an open system. The cervix opens into the uterus which open into the fallopian tubes which open directly into the body cavity. This is why it is possible to get endometriosis, pelvis inflammatory disease (often secondary to an undiagnosed STD...gonorrhea and chlamydia can remain asymptomatic and cause significant scarring / adhesions without being detected), and even extrauterine pregnancy. We also give birth and are more likely to have invasive pelvic procedures such as D&C, C-section, or hysterectomy.
My concern about the results is that until a (competent) Physician interprets them, all you know is that there is some scar tissue within your pelvis, which I am willing to bet is very common in asymptomatic females as well. As a non-physician, I can't figure out from the report if Dr. Potter is implying the nerve is encased or entrapped in scar tissue, or just that some scar tissue exists somewhere within the pelvis. I think there's quite a big difference.

[Charlie]

Thanks for that Ali. Muscles start to become tight in response to an entrapment so it makes sense that the tissue can also start to constrict as well.

Yes I have had the MRN but I am not convinced by it. Other Drs I have seen do not regard it very highly.

My concern with the 3T is whether or not it really changes the surgery? Does Dr Hibner change his surgery based on it's findings? If he does the surgery as he always does is it worth it?

I guess if it shows you have a dorsal entrapment then you know that you need to address that.

[AliPasha1]

Charlie,
I believe Dr. Hibner should change the surgical protocol.e.g If you are only entrapped in the Alcock's Canal and there is no pathology in the ligament grip or the ischial spine,why need to play with the SS/ST ligaments.I guess
then TIR surgry with Dr. Bautrant would be a better bet.

Regards,
Ali

[helenlegs 11]

Also you ask a really good question Meg

What causes scar tissue?

I want to know the answer to this question
If you have had previous surgery there I can understand why there might be some scar tissue but if you have not why would there be scar tissue there? I don't see how a nerve block is going to create scar tissue. The body can withstand a needle.

I am glad you mentioned that a nerve block isn't going to create scar tissue Charlie. I can't see how this could be possible although flares have been reported from them so I wouldn't worry too much about a block, although you said you have already had injections Meg, what were they for?
I'm sure my symptoms are partially due to scar tissue due to a fall and subsequent egg shaped lump in my buttock which was explained as a haematoma or rupture. Of course HerMajesty's point about childbirth etc is very relevant.
What do you think your worsening of symptoms post injection might be due to Ali?
Helen