Health Organization for Pudendal Education

Hi Everyone,

Some background, 47M and for the past 2 years I been trying to solve my pelvic pain issue but with very limited result. Had the usual route of rectal specialist, Urologist and Pelvic PT (she release me after 6mo and I just do self care). The PT did helped in some way but didn’t completely solve the issue.

The pain and problem I have is only at one location, it is on the right side 2” deep of my rectum canal with burning pain feeling 24/7. Sleeping is a challenge every night. Pelvic MRI did catch the problem with finding of:

1. Levator ani muscle appears within normal limits by MRI.
2. Evaluation of the prostate is limited on nondedicated study. Right peripheral zone wedge-shaped intermediate T2 signal intensity with asymmetric enhancement suggest focal prostatitis. Request clinical correlation on the whereabouts of patient's pain.

Then I had follow up MRI just on the prostate with result of:
Wedge-shaped area of mild restricted diffusion in the right posteromedial and posterolateral aspect of the peripheral zone at the level of the apex. Area of restricted diffusion corresponds with mild region of T2 hypointensity, as noted on the previous examination from 1/12/2024. On the T2-weighted coronal and sagittal images, this area demonstrates a somewhat linear/striated pattern.
On axial imaging, the area of restricted diffusion, with mild hypointensity on the ADC map, is 1.3 x 1.3 cm. On the sagittal images, the area of mild T2 hypointensity is approximately 1.6 cm.
There is mild volume loss of the right peripheral zone relative to the left.
On the postcontrast images, there is corresponding dynamic contrast enhancement.

Basically there is some kind of inflammation between the right side of rectum to the edge of prostate so I was referred to Urologist. Did two rounds of antibiotics but nothing really helps and at the same time I when back to my Pelvic floor PT. She did the internal work then immediately diagnostic me of:
Pudendal nerve that is being affected and that the obturator internus muscle is tight and putting increased pressure on the nerve as it passes through the Alcock's canal. The pudendal nerve has three branches which can all be involved to some extent (perineal nerve, dorsal nerve to the penis, and inferior rectal nerve). 

My Urologist also agree with the finding and concluded there is nothing wrong with my prostate and I need to work with Pain Management and PT to hopefully resolve the issue.

Basically my problem location is obvious as it was show clearly on the MRI. The problem is just finding the most effective treatment.

For pain currently I’m taking Amitriptyline 20mg before bed with ibuprofen during day time. Still I can’t really sit or drive since the pain is just bad. Currently waiting for appointment with Pain Management specialize. Right out of the gate I’m thinking I will request for Nerve Block but not sure if that would be a good idea to start with. However, I think the physician usually will start with conservative approach like maybe increase the Amt dosage and/or add other medication. Want to reach out and seek for any advice or recommendation regarding the next best steps. Appreciate for the help.

Thanks,

Alex

Hi Alex,

Welcome to the forum.

You could continue to try lifestyle changes and more PT, but it sounds like you have already been doing that for awhile. Increasing your pain meds could be a possible strategy but it's not fixing the underlying cause of the problem.

It's always hard to know whether to go to the next step and get a nerve block since there is a slight risk with them. I see nerve blocks as primarily valuable for diagnostic purposes because I don't know of very many people who had long-term improvement from them. But if there is any chance that you might have a nerve entrapment, it is one of the steps you would need to go through. You could read the Nantes Criteria article to see if that is a possibility: https://www.pudendalhope.info/wp-conten ... iteria.pdf
If you think you might have a nerve entrapment, then you have to consider the possibility of increased damage to the nerve over time if it's not treated/released.

My understanding is that some of the US doctors don't rely very heavily on MRI results for a diagnosis because they aren't entirely accurate at determining whether you have a nerve entrapment or not. For me, they were not accurate for determining an entrapment.

If your symptoms are severe, you may want to pursue more aggressive treatments, but if your symptoms are mild and getting better, then it might make sense to just wait and see and manage the pain. It's always difficult to make that decision.

Violet

Hi Violet,

Thank you for the reply, I understand MRI is mainly just for base reference and specialize usually wants to determine best course of action by combining clinical review and trial data with imaging. I’m thinking next step might be getting my medication to contorl the pain better first and do an MRN to have more detail at the problem site. Hopefully that will provide more insight on the situation for best course of action.

Alex

Hi Alex,

I hope that strategy works well for you. Amitriptyline can have side effects so make sure you are aware of them if you are increasing the dose. Of course, pretty much any drug has some side effects, unfortunately, so hopefully that will be a temporary solution for you, and you will be able to correct the underlying cause of the pain.

Violet