Health Organization for Pudendal Education

09/13/10:
Clinical concern is severe pelvic pain. The patient history status post hysterectomy. Clinical concern is directed towards the pudendal, ilioingual and obturator nerves.
There is no angulation of the coccyx in the oblique axial or sagittal planes. There is no impingement on the branch of the pudendal nerve to the rectum. The pudendal nerves at the sacrotuberous ligaments are unremarkable. The posterior margin of the alcock's canal is unremarkable. In the anterior margin of alcock's canal, there is pelvic floor scarring extending to the perivaginal fat planes. There is focal scar encasement of both pudendal nerves, left greater than right. Scar does extend to the posterior margin of the pubic symphis. There is scar surrounding both dorsal nerves to the clitoris. The fat planes around the rectum are preserved. There are no fluid collections or inflammatory soft tissue masses. There is no regional adenopathy. There is no occult fracture or osteonecrosis. Disc degeneration is noted in the lower lumbar spine. Hamstring origins are symmetric.
Signal characteristics and fat planes around the obturator nerves are preserved bilaterally. There is mild adductor tendinosis without tear. The fat planes around the ilioingual nerves are intact bilaterally.
Impression:
MRI of the pelvis demonstrates pelvic floor scarring of the surrounding perivaginal fat planes, entrapping both the anterior and distal branches of the pudendal nerves, as well as
the dorsal nerves, bilaterally, left greater than right. No posterior scar entrapment is seen and there is no impingement on the pudendal nerve at the level of the coccyx.

Hi,
Following is my report from Dr. Potter.
MRI of the pelvis was performed utilizing coronal fast inversion
recovery followed by coronal, sagittal, axial and oblique axial fast
spin echo techniques. Specific concern is pudendal nerve entrapment.
The patient reports both motor and sensory symptoms and is status post
left pudendal nerve decompression 02/19/2010, as well as treatment for
anal fistula in 2005. The patient has also undergone bilateral hernia
repair. Specific concern is entrapment in the Alcock's canal or at the
sacrotuberous ligament.
There is mild anterior deviation of the coccyx. Oblique and axial
images demonstrate that the coccyx is minimally deviated towards the
left but there is no coccygeal entrapment of the branch of the pudendal nerve to the rectum. The presacral and precoccygeal fat planes are maintained.
At the posterior margin of the pelvis, there is asymmetry of the
sacrotuberous ligaments. Moderate intermediate signal intensity scar tissue is seen to form at the posteromedial border of the left sacrotuberous ligament, seen to best advantage on series 7, images 26 through 38. Note is made of preservation of the fat planes around the right sacrotuberous ligament. This scar formation around the left ligament does focally encase a portion of the left pudendal nerve at the posterior margin of Alcock's canal. More anteroinferiorly, there is additional scarring of the pelvic floor, entrapping the anterior portion of the pudendal nerve, extending to the posterior aspect of the dorsal nerve to the penis. This is present bilaterally, right greater than left. Note is made of scarring of the pelvic floor fat at the anterior right aspect of the Alcock's canal seen on series 7, image 36. Scar formation tethers to the anteroinferior medial border of the obturator internus muscle. The distal branch nerves at the base of the penis are unremarkable.
The obturator nerves are unremarkable. The study was not centered on
the genitofemoral or ilioinguinal nerves but they appear symmetric bilaterally.
Hamstring origins are degenerated but not torn. There is no scar
entrapment of the sciatic nerves. No ischial bursitis is seen.
There is no occult fracture or osteonecrosis. No bulky synovitis ~s demonstrated.
There is no pelvic floor adenopathy.
Impression:
MRI of the pelvis demonstrates scar entrapment of the pudendal nerve in two locations, one localized adjacent to hypertrophic scar formation at the left sacrotuberous ligament, and also at the base of the pelvic floor and the anterior portion of Alcock's canal, entrapping the posterior margin of the dorsal nerve to the penis bilaterally, left greater than right. Findings may account for sensory symptoms relevant to the pelvic floor and specifically, to the pudendal nerve branch of the dorsal nerve to the penis.

Hi everyone i went to Dr Potter too I am new on this site but have been lurking for months this is what my mri says it scares me alot

1. Oblique images through the pelvic floor demonstrates scarring of the perivaginal fat planes abutting the branches of the pudendal nerve in Alcock's canal to the on the left side. The fat planes around the sacrotuberous ligaments are unremarkable.

2. There is moderate scar formation surronding the branch of the pn to the rectum, again more prominent on the left.

3. Mild degenerative changes of the pubic symphysis are noted with adductor tendinosis but no acute tear.

4. There is a dominant left adnexal cyst, disc ddegengeration is noted in the lower spine

Her impression is MRI of the pelvis demonstrates moderate linear scar formation surronding the anterior margin of Alcocks canal, abutting the distal branches of the left pn to the rectum. Nothing to do with my coccyx


My main problem with all this was a burning clitoris thats why i went for this, nothing was noted on the MRI but when I talked to her she told me my dorsal nerve which i guess was the distal branch she was talking about was entrapped but she did not say this on the report. So I was very concerned with this as i brought this to my physical therapist which she was amazed to see but it didnt say anything about the clitoris. So i kept emailing her and she finally made and addendum and that says.

Specific concern (is that my concern) is directed towards the dorsal nerve of the clitoris. Oblique axial images demonstrate scar entrapment of the left aspect of the pelvic floor, entrapping the dorsal nerve to the clitoris more posteriorly, there is no scar entrapment around the sacrotuberous ligament.

So what do you all think of this, please be gentle

My symptoms were burning clitoris thats it, now since everything that has done to me more has happened

Hi,
It seems that you are entrapped in the Alcock's Canal which is leading to the burning.In my opinion,TIR approach by Dr. Bautrant would be a good idea,but to be on the safe side,Dr. Hibner would be a better option.Dr. Bautrant's TIR approach has the best access to the Alcock's Canal.

Take care,
Ali

I really want to avoid surgery some how as i heard it can make you worse, as you yourself have too have it done again. There has to be something out there to help me besides surgery, I will go to hibner with all the reports and tests i have had. Does he push surgery on you? Isnt dr B inn Paris?

Hi Miss,
Dr. Bautrant is in Aix En Provence in the South of France.It's next to the French seaport of Marseille.You can see Dr. Jerome Weiss in San Francisco for conservative treatment and if it doesn't help in a few months then you can proceed with surgery.
Thanks to Dr. Potter's MRI, I know that I am still entrapped in the Sacrotubeous ligament on the surgical side and Alcock's Canal on the non-surgical side.I took a risk with Dr. Bautrant because I was 80% sure that I was entrapped in the Alcock's canal.I was right about the Alcock's canal ,but in addition to that I was also entrapped in the Sacrotuberous ligament and TIR approach by Dr. Bautrant cannot access the Sacrotuberous ligament.It has been known for some time that he cannot access the Sacrotuberous ligament.Dr. potter's MRI results just confirms it.
However,Trans gluetal approach has it's own draw backs especially when the Sacrotuberous ligament isn't repaired.I was just talking to a friend of mine yesterday who had his surgery with Professor Robert in Nantes four years ago and both his Sacrotuberous and Sacrospinal ligaments were sliced or severed and he cannot even lift his grocerry bags because his Pelvis hurts.
That's why I would always recommend Dr. Hibner becuase at least he repairs the Sacrotubeorus ligament and so far none of his patients has reported of SIJD issues or any Pelvic instabilty like that.In addition,he uses the neuro wrap,the Q-pain pump and platelets for better post surgical recovery.
Having said that his success rate is still 70%,40% cured,30% improved and the rest 30% remained the same.I belive he has done 200 surgeries so far.

Best Regards,
Ali

Since the Houston team has been doing the prerequisite of a PT consult for sacral issues, NOT ONE surgical patient has complained of SIJD post op, and that's without any kind of so-called ligament "repair".

Missingmylife42 wrote:I really want to avoid surgery some how as i heard it can make you worse

I and others like me are living proof that surgery can make you better. Sometimes it's the only thing that can.

Both Sacrotuberous and Sacrospinal Ligaments especially the Sacrotuberus ligament are very important for Pelvic stability.I can see proof of my friend who had surgery in Nantes that left him with sitting pain as well as inability to lift even objects like grocery bags.
Ligament repair is imperative for Pelvic stability.

I am attaching an anatomical diagram of both the Sacrotuberous ligament and Sacrospinal ligaments.It is a matter of common sense that if either of these ligaments especially the Sacrotuberous ligament(the big one) is severed,cut or sliced,it will make the whole Pelvis imbalance.
Hence,it is imperative that the Ligaments be repaired after surgery.