Health Organization for Pudendal Education

Hi All
I had a bilateral pudendal nerve block on Friday. Was completely numb below....it was wonderful. Now that the numbness has gone I still feel the burning and stabbing below. Plus my hip and leg are now sore. The doc told me that I wouldn`t know for up to 2 weeks if the block has helped. What am I supposed to feel right now. Do I just accept that it hasn`t worked or can it still improve over time. Looking to hear from people who have had the same block as me. I go for my second one Feb 6 and last one March 6.

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Hi Doc Jason

thanks for responding. So I shouldn`t panic yet that it may not be working? Too soon?
This whole nerve block and how it works is confusing to me.

Dear Jules1967,

I cannot comment directly on your case as I am not your treating physician.

However, I have performed many hundreds of pudendal nerve blocks and can discuss the experience of my patients. There are two phases:

1. The local anesthetic phase. The lasts 2-24 hours typically, depending on the local anesthetic used. Different local anesthetics have different durations of effect. During this phase, the nerve is anesthetized or "numbed." During this phase, if a patient's typical pain goes away, we can determine that the pudendal nerve is indeed the "pain generator," as we call it. The anesthetic will wear off and the pain will often return to baseline for a while. We then move onto the steroid phase.

2. The steroid phase. This may take up to 2 weeks to start working. Steroids are usually injected along with the local anesthetic. The steroids can take up the 2 weeks to start working and relieving pain. It is our hope that patients get long-term relief (weeks-to years) from the steroid injection. Not all nerves respond well to steroids and the patient may never get long term steroid phase relief.

If a patient gets great anesthetic phase pain relief, and great steroid phase relief, then great! Pain may go away completely or for months at a time.

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.

If a patient gets zero anesthetic phase pain relief, and no to poor steroid phase relief, pudendal neuralgia is highly unlikely and an alternate diagnosis can be investigated.

The above is true of any nerve being injected for pain issues, in general.

Hello, dr Attaman, I would like to ask you whether you prefer alcock canal or ischial spine for block? Which of both location is better visualised by high resolution ultrasound device? Thank you

Dr. Jason.......thank you thank you . This is probably the most information that I have gotten for this procedure. You have truly answered all my questions and concerns. I did not know that there are Docs on this site as well providing information and I really appreciate this.

Julie

Jules1967 wrote:Dr. Jason.......thank you thank you . This is probably the most information that I have gotten for this procedure. You have truly answered all my questions and concerns. I did not know that there are Docs on this site as well providing information and I really appreciate this.

Julie

My pleasure!

There is a very confusing maze of treatments and procedures patients with pudendal neuralgia have to navigate through. I'm happy to help.

flyer28 wrote:Hello, dr Attaman, I would like to ask you whether you prefer alcock canal or ischial spine for block? Which of both location is better visualised by high resolution ultrasound device? Thank you

Hello! Great question.

With ultrasound, both can be targeted.

Technically, the ischial spine is most easily targeted. We can catch the pudendal nerve as it passes between the sacrotuberous and sacrospinous ligaments.

Alcocks canal can also be reached with U/s imaging.

Personally for diagnosis I like to catch the pudendal nerve as proximal to its origin as possible. This would be at the ischial spine location.

If there is specific entrapment or inflammation at alcock's canal, then botox or steroid can be placed there.

Hope this helps!

Thanks, dr. Attaman, your answers are precise and clear. Highly apprecieted from my side.
I am suffering with pelvic pain cca 5 years, mainly in distal pudendus area (penis, scrotum, groin, pubic area). I still dont know exactly whether this is rather general pelvic myoneuropathy or PN. Two years ago I tried distal pudendal nerve block (dorsal nerve of penis) with no change in pain patten. I did not have any Tinel sign (higher sensitivity) in the course of pudendal nerve. However, some other indications favour pudedal nerve as a culprit (delayed onset of pain after stimulus in the initial stage of desease etc.).
My understanding is following: High resolution (15Mhz) ultrasound nerve block should be able to safely block pudendal nerve either in Alcock or in ischial spine. High resolution ultrasound is the top option, because it dispalys the real and immediate situation (unlike CT).

1. if there is immediate reaction regarding pain pattern, then pudendal nerve is playing the main role and we can try to find the spot of the entrapment or focus for the further treatment on the pudendal nerve. The block in the ischial spine (although my primary problem spot is almost sure NOT there, because I dont have sitting pain) should numb everything distal from this place, till the tip of the penis.

2. If there is no change in pain pattern (like it was during distal pudendal nerve block), the pain is rather related to classic CPPS/chronic prostatitis patterns, with more general mechanisms (muscles/nerves/tendons/trigger points) involved. PT is the the most viable option and treatment is multimodal.

Am I basically right?

flyer28 wrote:Thanks, dr. Attaman, your answers are precise and clear. Highly apprecieted from my side.
I am suffering with pelvic pain cca 5 years, mainly in distal pudendus area (penis, scrotum, groin, pubic area). I still dont know exactly whether this is rather general pelvic myoneuropathy or PN. Two years ago I tried distal pudendal nerve block (dorsal nerve of penis) with no change in pain patten. I did not have any Tinel sign (higher sensitivity) in the course of pudendal nerve. However, some other indications favour pudedal nerve as a culprit (delayed onset of pain after stimulus in the initial stage of desease etc.).
My understanding is following: High resolution (15Mhz) ultrasound nerve block should be able to safely block pudendal nerve either in Alcock or in ischial spine. High resolution ultrasound is the top option, because it dispalys the real and immediate situation (unlike CT).

1. if there is immediate reaction regarding pain pattern, then pudendal nerve is playing the main role and we can try to find the spot of the entrapment or focus for the further treatment on the pudendal nerve. The block in the ischial spine (although my primary problem spot is almost sure NOT there, because I dont have sitting pain) should numb everything distal from this place, till the tip of the penis.

2. If there is no change in pain pattern (like it was during distal pudendal nerve block), the pain is rather related to classic CPPS/chronic prostatitis patterns, with more general mechanisms (muscles/nerves/tendons/trigger points) involved. PT is the the most viable option and treatment is multimodal.

Am I basically right?

dear flyer28,

I'm glad you find my input useful. thanks

For blocking the dorsal penile nerve, yes indeed 15Mhz (or even higher if available, experimental probes are in the 20-30Mhz range) Ultrasound imaging would be most precise. This would be better than CT or MR.

However for blocking the pudendal nerve more proximally at the ischial spine or alcock's canal, 15Mhz ultrasound would not have enough acoustic power to penetrate deeply enough to visualize the target. Therefore a longer wavelength must be used, usually around 3 to 8 Mhz. This will visualize deeper objects. CT and MR would be good options as well. Ultrasound is very physician dependent, as it takes a lot of skill to visualize the pudendal nerve with ultrasound. CT and MR are easier for the physician.

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.

Re question #1, you are correct!

Re question #2, that may be correct, thought the differential diagnosis is very broad so I cannot be more specific.

I hope this helps.