Pudendusneuralgie

Pudendal neuralgia: description

Pudendal neuralgia is a rare disease. It is described as neuropathic because it affects the peripheral nervous system. Strictly speaking, these are only pain that can be attributed to the so-called pubic nerve (pudendal nerve). In some cases, unclear chronic pain in the pelvis or genital area is referred to as pudendal neuralgia. Women are about twice as likely as men.

Pudendal neuralgia: Anatomical foundations

The pudendal nerve (pubic nerve) is responsible for the sensory perception of the anal, perineum and testicles or labia. Physicians refer to the region between the scrotum and anus in the man or between vagina and anus in the woman as a dam. In addition, the pubic nerve innervates the muscles of the pelvic floor and the external anal sphincter. Thus it is important for the urinary and stool contingency as well as for the sexual function.

The pudendal nerve is formed by various nerves that leave the lower spinal cord and attach to each other. It runs laterally through different structures of the pelvis. In the so-called Alcock Canal, he pulls forward and then divides into various small branches. The Alcock Canal is considered to be an important constriction in the pudendal nerve – pinching the nerve in this area can cause pudendal neuralgia.

Pudendal neuralgia: symptoms

The pudendal neuralgia is characterized by severe pain in the genital and perineal area. Men feel the complaints mainly in the perineum and rarely in the penis. Women describe discomfort in the area from the lower outer vagina to the anus. Most of these are one-sided and may occur alternately. Only rarely do the complaints of pudendal neuralgia exist on both sides at the same time.

Patients describe the pain as burning, stinging, shooting, dull or oppressive. Some also speak of a “sense of a razor blade”. In a few cases, patients also experience discomfort (paresthesia) or muscle paralysis. Possible numbness sometimes prevents urination and bowel movements from being properly controlled. Pudendal neuralgia can thus lead to urinary and fecal incontinence. In addition, in rare cases, the sexual function may be disturbed.

The symptoms increase while sitting and improve when standing or while sitting on the toilet. The reason for this is the pressure relief in the small basin. The sleep of the patients is not disturbed by the complaints in the rule.

Pudendal neuralgia: causes and risk factors

There are many different causes of pudendal neuralgia. Most commonly, there is a mechanical cause behind it. This means that the pubic nerve is irritated or contracted by other structures as it passes through the pelvis. The mechanical damage occurs, for example, when pressure on the dam on as in cycling. Even operations in which the patient is stored in the same position for a long time can lead to pressure damage and thus to pudendal neuralgia.

Other causes of a pudendal neuralgia can be:

• Pelvic injuries such as a pelvic fracture, shot or stab wounds
• gynecological diseases such as endometriosis
• a difficult birth
• Vascular diseases of the pelvis such as thrombosis or varicose veins
• connective tissue narrowing of the Alcock canal

Rarely are the following diseases the cause of a pudendal neuralgia:

• Herpes zoster (shingles)
• Tumors in the pelvis
• Diabetes mellitus

Pudendal neuralgia: examinations and diagnosis

If you have pain in the perineal and genital area, your doctor will refer you to a urologist, gynecologist or proctologist. The task of these specialists is to exclude other diseases that can cause symptoms similar to those of a pudendal neuralgia (see below). Once this is done, the pudendal neuralgia as a nerve disease can finally be diagnosed and treated by a neurologist.

First, your doctor will ask you in detail about your medical history (anamnesis). He will ask you the following questions:

• Since when are you having those complaints?
• Are the complaints stronger on one side than the other?
• How would you describe the pain?
• Are you diabetic or suffering from shingles?

Then follows the physical examination. Typical for pudendal neuralgia is that pressure in the vagina, rectum, or perineum causes pain. Magnetic Resonance Imaging (MRI) is used to take a picture of the pelvis and spinal cord. It can be used to detect structures that may be pressing on the pubic or lower spinal cord, such as tumors or herniated discs.

Pudendal neuralgia: diagnosis with pudendal block

Often, the pudendal neuralgia is diagnosed by a therapeutic trial. Three times under image control (usually by computer tomography, CT) a narcotic (local anesthetic) is injected along the pubic nerve. This process is also called pudendal blockade. If the anesthesia causes an improvement in symptoms, it is considered to be a pudendal neuralgia. If the pudendal block is performed promptly at the onset of symptoms, it can provide long-term relief.

Pudendal neuralgia: measurement of nerve conduction velocity

By measuring the nerve conduction velocity (NLG), damage to the pudendal nerve can be detected, which can lead to pudendal neuralgia: In Electroneurography (ENG) electrodes are glued to the skin areas, which are innervated by the pudendal nerve. Current stimulates the nerve and the rate at which the nerve passes the information can be measured. In a pudendal neuralgia the nerve conduction velocity is changed.

Pudendal neuralgia: exclusion of other diseases

It is often difficult to diagnose pudendal neuralgia, and it often takes several months for the disease to be diagnosed. The reason for this is that many diseases can cause a similar symptoms. These must be excluded first. Such diseases are for example:

• dermatitis
• Diabetes mellitus
• Tumors of the nerves and spinal cord (neurinoma, ependymoma)
• psychological illnesses
• Nerve damage due to radiotherapy

Pudendal neuralgia: treatment

There are many ways to treat the pudendal neuralgia. If an underlying disease is behind it, this should be treated first. This means, for example, that the blood sugar level in a patient with diabetes mellitus must be correctly adjusted, or that a tumor that has grown in the pelvis is treated.

Pudendal neuralgia: pain medication

To get the acute pain attacks under control, various painkillers can help. First, try one of the following:

• Acetylsalicylic acid (ASA)
• paracetamol
• diclofenac
• ibuprofen
• naproxen
• metamizole

If these do not help, your doctor may prescribe stronger analgesics (opioids such as tramadol, dihydrocodeine or hydromorphone). These are available, for example, as tablets, patches or suppositories.

In the long term, the pain can be treated with antidepressants or anticonvulsants. Antidepressants (like amitriptyline or mianserin) are actually used for the treatment of depression, but also have an analgesic effect.

The group of anticonvulsants (antispasmodic) is widely used. In the treatment of pudendal neuralgia, they slow down the transmission of the pain signals in the nerves. Anticonvulsants include, for example, gabapentin, pregabalin, carbamazepine and lamotrigine.

The painkillers mentioned can also be combined by your doctor.

In the case of pudendal encephalalgia therapy, it can take a while for an improvement, as is the case with any other pain therapy, to find the right combination of active ingredients for each individual patient.

Pudendal neuralgia: TENS

The so-called TENS (transcutaneous electrical nerve stimulation) is a stimulation current therapy. Electrodes are stuck to the painful areas. The current impulses given through them irritate the nerves, but are not perceived as painful for the patient. They should serve to reduce pain transmission to the brain.

Pudendal neuralgia: further measures

Psychological support of pain therapy in pudendal neuralgia can provide further relief. Through patient training and various relaxation procedures can prevent the pain become chronic and then only extremely difficult to treat. Supportive therapies can be found in alternative medicine such as homeopathy, acupuncture or osteopathy.

Pudendal neuralgia: surgical therapy

There are several so-called invasive procedures to treat the pudendal neuralgia. Invasive treatment is an invasion of the body, for example, when the skin is damaged as a barrier. A minimally invasive therapy is the aforementioned pudendal block. The pubic nerve is anesthetized by local anesthetics. Another option is to inject cortisone into the nerves. But this can only be done a few times, otherwise the nerve is damaged.

The operation called neurolysis exposes the pudendal nerve. In this way any pressure bearing on it (for example through scar tissue) is taken. The nerve is either dissected from behind through the gluteal muscles or through the perineum or vagina.

Pudendal neuralgia: disease course and prognosis

Making a prognosis about pudendal neuralgia is difficult because there are many different causes. The important thing is the pain of one Pudendusneuralgie treated as early as possible so that they do not become chronic.