Analgesic effect of bilateral ultrasound-guided pudendal nerve blocks in management of interstitial cystitis

Abstract

Interstitial cystitis is a chronic inflammatory bladder syndrome with limited treatment options. Pudendal nerve stimulation is in vogue as treatment, yet its use has inherent drawbacks including availability and cost.Although pudendal nerve blocks are common practice [1], there has been no report of the specific use of ultrasound to treat interstitial cystitis. We describe bilateral ultrasound-guided pudendal nerve blocks in two patients with interstitial cystitis with excellent analgesic outcome.A 66-year-old man with a 7-year history of severe bladder pain and frequency/nocturia was diagnosed with interstitial cystitis. He had undergone transurethral resection of prostate and multiple therapeutic cystoscopies to alleviate his symptoms with no success. Despite long-term amitriptyline and analgesia, his pain continued to interfere with daily activities, and he was referred for further pain management.After skin preparation, a 2-5 MHz curved array ultrasound probe within a transparent sheath was used to visualize landmarks with the patient prone. The sacroiliac joint was identified, then the probe was moved inferolaterally where the sacrospinous ligament attaches to the ischial spine, as the pudendal nerve exits the greater sciatic foramen. Real-time imaging with color Doppler confirmation was used to direct a 22 G spinal needle in proximity to the pudendal nerve. Bilateral injections were performed sequentially by an experienced operator; using 4 ml 0.25% levobupivicaine and 40 mg methylprednisolone.His pain improved immediately after the intervention. At the 3-month follow-up, there was excellent sustained pain relief, mild improvement in his urinary symptoms, and no sensory loss in the pudendal nerve distribution.A 70-year-old woman diagnosed with refractory interstitial cystitis presented to our pain service. Her symptoms included pelvic and perineal pain and nocturia for 6 years. Her management included gabapentin, multiple cystoscopies, intravesical botulinum toxin injections, and intravesical instillation of dimethylsulfoxide, all with no relief.Bilateral pudendal nerve injections were performed in the same manner by the same operator. Injection dose was similar.There was relief of pain and urinary symptoms at her 3-month follow-up. Sustained pain and symptom relief was reported 9 months following the procedure, with no reported sensory loss. This is the first report of clinical outcomes following the use of ultrasound-guided pudendal nerve block for interstitial cystitis. It confirms that the pudendal nerve plays a role in interstitial cystitis [2], and that it can be thought of as a peripheral neuropathy based on neurogenic inflammation and sensitization [3]. In fact, interstitial cystitis as a manifestation of pudendal neuropathy is a current popular

Effect of Pudendal Nerve Block on the Prevention of Postoperative Bladder Spasm and Catheter-Related Bladder Discomfort in Male Patients Undergoing Transurethral Holmium Laser Enucleation of the Prostate

“…And, that study resulted in one patient with levator ani weakness after surgery. Lean et al 33 performed PNB with the ischial spine as a marker in patients with interstitial cystitis who did not respond well to surgery and analgesics. The symptoms of bladder pain, frequent urination, and nocturia were significantly reduced.…”

“…The symptoms of bladder pain, frequent urination, and nocturia were significantly reduced. They 32 , 33 all used the sciatic spine as a marker to perform PNB. However, it is easy to block the sciatic nerve and damage the pudendal artery and vein adjacent to the PN.…”

Challenges and current evidence on the management of bladder pain syndrome

“…Another method that alleviates pain (42% reported >50% improvement, at 6 months' follow‐up) and symptoms is that of bilateral S2–S4 sacral neuromodulation . Bilateral ultrasound‐guided pudendal nerve block relieved symptoms of IC in two patients in 9 months' time, with no sensory loss . Symptom improvements at 6 years follow‐up appear encouraging in a study by Marinkovic et al on IC patients for whom standard drug therapies have failed.…”

Regional anesthesia guided by ultrasound in the pudendal nerve territory☆

“…For chronic pain, a mix of long-acting local anaesthetic and coticosteroid is used in a volume ranging from 4 to 6 cc. 13,49 Fitchner et al suggest a slightly more caudal technique at the entry point to Alcock's canal in order to reduce the risk of a sciatic nerve block.…”

“…Pudendal nerve blocks have a wide range of clinical applications 1,2 that involve anaesthetic/analgesic goals: haemorrhoid, [3][4][5][6] ano-rectal, vaginal, and perineal 7 surgery; labour, 8 episiotomies, 9,10 prostate biopsy, 11 prostate brachytherapy, 12 interstitial cystitis, 13 and penile surgery. 14 Moreover it is an integral part of the diagnosis and therapy of pudendal neuropathy of which little is known, although there is growing research into its pathophysiology and therapeutic approaches.…”