Sacral Neuromodulation as a Treatment for Pudendal Neuralgia

Abstract

Pudendal neuralgia is a debilitating pain syndrome, and finding long-lasting treatment modalities has been challenging in pain management. The pudendal nerve has sensory and motor functions, and influences autonomic functions. Thus, entrapment or damage of this nerve can have multiple serious implications. The constellation of symptoms which result from injury to this nerve is commonly referred to as pudendal neuralgia. When conservative therapy does not provide adequate pain relief and surgical procedures fail or are not viable options, central and peripheral nerve stimulation can be effective treatment modalities. More recent approaches to treatment include the use of peripheral nerve stimulation through the use of an electrical lead placed next to the pudendal nerve in the ischioanal fossa. Also, epidural stimulation of the conus medullaris and pulsed radiofrequency ablation of the pudendal nerve have been shown to be effective in small patient populations. We present the case of a 36-year-old woman who sustained pudendal nerve injury during a hysterectomy and subsequently developed intractable pelvic pain and pudendal neuralgia. Conservative treatment measures failed, but she obtained excellent results from peripheral nerve stimulator therapy. Permanent implantation consisted of 4 tined Interstim leads, individually placed into the bilateral S3 and S4 foramina. The patient has been followed for approximately 4 years since her procedure, demonstrating increased function as she is able to stand and sit for prolonged periods of time. She has returned to her usual daily activities, including horseback riding. This is the first reported case of transforminal sacral neurostimulation providing excellent relief of pudendal neuralgia related symptoms. Key words: Pudendal neuralgia, sacral neurostimulation, peripheral nerve stimulator, pelvic pain, nerve stimulation, interventional pain procedures, surgical management of pain

Effectiveness of transcutaneous electrical nerve stimulation as an adjunct to selected physical therapy exercise program on male patients with pudendal neuralgia: A randomized controlled trial

“…The intensity of the stimulation was increased gradually according to the participant’s tolerance as to produce a comfortable perceptible paresthesia (tingling sensation) without significant muscle fasciculations or contractions. 22 Each patient was treated while assuming supine hook-lying comfortable position with abducted hips. Four self-adhesive square electrodes (2 inches in diameter) were applied as follows: two electrodes were positioned at the perineal area between scrotum and anus on the centrum tendineum, and the other two electrodes were applied at the level of the ischial spines (medial to the ischial spines bilaterally).…”

Right laparoscopic pudendal release + neurostimulator prosthesis (LION procedure) in pudendal neuralgia

“…Sacral root neurostimulation or posterior tibial nerve stimulation are used to rescue patients who either have not responded to surgery or have worsened after an initial improvement [6, 7].…”

Diagnostic and therapeutic algorithm for pudendal nerve entrapment syndrome

“…La estimulación epidural del cono medular se ha demostrado efectiva a largo plazo en estudios prospectivos 45 , sin embargo, no se consigue alcanzar un acuerdo respecto a la ubicación del estimulador, ya que en el cono medular puede moverse, llevando al fracaso del tratamiento. Con este fin se han planteado nuevas estrategias de estimulación nerviosa periférica mediante el uso de un electrodo localizado próximo al nervio pudendo en la fosa isquioanal 60 . Estas técnicas de neuromodulación aportan resultados prometedores en los estudios preliminares, pero precisan de estudios a mayor escala para confirmar su efectividad 60 .…”

“…Con este fin se han planteado nuevas estrategias de estimulación nerviosa periférica mediante el uso de un electrodo localizado próximo al nervio pudendo en la fosa isquioanal 60 . Estas técnicas de neuromodulación aportan resultados prometedores en los estudios preliminares, pero precisan de estudios a mayor escala para confirmar su efectividad 60 .…”