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Jean-jacques Labat - One of the best experts on this subject based on the ideXlab platform.
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Anatomical Variants of the Pudendal Nerve Observed during a Transgluteal Surgical Approach in a Population of Patients with Pudendal Neuralgia.
Pain Physician, 2017Co-Authors: Stephane Ploteau, Marie-aimée Perrouin-verbe, Jean-jacques Labat, Thibault Riant, Amélie Levesque, Roger RobertAbstract:BACKGROUND: Several studies have described the course and anatomical relations of the Pudendal nerve. Several surgical nerve decompression techniques have been described, but only the transgluteal approach has been validated by a prospective randomized clinical trial. The purpose of this study was to describe the course of the nerve and its variants in a population of patients with Pudendal Neuralgia in order to guide the surgeon in the choice of surgical approach for Pudendal nerve decompression. OBJECTIVES: In order to support the choice of the transgluteal approach, used in our institution, we studied the exact topography, anatomical relations, and zones of entrapment of the Pudendal nerve in a cohort of operated patients. STUDY DESIGN: Observational study. SETTING: University hospital. METHODS: One hundred patients underwent unilateral or bilateral nerve decompression performed by a single operator via a transgluteal approach. All patients satisfied the Nantes criteria for Pudendal Neuralgia. The operator meticulously recorded zones of entrapment, anatomical variants of the course of the nerve, and the appearance of the nerve in the operative report. RESULTS: One hundred patients and 145 nerves were operated consecutively. Compression of at least one segment of the Pudendal nerve (infrapiriform foramen, ischial spine, and Alcock's canal) was observed in 95 patients. The zone of entrapment was situated at the ischial spine between the sacrospinous ligament (or ischial spine) and the sacrotuberous ligament in 74% of patients.Anatomical variants were observed in 13 patients and 15 nerves. Seven patients presented an abnormal transligamentous course of the nerve (sacrotuberous or sacrospinous). A perineal branch of the fourth sacral nerve to the external anal sphincter was identified in 7 patients. In this population of patients with Pudendal Neuralgia, the Pudendal nerve was stenotic in 27% of cases, associated with an extensive venous plexus that could make surgery more difficult in 25% of cases, and the nerve had an inflammatory appearance in 24% of cases. LIMITATIONS: We obviously cannot be sure that the anatomical variants identified in this study can be extrapolated to the general population, as our study population was composed of patients experiencing perineal pain due to Pudendal nerve entrapment and their pain could possibly be related to these anatomical variants, especially a transligamentous course of the Pudendal nerve. The absence of other prospective randomized clinical trials evaluating other surgical approaches also prevents comparison of these results with those of other surgical approaches. CONCLUSIONS: This is the first study to describe the surgical anatomy of the Pudendal nerve in a population of patients with Pudendal Neuralgia. In more than 70% of cases, Pudendal nerve entrapment was situated in the space between the sacrospinous ligament and the sacrotuberous ligament. Anatomical variants of the Pudendal nerve were also observed in 13% of patients, sometimes with a transligamentous course of the nerve. In the light of these results, we believe that a transgluteal approach is the most suitable surgical approach for safe Pudendal nerve decompression by allowing constant visual control of the nerve.Key words: Surgical, operative technique, Pudendal, Neuralgia, transgluteal approach.
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Pudendal Neuralgia Due to Pudendal Nerve Entrapment: Warning Signs Observed in Two Cases and Review of the Literature.
Pain physician, 2016Co-Authors: Stephane Ploteau, Marie-aimée Perrouin-verbe, Thibault Riant, Claire Cardaillac, Jean-jacques LabatAbstract:Pudendal Neuralgia is a chronic neuropathic pelvic pain that is often misdiagnosed and inappropriately treated. The Nantes criteria provide a basis for the diagnosis of Pudendal Neuralgia due to Pudendal nerve entrapment. The 5 essential diagnostic criteria are pain situated in the anatomical territory of the Pudendal nerve, worsened by sitting, the patient is not woken at night by the pain, and no objective sensory loss is detected on clinical examination. The fifth criterion is a positive Pudendal nerve block. We have also clarified a number of complementary diagnostic criteria and several exclusion criteria that make the diagnosis unlikely. When Pudendal Neuralgia due to Pudendal nerve entrapment is diagnosed according to the Nantes criteria, no further investigation is required and medical or surgical treatment can be proposed. Nevertheless, a number of warning signs suggesting other possible causes of Pudendal Neuralgia must not be overlooked. These warning signs (red flags) are waking up at night, excessively neuropathic nature of the pain (for example, associated with hypoesthesia), specifically pinpointed pain, which can suggest neuroma and pain associated with neurological deficit. In these atypical presentations, the diagnosis of pain due to Pudendal nerve entrapment should be reconsidered and a radiological examination should be performed. The 2 cases described in this report (tumor compression of the Pudendal nerve) illustrate the need to recognize atypical Pudendal Neuralgia and clarify the role of pelvic magnetic resonance imaging (MRI), as MRI provides very valuable information for the evaluation of diseases involving the ischiorectal fossa. The presence of red flags must be investigated in all cases of Pudendal Neuralgia to avoid missing Pudendal Neuralgia secondary to a mechanism other than nerve entrapment.
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Spinal cord stimulation of the conus medullaris for refractory Pudendal Neuralgia: a prospective study of 27 consecutive cases.
Neurourology and urodynamics, 2013Co-Authors: Kevin Buffenoir, Jean-jacques Labat, Thibault Riant, B. Rioult, Olivier Hamel, Roger RobertAbstract:Aims Thirty percent of patients with Pudendal Neuralgia due to Pudendal nerve entrapment obtain little or no relief from nerve decompression surgery. The objective was to describe the efficacy of spinal cord stimulation of the conus medullaris in patients with refractory Pudendal Neuralgia. Methods This prospective study, conducted by two centers in the same university city, described the results obtained on perineal pain and functional disability in all patients with an implanted conus medullaris stimulation electrode for the treatment of refractory Pudendal Neuralgia. Twenty-seven consecutive patients were included by a multidisciplinary pelvis and perineal pain clinic between May 2011 and July 2012. Mean follow-up was 15 months. The intervention was an insertion of a stimulation electrode was followed by a test period (lasting an average of 13 days) before deciding on permanent electrode implantation. Maximum and average perineal pain scores and the pain-free sitting time were initially compared during the test and in the long-term (paired t-test). The estimated percent improvement (EPI) was evaluated in the long-term. Results Twenty of the 27 patients were considered to be responders to spinal cord stimulation and 100% of implanted patients remained long-term responders (mean tripling of sitting time, and mean EPI of 55.5%). Conclusions Spinal cord stimulation of the conus medullaris is a safe and effective technique for long-term treatment of refractory Pudendal Neuralgia. Routine use of this technique, which has never been previously reported in the literature in this type of patient, must now be validated by a larger scale study. Neurourol. Urodynam. 34:177–182, 2015. © 2013 Wiley Periodicals, Inc.
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Diagnostic criteria for Pudendal Neuralgia by Pudendal nerve entrapment (Nantes criteria).
Neurourology and urodynamics, 2008Co-Authors: Jean-jacques Labat, Thibault Riant, Roger Robert, Gérard Amarenco, Jean-pascal Lefaucheur, Jérôme RigaudAbstract:Aims: The diagnosis of Pudendal Neuralgia by Pudendal nerve entrapment syndrome is essentially clinical. There are no pathognomonic criteria, but various clinical features can be suggestive of the diagnosis. We defined criteria that can help to the diagnosis. Materials and Methods: A working party has validated a set of simple diagnostic criteria (Nantes criteria). Results: The five essentials diagnostic criteria are: (1) Pain in the anatomical territory of the Pudendal nerve. (2) Worsened by sitting. (3) The patient is not woken at night by the pain. (4) No objective sensory loss on clinical examination. (5) Positive anesthetic Pudendal nerve block. Other clinical criteria can provide additional arguments in favor of the diagnosis of Pudendal Neuralgia. Exclusion criteria are also proposed: purely coccygeal, gluteal, or hypogastric pain, exclusively paroxysmal pain, exclusive pruritus, presence of imaging abnormalities able to explain the symptoms. Conclusion: The diagnosis of Pudendal Neuralgia by Pudendal nerve entrapment syndrome is essentially clinical. There are no specific clinical signs or complementary test results of this disease. However, a combination of criteria can be suggestive of the diagnosis. Neurourol. Urodynam. 2007 Wiley-Liss, Inc.
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decompression and transposition of the Pudendal nerve in Pudendal Neuralgia a randomized controlled trial and long term evaluation
European Urology, 2005Co-Authors: R Robert, Jean-jacques Labat, M Bensignor, P Glemain, Cedric Deschamps, Sylvie Raoul, O HamelAbstract:Abstract Background: We assess that Pudendal Neuralgia is a tunnel syndrome due to a ligamentous entrapment of the Pudendal nerve and have treated 400 patients surgically since 1987. We have had no major complication. We conducted a randomized controlled trial to evaluate our procedure. Methods: A sequential, randomized controlled trial to compare decompression of the Pudendal nerve with non-surgical treatment. Patients aged 18–70, had chronic, uni/bilateral perineal pain, positive temporary response to blocks at the ischial spine and in Alcock's canal. They were randomly assigned to surgery ( n =16) and control ( n =16) groups. Primary end point was improvement at 3 months following surgery or assignment to the non-surgery group. Secondary end points were improvement at 12 months and at 4 years following surgical intervention. Results: A significantly higher proportion of the surgery group was improved at 3 months. On intention-to-treat analysis 50% of the surgery group reported improvement in pain at 3 months versus 6.2% of the non-surgery group ( p =.0155); in the analysis by treatment protocol the figures were 57.1% versus 6.7% ( p =.0052). At 12 months, 71.4% of the surgery group compared with 13.3% of the non-surgery group were improved, analyzing by treatment protocol ( p =.0025). Only those randomized to surgery were evaluated at 4 years: 8 remained improved at 4 years. No complications were encountered. Conclusions: In this study we demonstrate that decompression of the Pudendal nerve is an effective and safe treatment for cases of chronic Pudendal Neuralgia that have been unresponsive to analgesia and nerve blocks. Following surgery, other medical interventions may be necessary.
Stephane Ploteau - One of the best experts on this subject based on the ideXlab platform.
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Anatomical Variants of the Pudendal Nerve Observed during a Transgluteal Surgical Approach in a Population of Patients with Pudendal Neuralgia.
Pain Physician, 2017Co-Authors: Stephane Ploteau, Marie-aimée Perrouin-verbe, Jean-jacques Labat, Thibault Riant, Amélie Levesque, Roger RobertAbstract:BACKGROUND: Several studies have described the course and anatomical relations of the Pudendal nerve. Several surgical nerve decompression techniques have been described, but only the transgluteal approach has been validated by a prospective randomized clinical trial. The purpose of this study was to describe the course of the nerve and its variants in a population of patients with Pudendal Neuralgia in order to guide the surgeon in the choice of surgical approach for Pudendal nerve decompression. OBJECTIVES: In order to support the choice of the transgluteal approach, used in our institution, we studied the exact topography, anatomical relations, and zones of entrapment of the Pudendal nerve in a cohort of operated patients. STUDY DESIGN: Observational study. SETTING: University hospital. METHODS: One hundred patients underwent unilateral or bilateral nerve decompression performed by a single operator via a transgluteal approach. All patients satisfied the Nantes criteria for Pudendal Neuralgia. The operator meticulously recorded zones of entrapment, anatomical variants of the course of the nerve, and the appearance of the nerve in the operative report. RESULTS: One hundred patients and 145 nerves were operated consecutively. Compression of at least one segment of the Pudendal nerve (infrapiriform foramen, ischial spine, and Alcock's canal) was observed in 95 patients. The zone of entrapment was situated at the ischial spine between the sacrospinous ligament (or ischial spine) and the sacrotuberous ligament in 74% of patients.Anatomical variants were observed in 13 patients and 15 nerves. Seven patients presented an abnormal transligamentous course of the nerve (sacrotuberous or sacrospinous). A perineal branch of the fourth sacral nerve to the external anal sphincter was identified in 7 patients. In this population of patients with Pudendal Neuralgia, the Pudendal nerve was stenotic in 27% of cases, associated with an extensive venous plexus that could make surgery more difficult in 25% of cases, and the nerve had an inflammatory appearance in 24% of cases. LIMITATIONS: We obviously cannot be sure that the anatomical variants identified in this study can be extrapolated to the general population, as our study population was composed of patients experiencing perineal pain due to Pudendal nerve entrapment and their pain could possibly be related to these anatomical variants, especially a transligamentous course of the Pudendal nerve. The absence of other prospective randomized clinical trials evaluating other surgical approaches also prevents comparison of these results with those of other surgical approaches. CONCLUSIONS: This is the first study to describe the surgical anatomy of the Pudendal nerve in a population of patients with Pudendal Neuralgia. In more than 70% of cases, Pudendal nerve entrapment was situated in the space between the sacrospinous ligament and the sacrotuberous ligament. Anatomical variants of the Pudendal nerve were also observed in 13% of patients, sometimes with a transligamentous course of the nerve. In the light of these results, we believe that a transgluteal approach is the most suitable surgical approach for safe Pudendal nerve decompression by allowing constant visual control of the nerve.Key words: Surgical, operative technique, Pudendal, Neuralgia, transgluteal approach.
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Anatomical Variants of the Pudendal Nerve Observed during a Transgluteal Surgical Approach in a Population of Patients with Pudendal Neuralgia
January 2018, 2017Co-Authors: Stephane PloteauAbstract:Background: Several studies have described the course and anatomical relations of the Pudendal nerve. Several surgical nerve decompression techniques have been described, but only the transgluteal approach has been validated by a prospective randomized clinical trial. The purpose of this study was to describe the course of the nerve and its variants in a population of patients with Pudendal Neuralgia in order to guide the surgeon in the choice of surgical approach for Pudendal nerve decompression. Objectives: In order to support the choice of the transgluteal approach, used in our institution, we studied the exact topography, anatomical relations, and zones of entrapment of the Pudendal nerve in a cohort of operated patients. Study Design: Observational study. Setting: University hospital. Methods: One hundred patients underwent unilateral or bilateral nerve decompression performed by a single operator via a transgluteal approach. All patients satisfied the Nantes criteria for Pudendal Neuralgia. The operator meticulously recorded zones of entrapment, anatomical variants of the course of the nerve, and the appearance of the nerve in the operative report. Results: One hundred patients and 145 nerves were operated consecutively. Compression of at least one segment of the Pudendal nerve (infrapiriform foramen, ischial spine, and Alcock’s canal) was observed in 95 patients. The zone of entrapment was situated at the ischial spine between the sacrospinous ligament (or ischial spine) and the sacrotuberous ligament in 74% of patients. Anatomical variants were observed in 13 patients and 15 nerves. Seven patients presented an abnormal transligamentous course of the nerve (sacrotuberous or sacrospinous). A perineal branch of the fourth sacral nerve to the external anal sphincter was identified in 7 patients. In this population of patients with Pudendal Neuralgia, the Pudendal nerve was stenotic in 27% of cases, associated with an extensive venous plexus that could make surgery more difficult in 25% of cases, and the nerve had an inflammatory appearance in 24% of cases. Limitations: We obviously cannot be sure that the anatomical variants identified in this study can be extrapolated to the general population, as our study population was composed of patients experiencing perineal pain due to Pudendal nerve entrapment and their pain could possibly be related to these anatomical variants, especially a transligamentous course of the Pudendal nerve. The absence of other prospective randomized clinical trials evaluating other surgical approaches also prevents comparison of these results with those of other surgical approaches. Conclusions: This is the first study to describe the surgical anatomy of the Pudendal nerve in a population of patients with Pudendal Neuralgia. In more than 70% of cases, Pudendal nerve entrapment was situated in the space between the sacrospinous ligament and the sacrotuberous ligament. Anatomical variants of the Pudendal nerve were also observed in 13% of patients, sometimes with a transligamentous course of the nerve. In the light of these results, we believe that a transgluteal approach is the most suitable surgical approach for safe Pudendal nerve decompression by allowing constant visual control of the nerve. Key words: Surgical, operative technique, Pudendal, Neuralgia, transgluteal approach
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adding corticosteroids to the Pudendal nerve block for Pudendal Neuralgia a randomised double blind controlled trial
British Journal of Obstetrics and Gynaecology, 2017Co-Authors: J-j Labat, Thibault Riant, B. Rioult, A Lassaux, B Rabischong, M Khalfallah, C Volteau, A M Leroi, Stephane PloteauAbstract:Objective To compare the effect of corticosteroids combined with local anaesthetic versus local anaesthetic alone during infiltrations of the Pudendal nerve for Pudendal nerve entrapment. Design Randomised, double-blind, controlled trial. Setting Multicentre study. Population 201 patients were included in the study, with a subgroup of 122 women. Methods CT-guided Pudendal nerve infiltrations were performed in the sacrospinous ligament and Alcock's canal. There were three study arms: patients in Arm A (n = 68) had local anaesthetic alone, those in Arm B (n = 66) had local anaesthetic plus corticosteroid and those in Arm C (n = 67) local anaesthetic plus corticosteroid with a large volume of normal saline. Main outcome measures The primary end-point was the pain intensity score at 3 months. Patients were regarded as responders (at least a 30-point improvement on a 100-point visual analogue scale of mean maximum pain over a 2-week period) or nonresponders. Results Three months’ postinfiltration, 11.8% of patients in the local anaesthetic only arm (Arm A) were responders versus 14.3% in the local anaesthetic plus corticosteroid arms (Arms B and C). This difference was not statistically significant (P = 0.62). No statistically significant difference was observed in the female subgroup between Arm A and Arms B and C (P = 0.09). No significant difference was detected for the various pain assessment procedures, functional criteria or quality-of-life criteria. Conclusions Corticosteroids provide no additional therapeutic benefits compared with local anaesthetic and should therefore no longer be used. Tweetable abstract Steroid infiltrations do not improve the results of local anaesthetic infiltrations in Pudendal Neuralgia.
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Pudendal Neuralgia Due to Pudendal NerveEntrapment: Warning Signs Observed in TwoCases and Review of the Literature
March 2016, 2016Co-Authors: Stephane PloteauAbstract:Pudendal Neuralgia is a chronic neuropathic pelvic pain that is often misdiagnosed and inappropriately treated. The Nantes criteria provide a basis for the diagnosis of Pudendal Neuralgia due to Pudendal nerve entrapment. The 5 essential diagnostic criteria are pain situated in the anatomical territory of the Pudendal nerve, worsened by sitting, the patient is not woken at night by the pain, and no objective sensory loss is detected on clinical examination. The fifth criterion is a positive Pudendal nerve block. We have also clarified a number of complementary diagnostic criteria and several exclusion criteria that make the diagnosis unlikely. When Pudendal Neuralgia due to Pudendal nerve entrapment is diagnosed according to the Nantes criteria, no further investigation is required and medical or surgical treatment can be proposed. Nevertheless, a number of warning signs suggesting other possible causes of Pudendal Neuralgia must not be overlooked. These warning signs (red flags) are waking up at night, excessively neuropathic nature of the pain (for example, associated with hypoesthesia), specifically pinpointed pain, which can suggest neuroma and pain associated with neurological deficit. In these atypical presentations, the diagnosis of pain due to Pudendal nerve entrapment should be reconsidered and a radiological examination should be performed. The 2 cases described in this report (tumor compression of the Pudendal nerve) illustrate the need to recognize atypical Pudendal Neuralgia and clarify the role of pelvic magnetic resonance imaging (MRI), as MRI provides very valuable information for the evaluation of diseases involving the ischiorectal fossa. The presence of red flags must be investigated in all cases of Pudendal Neuralgia to avoid missing Pudendal Neuralgia secondary to a mechanism other than nerve entrapment. Key words: Pudendal nerve, Pudendal Neuralgia, Nantes criteria, pelvic pain, Pudendal canal, perineal pain
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Pudendal Neuralgia Due to Pudendal Nerve Entrapment: Warning Signs Observed in Two Cases and Review of the Literature.
Pain physician, 2016Co-Authors: Stephane Ploteau, Marie-aimée Perrouin-verbe, Thibault Riant, Claire Cardaillac, Jean-jacques LabatAbstract:Pudendal Neuralgia is a chronic neuropathic pelvic pain that is often misdiagnosed and inappropriately treated. The Nantes criteria provide a basis for the diagnosis of Pudendal Neuralgia due to Pudendal nerve entrapment. The 5 essential diagnostic criteria are pain situated in the anatomical territory of the Pudendal nerve, worsened by sitting, the patient is not woken at night by the pain, and no objective sensory loss is detected on clinical examination. The fifth criterion is a positive Pudendal nerve block. We have also clarified a number of complementary diagnostic criteria and several exclusion criteria that make the diagnosis unlikely. When Pudendal Neuralgia due to Pudendal nerve entrapment is diagnosed according to the Nantes criteria, no further investigation is required and medical or surgical treatment can be proposed. Nevertheless, a number of warning signs suggesting other possible causes of Pudendal Neuralgia must not be overlooked. These warning signs (red flags) are waking up at night, excessively neuropathic nature of the pain (for example, associated with hypoesthesia), specifically pinpointed pain, which can suggest neuroma and pain associated with neurological deficit. In these atypical presentations, the diagnosis of pain due to Pudendal nerve entrapment should be reconsidered and a radiological examination should be performed. The 2 cases described in this report (tumor compression of the Pudendal nerve) illustrate the need to recognize atypical Pudendal Neuralgia and clarify the role of pelvic magnetic resonance imaging (MRI), as MRI provides very valuable information for the evaluation of diseases involving the ischiorectal fossa. The presence of red flags must be investigated in all cases of Pudendal Neuralgia to avoid missing Pudendal Neuralgia secondary to a mechanism other than nerve entrapment.
Roger Robert - One of the best experts on this subject based on the ideXlab platform.
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Anatomical Variants of the Pudendal Nerve Observed during a Transgluteal Surgical Approach in a Population of Patients with Pudendal Neuralgia.
Pain Physician, 2017Co-Authors: Stephane Ploteau, Marie-aimée Perrouin-verbe, Jean-jacques Labat, Thibault Riant, Amélie Levesque, Roger RobertAbstract:BACKGROUND: Several studies have described the course and anatomical relations of the Pudendal nerve. Several surgical nerve decompression techniques have been described, but only the transgluteal approach has been validated by a prospective randomized clinical trial. The purpose of this study was to describe the course of the nerve and its variants in a population of patients with Pudendal Neuralgia in order to guide the surgeon in the choice of surgical approach for Pudendal nerve decompression. OBJECTIVES: In order to support the choice of the transgluteal approach, used in our institution, we studied the exact topography, anatomical relations, and zones of entrapment of the Pudendal nerve in a cohort of operated patients. STUDY DESIGN: Observational study. SETTING: University hospital. METHODS: One hundred patients underwent unilateral or bilateral nerve decompression performed by a single operator via a transgluteal approach. All patients satisfied the Nantes criteria for Pudendal Neuralgia. The operator meticulously recorded zones of entrapment, anatomical variants of the course of the nerve, and the appearance of the nerve in the operative report. RESULTS: One hundred patients and 145 nerves were operated consecutively. Compression of at least one segment of the Pudendal nerve (infrapiriform foramen, ischial spine, and Alcock's canal) was observed in 95 patients. The zone of entrapment was situated at the ischial spine between the sacrospinous ligament (or ischial spine) and the sacrotuberous ligament in 74% of patients.Anatomical variants were observed in 13 patients and 15 nerves. Seven patients presented an abnormal transligamentous course of the nerve (sacrotuberous or sacrospinous). A perineal branch of the fourth sacral nerve to the external anal sphincter was identified in 7 patients. In this population of patients with Pudendal Neuralgia, the Pudendal nerve was stenotic in 27% of cases, associated with an extensive venous plexus that could make surgery more difficult in 25% of cases, and the nerve had an inflammatory appearance in 24% of cases. LIMITATIONS: We obviously cannot be sure that the anatomical variants identified in this study can be extrapolated to the general population, as our study population was composed of patients experiencing perineal pain due to Pudendal nerve entrapment and their pain could possibly be related to these anatomical variants, especially a transligamentous course of the Pudendal nerve. The absence of other prospective randomized clinical trials evaluating other surgical approaches also prevents comparison of these results with those of other surgical approaches. CONCLUSIONS: This is the first study to describe the surgical anatomy of the Pudendal nerve in a population of patients with Pudendal Neuralgia. In more than 70% of cases, Pudendal nerve entrapment was situated in the space between the sacrospinous ligament and the sacrotuberous ligament. Anatomical variants of the Pudendal nerve were also observed in 13% of patients, sometimes with a transligamentous course of the nerve. In the light of these results, we believe that a transgluteal approach is the most suitable surgical approach for safe Pudendal nerve decompression by allowing constant visual control of the nerve.Key words: Surgical, operative technique, Pudendal, Neuralgia, transgluteal approach.
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Spinal cord stimulation of the conus medullaris for refractory Pudendal Neuralgia: a prospective study of 27 consecutive cases.
Neurourology and urodynamics, 2013Co-Authors: Kevin Buffenoir, Jean-jacques Labat, Thibault Riant, B. Rioult, Olivier Hamel, Roger RobertAbstract:Aims Thirty percent of patients with Pudendal Neuralgia due to Pudendal nerve entrapment obtain little or no relief from nerve decompression surgery. The objective was to describe the efficacy of spinal cord stimulation of the conus medullaris in patients with refractory Pudendal Neuralgia. Methods This prospective study, conducted by two centers in the same university city, described the results obtained on perineal pain and functional disability in all patients with an implanted conus medullaris stimulation electrode for the treatment of refractory Pudendal Neuralgia. Twenty-seven consecutive patients were included by a multidisciplinary pelvis and perineal pain clinic between May 2011 and July 2012. Mean follow-up was 15 months. The intervention was an insertion of a stimulation electrode was followed by a test period (lasting an average of 13 days) before deciding on permanent electrode implantation. Maximum and average perineal pain scores and the pain-free sitting time were initially compared during the test and in the long-term (paired t-test). The estimated percent improvement (EPI) was evaluated in the long-term. Results Twenty of the 27 patients were considered to be responders to spinal cord stimulation and 100% of implanted patients remained long-term responders (mean tripling of sitting time, and mean EPI of 55.5%). Conclusions Spinal cord stimulation of the conus medullaris is a safe and effective technique for long-term treatment of refractory Pudendal Neuralgia. Routine use of this technique, which has never been previously reported in the literature in this type of patient, must now be validated by a larger scale study. Neurourol. Urodynam. 34:177–182, 2015. © 2013 Wiley Periodicals, Inc.
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Diagnostic criteria for Pudendal Neuralgia by Pudendal nerve entrapment (Nantes criteria).
Neurourology and urodynamics, 2008Co-Authors: Jean-jacques Labat, Thibault Riant, Roger Robert, Gérard Amarenco, Jean-pascal Lefaucheur, Jérôme RigaudAbstract:Aims: The diagnosis of Pudendal Neuralgia by Pudendal nerve entrapment syndrome is essentially clinical. There are no pathognomonic criteria, but various clinical features can be suggestive of the diagnosis. We defined criteria that can help to the diagnosis. Materials and Methods: A working party has validated a set of simple diagnostic criteria (Nantes criteria). Results: The five essentials diagnostic criteria are: (1) Pain in the anatomical territory of the Pudendal nerve. (2) Worsened by sitting. (3) The patient is not woken at night by the pain. (4) No objective sensory loss on clinical examination. (5) Positive anesthetic Pudendal nerve block. Other clinical criteria can provide additional arguments in favor of the diagnosis of Pudendal Neuralgia. Exclusion criteria are also proposed: purely coccygeal, gluteal, or hypogastric pain, exclusively paroxysmal pain, exclusive pruritus, presence of imaging abnormalities able to explain the symptoms. Conclusion: The diagnosis of Pudendal Neuralgia by Pudendal nerve entrapment syndrome is essentially clinical. There are no specific clinical signs or complementary test results of this disease. However, a combination of criteria can be suggestive of the diagnosis. Neurourol. Urodynam. 2007 Wiley-Liss, Inc.
Thibault Riant - One of the best experts on this subject based on the ideXlab platform.
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Anatomical Variants of the Pudendal Nerve Observed during a Transgluteal Surgical Approach in a Population of Patients with Pudendal Neuralgia.
Pain Physician, 2017Co-Authors: Stephane Ploteau, Marie-aimée Perrouin-verbe, Jean-jacques Labat, Thibault Riant, Amélie Levesque, Roger RobertAbstract:BACKGROUND: Several studies have described the course and anatomical relations of the Pudendal nerve. Several surgical nerve decompression techniques have been described, but only the transgluteal approach has been validated by a prospective randomized clinical trial. The purpose of this study was to describe the course of the nerve and its variants in a population of patients with Pudendal Neuralgia in order to guide the surgeon in the choice of surgical approach for Pudendal nerve decompression. OBJECTIVES: In order to support the choice of the transgluteal approach, used in our institution, we studied the exact topography, anatomical relations, and zones of entrapment of the Pudendal nerve in a cohort of operated patients. STUDY DESIGN: Observational study. SETTING: University hospital. METHODS: One hundred patients underwent unilateral or bilateral nerve decompression performed by a single operator via a transgluteal approach. All patients satisfied the Nantes criteria for Pudendal Neuralgia. The operator meticulously recorded zones of entrapment, anatomical variants of the course of the nerve, and the appearance of the nerve in the operative report. RESULTS: One hundred patients and 145 nerves were operated consecutively. Compression of at least one segment of the Pudendal nerve (infrapiriform foramen, ischial spine, and Alcock's canal) was observed in 95 patients. The zone of entrapment was situated at the ischial spine between the sacrospinous ligament (or ischial spine) and the sacrotuberous ligament in 74% of patients.Anatomical variants were observed in 13 patients and 15 nerves. Seven patients presented an abnormal transligamentous course of the nerve (sacrotuberous or sacrospinous). A perineal branch of the fourth sacral nerve to the external anal sphincter was identified in 7 patients. In this population of patients with Pudendal Neuralgia, the Pudendal nerve was stenotic in 27% of cases, associated with an extensive venous plexus that could make surgery more difficult in 25% of cases, and the nerve had an inflammatory appearance in 24% of cases. LIMITATIONS: We obviously cannot be sure that the anatomical variants identified in this study can be extrapolated to the general population, as our study population was composed of patients experiencing perineal pain due to Pudendal nerve entrapment and their pain could possibly be related to these anatomical variants, especially a transligamentous course of the Pudendal nerve. The absence of other prospective randomized clinical trials evaluating other surgical approaches also prevents comparison of these results with those of other surgical approaches. CONCLUSIONS: This is the first study to describe the surgical anatomy of the Pudendal nerve in a population of patients with Pudendal Neuralgia. In more than 70% of cases, Pudendal nerve entrapment was situated in the space between the sacrospinous ligament and the sacrotuberous ligament. Anatomical variants of the Pudendal nerve were also observed in 13% of patients, sometimes with a transligamentous course of the nerve. In the light of these results, we believe that a transgluteal approach is the most suitable surgical approach for safe Pudendal nerve decompression by allowing constant visual control of the nerve.Key words: Surgical, operative technique, Pudendal, Neuralgia, transgluteal approach.
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adding corticosteroids to the Pudendal nerve block for Pudendal Neuralgia a randomised double blind controlled trial
British Journal of Obstetrics and Gynaecology, 2017Co-Authors: J-j Labat, Thibault Riant, B. Rioult, A Lassaux, B Rabischong, M Khalfallah, C Volteau, A M Leroi, Stephane PloteauAbstract:Objective To compare the effect of corticosteroids combined with local anaesthetic versus local anaesthetic alone during infiltrations of the Pudendal nerve for Pudendal nerve entrapment. Design Randomised, double-blind, controlled trial. Setting Multicentre study. Population 201 patients were included in the study, with a subgroup of 122 women. Methods CT-guided Pudendal nerve infiltrations were performed in the sacrospinous ligament and Alcock's canal. There were three study arms: patients in Arm A (n = 68) had local anaesthetic alone, those in Arm B (n = 66) had local anaesthetic plus corticosteroid and those in Arm C (n = 67) local anaesthetic plus corticosteroid with a large volume of normal saline. Main outcome measures The primary end-point was the pain intensity score at 3 months. Patients were regarded as responders (at least a 30-point improvement on a 100-point visual analogue scale of mean maximum pain over a 2-week period) or nonresponders. Results Three months’ postinfiltration, 11.8% of patients in the local anaesthetic only arm (Arm A) were responders versus 14.3% in the local anaesthetic plus corticosteroid arms (Arms B and C). This difference was not statistically significant (P = 0.62). No statistically significant difference was observed in the female subgroup between Arm A and Arms B and C (P = 0.09). No significant difference was detected for the various pain assessment procedures, functional criteria or quality-of-life criteria. Conclusions Corticosteroids provide no additional therapeutic benefits compared with local anaesthetic and should therefore no longer be used. Tweetable abstract Steroid infiltrations do not improve the results of local anaesthetic infiltrations in Pudendal Neuralgia.
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Pudendal Neuralgia Due to Pudendal Nerve Entrapment: Warning Signs Observed in Two Cases and Review of the Literature.
Pain physician, 2016Co-Authors: Stephane Ploteau, Marie-aimée Perrouin-verbe, Thibault Riant, Claire Cardaillac, Jean-jacques LabatAbstract:Pudendal Neuralgia is a chronic neuropathic pelvic pain that is often misdiagnosed and inappropriately treated. The Nantes criteria provide a basis for the diagnosis of Pudendal Neuralgia due to Pudendal nerve entrapment. The 5 essential diagnostic criteria are pain situated in the anatomical territory of the Pudendal nerve, worsened by sitting, the patient is not woken at night by the pain, and no objective sensory loss is detected on clinical examination. The fifth criterion is a positive Pudendal nerve block. We have also clarified a number of complementary diagnostic criteria and several exclusion criteria that make the diagnosis unlikely. When Pudendal Neuralgia due to Pudendal nerve entrapment is diagnosed according to the Nantes criteria, no further investigation is required and medical or surgical treatment can be proposed. Nevertheless, a number of warning signs suggesting other possible causes of Pudendal Neuralgia must not be overlooked. These warning signs (red flags) are waking up at night, excessively neuropathic nature of the pain (for example, associated with hypoesthesia), specifically pinpointed pain, which can suggest neuroma and pain associated with neurological deficit. In these atypical presentations, the diagnosis of pain due to Pudendal nerve entrapment should be reconsidered and a radiological examination should be performed. The 2 cases described in this report (tumor compression of the Pudendal nerve) illustrate the need to recognize atypical Pudendal Neuralgia and clarify the role of pelvic magnetic resonance imaging (MRI), as MRI provides very valuable information for the evaluation of diseases involving the ischiorectal fossa. The presence of red flags must be investigated in all cases of Pudendal Neuralgia to avoid missing Pudendal Neuralgia secondary to a mechanism other than nerve entrapment.
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Spinal cord stimulation of the conus medullaris for refractory Pudendal Neuralgia: a prospective study of 27 consecutive cases.
Neurourology and urodynamics, 2013Co-Authors: Kevin Buffenoir, Jean-jacques Labat, Thibault Riant, B. Rioult, Olivier Hamel, Roger RobertAbstract:Aims Thirty percent of patients with Pudendal Neuralgia due to Pudendal nerve entrapment obtain little or no relief from nerve decompression surgery. The objective was to describe the efficacy of spinal cord stimulation of the conus medullaris in patients with refractory Pudendal Neuralgia. Methods This prospective study, conducted by two centers in the same university city, described the results obtained on perineal pain and functional disability in all patients with an implanted conus medullaris stimulation electrode for the treatment of refractory Pudendal Neuralgia. Twenty-seven consecutive patients were included by a multidisciplinary pelvis and perineal pain clinic between May 2011 and July 2012. Mean follow-up was 15 months. The intervention was an insertion of a stimulation electrode was followed by a test period (lasting an average of 13 days) before deciding on permanent electrode implantation. Maximum and average perineal pain scores and the pain-free sitting time were initially compared during the test and in the long-term (paired t-test). The estimated percent improvement (EPI) was evaluated in the long-term. Results Twenty of the 27 patients were considered to be responders to spinal cord stimulation and 100% of implanted patients remained long-term responders (mean tripling of sitting time, and mean EPI of 55.5%). Conclusions Spinal cord stimulation of the conus medullaris is a safe and effective technique for long-term treatment of refractory Pudendal Neuralgia. Routine use of this technique, which has never been previously reported in the literature in this type of patient, must now be validated by a larger scale study. Neurourol. Urodynam. 34:177–182, 2015. © 2013 Wiley Periodicals, Inc.
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Somatic perineal pain other than Pudendal Neuralgia
Neuro-Chirurgie, 2009Co-Authors: R Robert, Thibault Riant, J-j Labat, J-m Louppe, O Lucas, O HamelAbstract:In addition to the well-established syndrome of Pudendal compression, and given the rich nerve trunk innervation of the perineum, pain originating in other nerve trunks can occur and must be remembered. Nerves originating high in the thoracolumbar area (ilioinguinal nerve, iliohypogastric nerve, genitor femoral nerve) can be the seat of traumatic lesions occurring during surgical approaches through the abdominal wall or can undergo compressions when crossing the fascia of the large abdominal muscles. Misleading perineal irradiations do not resemble Pudendal Neuralgia and should suggest pain in these trunks whose cutaneous territories are not solely perineal and whose clinical expression as pain is does not occur in the seated position. Similarly, painful minor intervertebral dysfunction of the thoracolumbar junction is not simply in the mind and should be considered, searched for, and treated. Related more to Pudendal Neuralgia, pain in the inferior cluneal nerve, triggered by the seated position, should be considered when the pain reaches the lateral anal region, the scrotum, or the labia majora but not involving the glans penis or the clitoris. Specific treatments (physical therapy, infiltrations, surgery) have proven effective.
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Pudendal Neuralgia following transobturator inside out tape procedure tvt o case report and anatomical study
International Urogynecology Journal, 2012Co-Authors: Jaromir Masata, Petr Hubka, Alois MartanAbstract:Persistent pain after TVT-O procedure is a rare complication. Nerve injuries have been suspected as a cause of persistent pain. We present one case of atypical postoperative pain—Pudendal Neuralgia following TVT-O procedure—which persisted 3 years after the primary procedure. The patient required surgical removal of the tape, which brought only partial relief. Complete relief from pain was afterwards achieved with repeated local applications of anesthetics with corticosteroids. The recurrent stress urinary incontinence was treated with retropubic TVT. Pudendal nerve irritation was also described after retropubic sling procedure, and the cadaveric dissection indicated the theoretic possibility of nerve injury during retropubic sling procedure. To explain the mechanism of nerve injury, we performed cadaveric dissections on a formalin-embalmed female body. We were able to demonstrate the contact of the needle with the Pudendal nerve after aberrant passage of the inserter.
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Pudendal Neuralgia following transobturator inside-out tape procedure (TVT-O)—case report and anatomical study
International Urogynecology Journal, 2012Co-Authors: Jaromir Masata, Petr Hubka, Alois MartanAbstract:Persistent pain after TVT-O procedure is a rare complication. Nerve injuries have been suspected as a cause of persistent pain. We present one case of atypical postoperative pain—Pudendal Neuralgia following TVT-O procedure—which persisted 3 years after the primary procedure. The patient required surgical removal of the tape, which brought only partial relief. Complete relief from pain was afterwards achieved with repeated local applications of anesthetics with corticosteroids. The recurrent stress urinary incontinence was treated with retropubic TVT. Pudendal nerve irritation was also described after retropubic sling procedure, and the cadaveric dissection indicated the theoretic possibility of nerve injury during retropubic sling procedure. To explain the mechanism of nerve injury, we performed cadaveric dissections on a formalin-embalmed female body. We were able to demonstrate the contact of the needle with the Pudendal nerve after aberrant passage of the inserter.
