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_______________________ Diagnosis History and physical as well as other diagnostic tests will help differentiate between pudendal nerve entrapment versus nerve dysfunction. For patients with pudendal neuralgia, the patient will describe pain or other nerve dysfunction in accordance with the distribution of the pudendal nerve. The patient may or may not give a history of a common triggering factors (i.e. pelvic surgery, trauma, delivery, etc.). Patients will state that sitting increases symptoms and standing decreases symptoms somewhat. On exam, altered skin sensitivity will be noted. Pressure on the pudendal trunk will produce pain (equivalent to Tinel’s sign). This can be performed both transvaginally and transrectally. A pudendal nerve block may produce significant or complete pain relief for several hours to several weeks. The block may be used as a diagnostic tool; resultant pain relief demonstrates at least some of the symptoms are stemming from an inflamed nerve. The block may be performed via the transperineal, transvaginal or transgluteal route with or without radiographic assistance. Finally, electrophysiologic evaluation can help confirm the site of entrapment and the type of nerve damage. The studies consist of EMG testing of the external sphincter, sacral reflex, pudendal nerve terminal motor latency (PNTML) and somatosensory evoked potential studies. In addition to entrapment, pudendal neuralgia can also be caused by compression or tension dysfunctions. On exam, a patient will still present with a positive Tinel's sign and often pelvic floor dysfunction. Specialized physical therapy in conjunction with pudendal nerve blocks can result in significant reductions in pain and can improve function. When the pudendal neuralgia is caused by an actual nerve entrapment, physical therapy and injections alone are often not successful in completely eradicating the problem. In the event conservative management is failing, sacral reflex testing is indicated to confirm or rule out an entrapment. This will determine if the patient requires further conservative management or a surgical decompression. _______________________ |
