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_______________________ Treatment Medical - Analgesic medications, even those containing narcotics may have limited efficacy for neuropathic pain. Pain modulators such as tricyclic antidepressants and neuroleptics (i.e. Neurontin, Zonegran, etc.) have varied efficacy. Nerve infiltration with a combination of local anesthetic (Lidocaine or Marcaine) combined with steroid (Triamcinolone or Solu-Medrol) or combined with Heparin can be used. Multiple injections (usually 3-5) may be required. Timing intervals vary but 3-6 week interval between infiltration seems reasonable. Success rates also vary widely where between 15-60% are cured or improved with this approach alone. Lifestyle Modifications – Avoiding activities which worsen the condition is crucial (cycling, sitting, etc.). Sitting pads, especially those designed with cutouts to transmit pressure away from the perineum, can be very helpful. Physical Therapy - Musculoskeletal dysfunctions can cause pudendal neuralgia as well as other painful pelvic syndromes. Physical therapy is an effective method of minimizing or eliminating the concurrent pain generators that occur when the pudendal nerve is irritated (i.e., pelvic floor hypertonicity and myofascial trigger points, extrapelvic hypertonicity and trigger points, adverse neural tension, sacro-iliac joint dysfunctions, connective tissue restrictions, and faulty neuromuscular recruitment patterns). It is important to acknowledge this interaction between musculoskeletal and neural dysfunction as it is unusual that one exists without the other. Physical therapists require special training to treat pudendal neuralgia. The therapist should have a strong manual therapy bias and an extensive working knowledge of pudendal neuralgia. The program should emphasize restoring normal length to the pelvic floor (through internal myofascial release) and pelvic floor relaxation techniques. Typically, the shortened pelvic floor/pudendal neuralgia will become symptomatically exacerbated with Kegel exercises and these should be avoided until otherwise instructed by a professional. The program should also include connective tissue mobilization, neural mobilization and a home exercise program. Surgical - Three main surgical techniques are currently available (worldwide) for nerve decompression. The theory is similar to other nerve decompression procedures performed for nerve entrapments in other regions of the body (i.e. carpal tunnel release). The procedures differ in their approach to the area of entrapment and have never been compared head to head. Post-Operative Physical Therapy - The above mentioned musculoskeletal dysfunctions can be responsible for pain that persists after a decompression procedure. It is recommended that external physical therapy begin one month post-operatively and that pelvic floor rehabilitation gets initiated at three months. Sacro-iliac joint dysfunction commonly co-exists with pelvic pain. When the sacrotuberous ligament is severed during decompression, SIJD is a common post-operative complication. Patients typically will have persistent (or ‘new’) pain and pelvic dysfunction. This situation is correctable through proper stabilization techniques: through physical therapy in less involved circumstances and through proliferative therapy and physical therapy in more severe circumstances.. _______________________ |
