Neuropathy of the pudendal nerve is a disease that is a consequence of the development of compression processes affecting the coccygeal plexus and the nerve itself.

Neuropathy of the pudendal nerve is a disease that is a consequence of the development of compression processes affecting the coccygeal plexus and the nerve itself. As a rule, such a disorder occurs against the background of dystrophic changes in the ligaments and muscles of the pelvis. Pathology develops in both men and women of different ages. Despite the prevalence of this problem, neuropathy is diagnosed extremely rarely. This is due to the fact that only a small percentage of patients pay attention to the symptoms of the disease and seek medical help.

Genital neuropathy can affect various nerve fibers surrounding the genital organs (genital femoral, ilioinguinal nerve).

The main etiological factor provoking pudendal neuropathy is pinching of the pudendal nerve, which occurs in the Alcock canal.

Clinical case

Patient S., 68 years old, was admitted for treatment to the II neurological department on January 11, 2016. with complaints of pain in the glans penis, pain in the rectum during defecation, painful urination, pain in the lumbar region. The above complaints intensify as the patient assumes a vertical position.

From the anamnesis it is known that for many years he has been suffering from osteochondrosis of the lumbosacral spine. In 2006 Surgical removal of a herniated intervertebral disc L4-L5 was performed. In 2008 The patient first noted frequent urination. In 2009 Additional examination revealed bladder formation, and histological findings revealed urothelial cancer G2 with ulceration and inflammation. In 2009 The patient underwent hemiresection of the bladder with ureteroneocystoanastomosis on the left. In 2012 A TUR of the bladder neck and prostate was performed; repeated histological examination did not reveal tumor cells. Since 2013 and to this day, the patient has developed pain along the urethra with irradiation to the head of the penis, painful urination and defecation. Repeatedly consulted urologists, received antibacterial therapy, M-anticholinergics (Vesicar), alpha-blockers (Omnic) with minimal effect.

In 2015 The patient underwent a comprehensive additional examination in several medical institutions: MRI of the lumbosacral spine: pronounced degenerative-dystrophic changes, posterior central herniation of the L4-L5 intervertebral disc, spinal canal stenosis at the L2-L4 level. FSC: signs of chronic colitis, hemorrhoids. TRUS of the prostate: Ultrasound signs of chronic urethroprostatitis, fibrosis, calcification of the prostate parenchyma and bladder neck. Uroflowmetry: the bladder is overactive with reduced functional elasticity. CT scan of the retroperitoneum: CT scan signs of bladder shrinkage, atherosclerosis of the abdominal aorta. IN RostSMU was carried out consultation under the leadership of the head. department Urology Doctor of Medicine prof. Kogan M.I., who came to the conclusion that the cause of persistent pain in the genital area is neuropathy of the pudendal nerve. In order to exclude recurrence of bladder cancer, the patient was offered diagnostic surgery, which the patient refused.

Considering the persistence of the above complaints, the patient was routinely hospitalized in Clinical Hospital No. 1 for examination and treatment.

Neurological status at the time of admission: Conscious, alert, oriented. The background mood is reduced. Fixed on his feelings. There are no meningeal signs. CMN: Palpebral fissures D=S. Pupils D=S. Photoreactions are live. Movement of the eyeballs is not limited. There are no sensory disturbances on the face. The exit points of the trigeminal nerve are painless. The face is symmetrical. There is no nystagmus. The pharyngeal reflex is preserved. Swallowing and phonation are not impaired. Tongue in the midline. There are no paresis. Tendon reflexes are low, from the hands, knees S=D, the Achilles reflex on the right is reduced. No pathological foot signs are detected. Moderate defence of the lumbar muscles on both sides. Paravertebral points and spinous processes in the lumbar region are moderately painful. No clear sensitivity disturbances are detected (including in the perineal area). Stable in the Romberg position. PNP performs satisfactorily on both sides.

A clinical diagnosis was made: Chronic pelvic pain syndrome: postoperative neuropathy of the pudendal nerve.

The patient was consulted by a urologist and oncologist: at present there is no data on the progression of the oncological process, given the long relapse-free period, FTL is not contraindicated.

The patient received drug treatment, including anticonvulsants (Neurontin), antidepressants (Paxil), muscle relaxants (Sirdalud), vascular drugs (Trental), non-steroidal anti-inflammatory drugs (Arcoxia), metabolic drugs (Kombilipen injections), pain-relieving droppers, including antispasmodics, sedatives, corticosteroids, local anesthetics. Physiotherapeutic methods of treatment, acupuncture, and physical therapy were also included in the complex therapy.

After treatment, the patient's condition improved. In the neurological status, positive dynamics were noted: paravertebral points, spinous processes in the lumbar region are painless, the defence of the lumbar muscles has regressed, the pain syndrome has been relieved. The frequency, intensity and duration of attacks of pain in the area of ​​the glans penis have decreased, and the mood has stabilized.

The patient was discharged home in satisfactory condition with recommendations for outpatient antidepressant, anticonvulsant, and anti-inflammatory therapy for 2 months.

The main factor in the occurrence of this disease is pinching of the pudendal nerve, which occurs in the Alcock canal. Neuropathy pudendal nerve occurs in the following cases:

• Injuries during childbirth.
• Development of oncology in the pelvic area.
• Complicated course of herpes.
• Fracture of the pelvic bones.
• Nerve damage due to cycling.

All these reasons cause pain in the pelvic area.

Symptoms of pathology

Neuropathy pudendal nerve characterized by many features. Patients complain of the following:

1. Aching pain that occurs in the anus or genital area.
2. Burning and tingling in the groin.
3. Genital dysfunction.
4. Urinary incontinence.
5. Particular sensitivity of the skin in the pubic area.

When the disease occurs, women feel itching and pain in the area of ​​the labia, clitoris and vagina.

Diagnosis and treatment of pathology

When patients consult a specialist with signs of infringement pudendal nerve, then the diagnosis is established according to the characteristic features. Patients undergo Doppler ultrasound scanning. As a result, a slowdown in the speed of blood flow in the penile artery is determined.

To the basic principles treatment include:

• "Gabapentin." The drug helps reduce pain.
• A muscle relaxant (“Mydocalm”) is used to relax muscles.
• Blockade of the pudendal nerve using anesthetics and hormones.
• Physiotherapeutic methods (electrophonophoresis).

If you experience discomfort caused by pinching of the pudendal nerve, you should urgently seek help from a specialist.

It is responsible for the innervation of the pelvic floor muscles, and when this bundle is pinched, people experience chronic pain in the pelvic area. This phenomenon usually occurs due to compressive neuropathy. It represents compression (pinched nerve). In men, this problem occurs 2-3 times more often than in women due to anatomical features.

Features of the anatomy of the pudendal nerve

The pudendal nerve tract begins significantly above the innervated zones, which is why doctors often call it the femoral-genital nerve. It passes through the muscles of the lower back and over the ureter, and then extends to the groin area. At this point it is divided into 2 branches:

The femoral-genital nerve, passing into the inguinal branch, has 2 options for continuation depending on the gender of the person:

• Male. It exits through the canal along with the spermatic cord and follows into the scrotum;
• Female. In the case of the weaker sex, the pudendal nerve leaves the canal along with the round ligament of the uterus and smoothly passes into the skin of the labia majora.

The inguinal nerve in women and men innervates the following tissues:

• Muscle tissue of the anus;
• The outer skin of the anus and genitals;
• Anal sphincter;
• Muscles of the perineum;
• Female clitoris;
• Male cavernous bodies of the penis;
• Bladder sphincter.

The pudendal nerve tract is responsible not only for the sensations experienced during sexual intercourse, but also directly for defecation and urination.

It performs the last two functions thanks to the vegetative fibers in its composition. It is the autonomous (vegetative) part of the nervous system that is responsible for many systems that are not controlled by human consciousness, for example, constriction of the pupils, heart rhythm, etc.

Damage to this nerve is caused by pinching of the piriformis muscle, ligaments, etc. Sometimes the cause of such compression lies in the injury received, as a result of which the pelvic bones were crushed or ligaments were torn. This type of neuralgia is usually accompanied by a feeling of tension and inflammation.

Causes of inflammation

Traction-compression neuropathy of the left or right nerve tract occurs in the Alcock canal. Therefore, pinching of the pudendal nerve that occurs in this area is called Alcock syndrome. Among other types of neuropathy characteristic of this nerve pathway, one can distinguish the femoral-genital form. It manifests itself mainly due to groin injury or the development of an inguinal hernia. Ilioinguinal nerve neuropathy also falls into this group. It occurs due to the appearance of scars on muscle tissue, which are a consequence of surgery.

Pinching of the pudendal nerve occurs mainly due to the following factors:

• Trauma sustained during childbirth;
• Spasm of the muscle tissue of the anus;
• Pelvic fracture;
• Development of malignant oncological diseases;
• High tone of the piriformis muscle;
• Complications of herpes;
• Spasm of the obturator internus muscle;
• Compression of the pudenda due to riding a horse or bicycle.

Symptoms

Compressive neuropathy of the pudendal nerve is characterized by many symptoms, but their severity is rather mild. For this reason, it is extremely difficult to diagnose pathology. Among the main manifestations of the disease are the following:

• Aching pain in the pelvic area;
• Genital dysfunction;
• Constant feeling of discomfort in the anal area;
• Involuntary urination;
• False sensation of a foreign object in the groin area;
• Feeling of burning and slight tingling in the groin area;
• Excessively high sensitivity of the skin in the groin area.

In women, severe itching and burning in the genital area can be added to the main symptoms of neuropathy. In a sitting position, these symptoms intensify significantly.

In more rare cases, the following symptoms are observed:

• Abnormal bowel movements (constipation);
• Numbness of the genitals;
• Pain during sexual intercourse and when urinating.

Diagnostics

The doctor identifies the presence of a problem, focusing on the symptoms and ultrasound results. With neuropathy, it will indicate impaired blood flow in the pudendal artery, which passes through the Alcock canal. From this we can conclude that along with it there was compression of the pudendal nerve tract.

An effective diagnostic method is blockade of the pudendal nerve tract. If the discomfort disappears, then all the blame lies with neuropathy. Typically, in such a situation, a course of therapy is prescribed, which includes glucocorticoid injections, vaginal suppositories and other methods of restoring pinched nerve fibers.

Course of therapy

Treatment of neuropathy should consist of a set of measures aimed at eliminating inflammation, relieving pain and restoring nerve conduction. Typically it includes the following treatment methods:

• Elimination of pain with the help of anticonvulsants (Gebapentin);
• The use of physiotherapeutic procedures (phonopharesis, electropheresis, etc.);
• Blocking the nerve pathway with a solution of hormones and anesthetics;
• Use of muscle relaxants (Mydocalm);
• The use of vitamin complexes (Neuromultivit).

Neuromultivit vitamins and their analogues can be taken both as a component of a blockade solution and in the form of tablets. If the discomfort is severe, then suppositories for rectal or vaginal use based on Diazepam and special sets of exercises are used. The essence of physical therapy for neuropathy of the pudendal nerve is to compress and relax the muscles of the perineum.

If there is no point in continuing to treat medically damaged nerve tissue due to lack of results, then surgery will be required to decompress the compressed nerve. Such operations are extremely effective, but have a long recovery period.

With prolonged absence of treatment, the consequences of the pathology may develop. The disease can become chronic and some symptoms will be extremely difficult to eliminate. There have been cases of impotence and decreased libido, as well as increased involuntary urination and defecation.

Pudendal neuropathy is an unpleasant condition, but some people live with it for years. This is usually associated with vague symptoms and a chronic course. You can avoid such discomfort, but to do this you will have to undergo an examination and follow all the doctor’s recommendations.

Pinched and neuropathy of the pudendal nerve in women and men

Does the pudendal (genital) nerve and its damage differ from similar pathologies in other “regions” of the body?

Yes, the nature of the pathology is different in that the pudendal nerve serves the pudendal area - the genital area, the structure of which is different in men and women. The words of one very concentrated boy from the film “Kindergarten Policeman” immediately come to mind, with which he stopped everyone entering the door of the kindergarten: boys have a penis, girls have a vagina.

In men, the concept of external genitalia includes much more structures in terms of number, volume, and area, therefore the pudendal nerve has a more complex and branched structure, while in women, due to the greater “compactness” of the external genitalia, its length is much shorter.

The pudendal nerve is a paired structure formed on both sides of the body also by paired branches of the sacral spinal nerves, which provides innervation to organs present in both sexes: the perineum, sphincters of the bladder and rectum, as well as the levator ani muscle, and then they begin differences in structure: in women it provides sensitivity and vegetative function of the labia majora and minora and the clitoris, in men it provides the same functions in relation to the cavernous bodies of the penis and scrotum.

In the photo, the same painful area in women is highlighted in yellow.

About the causes and symptoms of functional disorders

For the etiology of damage, the proximity to the ischium, which the nerve bends around, entering the pelvic cavity, as well as the relatively shallow depth of the terminal branches under the surface of the skin and mucous membranes of the pelvic organs, are important. Therefore, dysfunction can occur as a result of:

• injuries to the perineal area;

Perineal trauma can lead to more serious consequences

Provoking factors may be:

• horse riding or cycling (frequently or professionally);
• prolonged labor;
• fracture of the pelvic bones (from a fall from a height, in a car or plane accident).

To understand that something is wrong with the genitofemoral nerve is made possible by dysfunctions of the organs located in the pelvis. These may be sensitivity disorders or autonomic disorders.

Deviations in autonomics are expressed by disturbances in the functioning of glands and other structures containing smooth muscle fibers, in particular, disorders of the mechanism of blood supply to the cavernous bodies of the penis or clitoris.

Trophic disorders of the skin of the perineum, scrotum and peri-anal area can also be a sign of disorders.

In addition to physical factors, the cause of pathology can also be general somatic diseases:

• tuberculosis;
• collagenoses;
• blood supply disorders due to endocrine disorders and vascular accidents or for any other reason.

Infringement of rights, or neuralgia

It has long been noticed that those who are violated in their rights either scream loudly about this fact, or mutter about it in a low voice until no one hears.

Provoking factors

The situation is exactly the same if the pudendal nerve is pinched in the canal containing it. A canal with a narrowed diameter for some reason (due to bone growths, bone fractures, or for some other reason) puts pressure on the nerve, which leads to predominantly pain of varying intensity.

Compression of the nerve can be caused by its “swelling”, accompanied by an increase in diameter, which causes its discrepancy with the diameter of the enclosing canal.

But the structure of the affected pudendal nerve does not change during neuralgia. Movement disorders do not occur in the same way as loss of sensitivity.

Therefore, neuralgia is exclusively pain of varying nature and intensity.

And pinching of the pudendal nerve can occur in the inguinal canal:

• with varicose veins of the spermatic cord in men;
• due to pathology of the round ligament of the uterus in women;
• due to an inguinal hernia or the occurrence of cicatricial changes after hernia repair.

Pelvic neuralgia, which often accompanies pinched pudendal nerve, can also occur due to:

• trauma during childbirth;
• muscle spasm in the area of ​​the anus, hypertonicity of the piriformis muscle or obturator internus muscle;
• development of oncopathology in the pelvic organs;
• the onset of complications of herpes.

Features of symptoms

Symptoms of this form of neuralgia are chronic pain in the pelvic area, having the following character:

• aching;
• feelings of burning and itching, especially strong in women and especially in a sitting position;
• excessively high sensitivity of the skin of the groin and perineum area;
• sensations of constant discomfort in the area of ​​natural orifices of the body;
• false-obsessive sensation of a foreign body in the genital area.

Against the background of chronic stress, the following sensations may appear from long-term sensations:

• urination disorders (involuntary act) or pain when urinating;
• dysfunction of the genital organs (pain during coitus);
• bowel disorders (constipation).

Diagnostic criteria and treatment

For diagnosis, symptoms are important - the patient’s sensations, as well as the absence of external manifestations of pathology.

The use of:

In the first case, a violation of blood flow through the pudendal artery is detected, in the second - the disappearance of discomfort after manipulation.

The main goals of treatment are: pain relief, elimination of inflammation and restoration of nerve conduction.

Therefore, it is advisable to use:

• anticonvulsants (Gabapentin), which provide pain relief;
• muscle relaxants (Mydocalm), used to relax muscles;
• blockade of the pudendal nerve with a combination of solutions of anesthetics and hormones;
• vitamin complexes (Neuromultivita class);
• physiotherapeutic techniques (electro-, phonophoresis and the like).

To reduce discomfort, vaginal or rectal suppositories with Diazepam and exercise therapy (for massaging the perineal muscles) are used.

If therapeutic methods are ineffective, surgical decompression is used to relieve the injury and symptoms.

Surgical decompression is sometimes the only option

Since there is no limit to indignation, or about neuropathy

In addition to neuralgia, the pudendal nerve can also become the scene of an inflammatory process, then they speak of neuropathy (neuropathy), or neuritis of the pudendal nerve (a term rarely used today).

Neuropathy differs from neuralgia in the presence of structural changes in the pudendal nerve, as well as movement disorders and the possibility of loss of sensitivity, which serves as a reason for indignation and upset of the patient, because we are talking about neither more nor less than the genitals.

What could be the reason?

The cause of the pathology (also called pudendoneuropathy) is the implementation of two mechanisms:

• compression-squeezing of the nerve trunk in the “scissors” of the sacrospinous ligament-piriformis muscle;
• traction due to overstretching of the nerve in the zone of its transfer over the ischial spine.

The first is illustrated by the consequences of long-term or unsuccessful horse riding or cycling (compression by a hard saddle), and the second by the consequences of surgical intervention - for example, when traction of the hip with the use of a perineal fixator, tension occurs on the nerve pressed to the pubic region.

Features of symptoms

The clinic may consist of lesions of the main nerve trunk or signs of involvement of various branches of the pudendal nerve.

When a surgical fixation is used in the perineal area, isolated damage to the dorsal nerve of the penis occurs with anesthesia of the penis and complete disruption of the previously normal erection.

Full restoration of sensitivity can occur within 6 to 18 months after surgery, but restoration of erection can be only partial.

When compressed by a hard saddle, the disorder is felt as transient numbness or the appearance of paresthesia in the genital area.

Both unilateral and bilateral loss of sensitivity may be observed, not limited to the penile area, but continuing to manifest itself also in the scrotum area.

Neuropathies of the pudendal nerve can signal themselves by pain in the lower buttock and in the anus, short-term urinary retention or a disorder of the imperatives to urinate, accompanied by sharp pain when palpated in the projection of the ischium.

In men, an inflamed pudendal nerve manifests itself with characteristic symptoms - paresthesia or hypoesthesia and pain in the peri-anal area, in the area of ​​the penis and scrotum.

Diagnosis and treatment methods

The main diagnostic criterion is that the pull of the knee towards the opposite shoulder causes pain in the buttock (due to stretching of the sacrospinous ligament).

A simple diagnostic method is to pull the knee towards the shoulder

The clinic is confirmed by electromyography, noting the lengthening of the anal reflex, which closes on the pudendal nerve trunk, as well as a test blockade with the introduction of a novocaine solution into the area of ​​the ischial spine.

The choice of treatment method depends on whether the process is advanced or in an acute stage.

Thus, all the symptoms disappeared in a group of cyclists on their own, after they agreed to refrain from cycling for a month. In case of chronic neuropathy, long-term restorative therapy is necessary.

In chronic cases, methods of drug therapy in combination with rational exercise therapy and physiotherapy are applicable.

Drug therapy includes the use of anti-inflammatory drugs (glucocorticoids Prednisolone, Triamcinolone, Hydrocortisone) in combination with anesthetics (Novocaine 0.5 or 1%) in the form of blockades. A case of pain that had been observed for 14 years disappearing after a course of perineural administration of Triamcinolone is described.

Blockade is an effective method, the injection point is indicated with a finger

Pure novocaine blockades are usually less effective.

In order to relieve pain, suppositories of a combined formulation with anesthetics, sedatives and antispastic compounds, both rectal and vaginal, are used.

Vitamin therapy (administration of vitamin C and group B in adequate doses) is especially effective in combination with physiotherapy techniques (various methods of heat therapy), while exercise therapy allows you to increase the capabilities of muscles spasmed by pain and helps to increase the overall tone of the body.

Surgical intervention is applicable if there is no effect from treatment with therapeutic methods.

You should be extremely careful in the case of neuropathy of oncogenic etiology.

Preventive measures

When riding a bicycle or horse professionally, you should take precautions and follow a routine with mandatory breaks.

Implementing traction for a hip fracture requires the use of a perineal fixator with an adequate support area (up to 9 cm) with a mandatory softening pad.

Intramuscular injections of Magnesium sulfate solution in large doses require caution to prevent the occurrence of ischemic necrosis of the gluteal muscles.

If painful sensations in the pelvis, perineum and genitals appear, and even more so if they increase, you must immediately seek help from a neurologist.

Incontinence due to damage to the pudendal nerve

The pudendal nerve is responsible for sensation in the external genitalia, lower rectum, and perineum. The perineum is the space between the genitals and the anus. Neuropathy occurs due to disease or damage to the nerves, and pudendal neuropathy can cause symptoms in these areas.

Pudendal nerve entrapment is often misdiagnosed as a prostate disease, such as prostatodynia or nonbacterial prostatitis. Unknown causes of vaginal pain, ovarian pain, rectal pain, penile pain, tailbone pain and buttock pain can occur as a result of pudendal nerve neuropathy. About 2/3 of patients with pudendal nerve entrapment are women.

Pudendal nerve entrapment can occur suddenly or develop over time. Prolonged sitting, cycling. Repetitive movements and leg exercises can lead to pinching of the pudendal nerve.

Some people have primarily rectal pain, sometimes with problems with bowel movements. For others, pain predominates in the perineum or genitals. Symptoms may include stabbing, cramping or burning pain, tingling, numbness or sensitivity. Symptoms are usually worse when sitting and better when standing or lying down. There may be a feeling that the person is sitting on a bump.

Damage to the pudendal nerve is identical to Carpal Tunnel syndrome, which is also a form of nerve entrapment. However, damage to the pudendal nerve is much more difficult to treat due to its location.

Pudendal nerve entrapment is a condition that causes pain without any apparent cause in the area innervated by the pudendal nerve. There is no dominant pain pattern. The pain can be localized in one area, several, or all. It can be one-sided, two-sided or in the middle. Problems in the urinary, rectal and reproductive systems are also common.

Pudendal neuropathy is often caused by inflammatory injury or chronic mechanical compression of the pudendal nerve.

Damage to the pudendal nerve can occur suddenly as a result of trauma, such as pelvic surgery, falls, bicycle accidents or childbirth, and sometimes severe constipation. It can also occur from repeated trauma over a long period of time, such as cycling, or aggressive lifting of heavy objects, which causes tension in the pelvic muscles. It can also be caused by diseases such as diabetes or multiple sclerosis. Trauma may directly stretch or compress the nerve, or fibrosis may impinge on the nerve.

Treatment for neuropathy of the pudendal nerve should be comprehensive.

The course of therapy is prescribed individually by the attending physician and includes:

• taking special medications that affect neuropathic and chronic pain;
• physiotherapeutic procedures (neuromodulation, acupuncture);
• pudendal nerve blockade - droppers using anesthetics and glucocorticoids;
• massage;
• physical therapy

Massage, IVs and blockades are the most effective ways to relieve pain. They significantly improve treatment results. Physiotherapeutic procedures will help restore impaired nerve function. Also, for this purpose, a specialist can prescribe appropriate exercises to strengthen the pelvic floor muscles. The duration of treatment is at least 6 months.

Pinched pudendal nerve in men and women

The “pudendal” or pudendal nerve (n. Pudendus) is very often the cause of chronic pelvic pain that occurs in adults. The most common cause of this is compression neuropathy. Moreover, “pinching” of the pudendal nerve is three times less common in men than in women.

A little anatomy

The pudendal nerve is small in length, but a very important nerve of the latter, if you go from the brain, the sacral plexus. It lies in the pelvic cavity, along the way it goes around the ischium. It further divides into three branches - the rectal, perineal and dorsal nerve of the penis (clitoris). Its functions are varied:

• it innervates the levator ani muscle;

• innervates the anal sphincter;

sphincter

• gives branches to the muscles of the perineum;

• innervates the genital organs: cavernous bodies of the penis in men, clitoris in women;

• gives sensitivity to the skin of the external genitalia and anus;

• innervates the sphincter of the urethra.

As you can see, this nerve plays a big role not only in a person’s intimate life, but also in urination and defecation. The pudendal nerve contains a large number of autonomic fibers, which ensure the “unconscious work” of the sphincters. After all, a person never thinks, controls or consciously contracts muscles so as not to accidentally defecate or urinate in broad daylight. This is done by autonomic nerve fibers entering the lumen of the pudendal nerve.

The pudendal nerve in the male body (in yellow)

This nerve can be pinched either by the piriformis muscle, which is located in the pelvic cavity, or be pinched between two ligaments.

In addition, the nerve can be damaged, for example, due to a car accident or a fall from a great height, which results in a fracture of the pelvic bones. A fairly common cause of chronic pelvic pain is nerve damage during childbirth, as well as involvement of the nerve trunk in the growth of a malignant neoplasm.

In addition, activities such as horseback riding or cycling can also lead to compressive neuropathy of the pudendal nerve over time.

Symptoms of pudendal neuropathy

As with any neuropathic lesions, all symptoms consist of pain, sensory disturbances, autonomic disorders and muscle weakness. A pinched pudendal nerve is manifested by the following symptoms:

• painful sensations in the perineum;

• discomfort in the anus and genitals;

• burning tinge of pain;

• decreased skin sensitivity in these areas, “crawling goosebumps”;

• an unpleasant feeling of a foreign body in the urethra and anus;

• fecal and urinary incontinence. It may be incomplete and manifest itself in the form of spotting or drip urinary incontinence;

• sexual disorders: impotence, anorgasmia.

Pinching of the pudendal nerve in women causes the above symptoms also in the lower third of the vagina.

Pinched pudendal nerve in men, in addition to the above, can cause pain during sexual intercourse.

The very nature of the pain becomes burning, touching the skin becomes excruciatingly unpleasant. There are sensations of electric shocks, a sensation of either a hot or cold foreign body, problems with urination and defecation, and other various and unpleasant symptoms.

About diagnosing neuropathy

With such unpleasant and painful sensations, a person is not inclined to endure for long, as, for example, with pain in the arm or leg. Therefore, most often he turns to a neurologist or proctologist if the anal sphincter disorders are severe and there are problems with urinary and fecal retention.

Less often, a patient consults a sex therapist, but a competent specialist should, with the help of basic questioning, identify organic disorders and refer the patient to a specialist. Pudendal nerve neuropathy is diagnosed based on the following complaints and studies;

• patient complaints, which were discussed in detail above;

• the nature of the pain, which indicates neuropathic changes (burning, crawling, all kinds of itching, discomfort when touched);

• a trial therapeutic and diagnostic novocaine blockade of this nerve reliably reduces the severity of symptoms, or completely relieves the patient of suffering for the period of action of novocaine - from 12 hours to 3 days;

• When performing an ultrasound of the perineum and pelvis with Doppler ultrasound, almost always with compression-ischemic neuropathy of the pudendal nerve, a decrease in the volumetric velocity of blood flow in the nearby pudendal artery is observed. This happens “for company”: the pudendal artery passes along with the nerve in the same canals, and its narrowing indirectly confirms the compression of the pudendal nerve;

• An important diagnostic criterion is that the pain increases if the person sits and the pain decreases if the person lies on his back. Also, neuropathy of the pudendal nerve is characterized by unilateral damage. Disorders occur on the same side;

• patients often note that if they apply cold to the perineum, it causes relief and burning pain decreases. This symptom indicates the neuropathic nature of the nerve damage.

In addition to these diagnostic criteria, it is possible to palpate the perineum to identify characteristic pain points that reflect spasm in the piriformis muscle.

It is important that the pathology of this nerve has a deep connection with the progression of myofascial syndrome. This syndrome is more difficult to treat because the muscles are deeply located.

In addition, pudendal neuropathy worsens depression, anxiety, and makes people more susceptible to negative events.

Treatment of neuropathy

As in all other cases, therapy for this disease must be comprehensive. The basic principles of treatment are as follows:

• impact on the neuropathic nature of pain using gabapentin (Tebantin, Lyrica);

• conducting regular nerve blocks with anesthetics and hormones;

• physiotherapeutic effects: phonophoresis, Amplipulse therapy, electrophoresis;

• centrally acting muscle relaxants (Mydocalm). Allows you to relax muscles, including reducing the tone of the piriformis muscle;

• B vitamins included in the blockade, as well as tablet forms.

Sometimes treatment requires the support of a psychologist, correctional therapy is performed, and antidepressants are prescribed. Sometimes it is necessary to prescribe rectal or vaginal suppositories with diazepam, as well as perform special exercises. Their meaning is gradual relaxation - compression of the muscles of the perineum.

You should find out what exercises you need to do when the pudendal nerve is pinched

If conservative treatment is ineffective, then decompressive surgical operations are performed, which are performed in centers for the treatment of chronic pelvic pain.

It should be remembered that treatment of pudendal nerve neuropathy is a long process, and you need to follow all the instructions of specialists for at least 6 months.

How to treat the pudendal nerve?

The pudendal nerve, which is called the genital nerve, is the cause of chronic pain in the pelvic area. The disease occurs due to a pinched nerve. Despite the fact that this problem is common in men and women, neuropathy is diagnosed extremely rarely. If the pudendal nerve is pinched, only a specialist will prescribe treatment.

Causes of the disease

The main factor in the occurrence of this disease is pinching of the pudendal nerve, which occurs in the Alcock canal. Pudendal nerve neuropathy occurs in the following cases:

All these reasons cause pain in the pelvic area.

Symptoms of pathology

Pudendal nerve neuropathy is characterized by many symptoms. Patients complain of the following:

1. Aching pain that occurs in the anus or genital area.

When the disease occurs, women feel itching and pain in the area of ​​the labia, clitoris and vagina.

Diagnosis and treatment of pathology

When patients consult a specialist with signs of pudendal nerve entrapment, a diagnosis is made according to the characteristic signs. Patients undergo Doppler ultrasound scanning. As a result, a slowdown in the speed of blood flow in the penile artery is determined.

• "Gabapentin." The drug helps reduce pain.

If you experience discomfort caused by pinching of the pudendal nerve, you should urgently seek help from a specialist.

Pudendal Neuralgia Symptoms

Pudendal Neuralgia Symptoms

Here is this nerve itself (about the other nerves of the pelvic floor and the corresponding diseases, see the link):

Let me remind you that neuralgia (from “nerv” - nerve, “algo” - pain) is a painful condition caused by damage to the peripheral nerves (for example, due to injury, pinching, toxin poisoning, destruction by microorganisms, metabolic disorders, etc.). d.)

There is an English-language site dedicated to this problem (and in general, the problem of diseases associated with damage to the pudendal nerve, and not just nerve pain): www.pudendalhope.info Some excerpts from there [in my free translation! ]:

Possible symptoms include burning, numbness, increased sensitivity, electric shock or stabbing pain, sharp or aching pain, feeling of bloating or a foreign body in the rectum, twisting or pinching, abnormal sensation of temperature, sensation of a hot poker, constipation, pain and tension when moving the intestines, tension or burning during urination, painful sexual intercourse, sexual dysfunction - persistent erectile disorder (erection without desire) or, on the contrary, loss of sensitivity.

PN is often accompanied by musculoskeletal pain in other parts of the pelvis, such as the sacroiliac joint, piriformis muscle, and coccyx. It is usually very difficult to distinguish PN (pudental neuralgia) from pelvic dysfunction because they often occur together. Some use the term myoneuropathy to denote this unity, which emphasizes the neuro- and muscular (myo-) component (in the form of pelvic muscle tension).

Note. This pathology should not be confused with the so-called myofascial pain syndrome (MFPS, see, for example, http://medspecial.ru/for_patients/34/609/), although they often go hand in hand. MFPS is associated with the formation of areas of increased tension in the muscles - trigger points, the impact of which causes pain. Whereas PN and PNE are directly related to disruption of the conduction of the nerve fiber or its complete damage, which causes the corresponding symptoms.

On the above site there is a separate article devoted to the issue of diagnosing neuralgia caused by pinched pudendal nerve: [ http://www.pudendalhope.info/sites/default/files/NantesDiagnosticCriteria.pdf ]

For those who do not have a very good relationship with English, again, my free translation of this article:

Objectives: The diagnosis of pudendal nerve pain caused by pinched nerve syndrome is mainly clinical. There are no clear criteria indicating the presence of this disease, but there are various clinical signs that may suggest an appropriate diagnosis. We have identified criteria that can help in making a diagnosis.

Materials and methods: The working group confirmed a set of simple diagnostic criteria (Nantes criteria).

Results: The five main diagnostic criteria are:

(1) Pain in the anatomical region of the pudendal nerve

(2) Worsening while sitting

(3) Patients do not wake up at night with pain

(4) Unexplained sensory loss on clinical examination.

(5) Positive effect of anesthetic blockade of the pudendal nerve

Other clinical criteria may provide additional support for the diagnosis of pudendal neuralgia.

Criteria have also been proposed to exclude this diagnosis:

pure coccygeal, gluteal or hypogastric pain, exclusively paroxysmal pain, exclusively itching, the presence of observable abnormalities that can explain the symptoms.

The purpose of this work was to gather together and publish a limited number of simple criteria designed to avoid incorrect diagnoses of pudendal neuralgia. [. ]

These criteria were discussed and ratified by a multidisciplinary working group in Nantes (France) September 2006 (Nantes criterion) and subsequently approved by SIFUP PP.

In the absence of disease-proving tomographic, laboratory, or electrophysiological criteria, the diagnosis of pudendal neuralgia remains clinical and empirical and must be continually re-evaluated in the light of clinical management. Pudendal nerve entrapment (PCN) is the most common cause of this neuralgia and is also diagnosed based on elements of clinical suspicion. We will also describe other causes: postherpetic neuropathy, neuropathy caused by stretching (although it is usually not painful or slightly painful), peripheral polyneuropathy, post-radiation neuropathy, compression caused by a neoplasm, etc. In fact, only the discovery of entrapment as a result of surgery and the resolution of pain after surgery can formally confirm the diagnosis of pudendal neuralgia caused by entrapment (barring a placebo effect from surgery).

Basic criteria for diagnosing neuralgia;

Complementary diagnostic criteria

Associated signs that do not exclude the diagnosis

Pain is predominantly associated with sitting position

Pain doesn't make you wake up at night

The introduction of an anesthetic into the pudendal nerve significantly relieves pain for the duration of the anesthetic. This is a basic criterion, but not specific, since it simply indicates that the pain is located in the territory of the pudendal nerve; pain associated with any perineal disease (eg, *-posterior) should also resolve with such a block, and other types of nerve injury would respond positively to block if located distal to the point of anesthetic injection. A negative block result does not formally exclude the diagnosis, since the block may be performed inaccurately or too distally to the point of nerve injury. [. ]

Allodynia or hypersthesia

This pain has an independent sound, and temporary relief from these sensations after blockade of the sympathetic fibers of the azygos ganglion with an anesthetic suggests that they arise with the participation of sympathetic fibers, justifying the term symptomatalgia.

Referred sciatic pain

Suprapubic pain may occur due to hypertonia of the puborectal component of the levator ani muscles. Bone tenderness may suggest a complex of secondary pelvic pain syndrome (low-grade reflex sympathetic dystrophy).

The diagnosis of pudendal neuralgia, caused by pinching of this nerve, is mainly clinical. There are no clear criteria, but individual clinical signs may suggest a diagnosis. If 4 basic clinical diagnostic criteria are met (pain in the area of ​​the pudendal nerve, worsening in a sitting position, the patient does not wake up at night from pain and unexplained loss of sensation), a diagnostic blockade with an anesthetic of the pudendal nerve should be performed; a positive response to blockade would be strong evidence in favor of these clinical suspicions (5th criterion). Because pain associated with the pudendal nerve is complex, understanding the various signs that often accompany it may improve the understanding and management of this disease (Table 1)

The pain mainly occurs in a sitting position;

The pain does not cause the patient to wake up at night;

Pain with no objective sensory impairment;

Pain that disappears with diagnostic blockade of the pudendal nerve;

Sensation of a foreign object in the rectum (sympathalgia)

Worsening during the day

Predominantly unilateral pain

Bowel movements are a pain trigger

Presence of extreme tenderness to palpation of the ischial spine

Exclusively paroxysmal (paroxysmal) pain

Tomographic abnormalities that may explain pain

Concomitant signs that do not exclude the diagnosis

Referred sciatic pain

Pain referred to the middle of the thigh

Frequent urination and/or pain with a full bladder

Pain after ejaculation

Normal clinical neurophysiology findings

The Small Pelvis http://www.hirslanden.ch/global/en/home/hospitals_and_centres/centers_and_institutes/zuerich/neuropelveology_centre/about_neuropelveology/pelvis.html

Re: Pudendal Neuralgia Symptoms

Possible symptoms include burning, numbness, increased sensitivity, electric shock or stabbing pain, sharp or aching pain, sensation of a lump or foreign body in the vagina or bowel, twisting or squeezing, abnormal temperature sensations, hot burning, constipation, pain and straining with bowel movements, straining or burning when urinating, painful intercourse and sexual dysfunction - persistent genital arousal disorder (genital arousal without desire) or the opposite problem - loss of sensation.

PN is often accompanied by musculoskeletal pain in other parts of the pelvis, such as the sacroiliac joint, piriformis muscle, and coccyx. It is usually very difficult to distinguish PN (pudental neuralgia) from pelvic dysfunction because they often occur together. Some people refer to this as pelvic myoneuropathy, which suggests both a neural and muscular component to tight pelvic floor muscles.

Several tests can be used to diagnose PN/PNE, as described in the diagnostics section. However, most diagnosis is based on a systematic examination of symptoms. This page aims to help patients and clinicians identify a stronger likelihood of PN/PNE as opposed to looking at symptoms alone. History is also a factor in diagnosis, so it is important to consider possible causes as well as symptoms.

If left untreated for a long time, a progressive worsening of symptoms may occur, ranging from mild perineal discomfort that develops into a chronic condition, to a constant state of pain that does not improve even when standing or lying down.

Pudental neuralgia can be caused by inflammation of the nerve or mechanical damage/trauma to the nerve. Sometimes the pain develops slowly and almost imperceptibly, sometimes it is preceded by paresthenia in the area innervated by the pudental nerve. Paresthenia is a pins and needles sensation or a feeling of tingling and numbness.

Many people, however, remember one particular incident as the beginning of their symptoms. Some recall the supposed sensation of electric shock after an unsuccessful movement. Some people report their symptoms began after a shock such as a fall on their buttocks or a car accident. Others report that pain appeared after abdominal surgery, in the sacroiliac joint, pelvic surgery, etc. Sometimes it is direct nerve injury or from pretensioners or misplaced sutures. Pelvic surgery, such as a hysterectomy, can cause genital neuralgia even though the nerve is not directly affected. One theory is that the nerve can be damaged if the body is held in a certain position for a long period of time during surgery. Sometimes women develop pudendal nerve pain immediately after giving birth and eventually go away, but for some women the pain does not go away. Women with severe endometriosis may develop scarring or inflammation if the endometriosis affects a nerve.

Sitting for long periods of time at work and frequent long trips are common causes of nerve compression. Sports that involve frequent squeezing of the hip while carrying heavy weights lead to enlargement of the ligaments and muscles that put pressure on the nerve. Some young athletes have been shown to have an elongated ischial spine, a bone that protrudes into the pelvis near the pudendal nerve. Cycling is one of the leading favorable risk factors for the development of this disease. In the sports medicine community it is sometimes called "cyclist's syndrome."

One hypothesis suggests that some people were predisposed to PN and something happened to cause it. Other people who have been predisposed may never have such problems if they have never participated in an activity or had an incident that causes it. For example, someone who is predisposed to PN might take up weightlifting and therefore get PN, while another person who is predisposed but does not lift weights will not get PN.

Tight muscles, tendons, enlarged ligaments can cause constant friction on the nerve or, if the pelvis is misaligned, there can also be excessive pressure on the nerve. In some, the pudendal nerve may follow the wrong path or have little room between the ligaments on the ischium or in the Alcock canal. Some physicians have observed PN in families with several offspring in subsequent generations developing PN. Some people are prone to developing excess scar tissue, which can lead to nerve entrapment. Several autoimmune or inflammatory diseases have been associated with pudendal neuralgia.

However, sometimes the reasons remain unknown.

The pain may be less when sitting on a toilet seat or donut pillow, as this reduces pressure on the pudendal nerve. Most people simply have to avoid sitting because they can't find a pillow that relieves pain in all areas.

The pain often does not go away immediately, but with a delay and remains for a long time, after stopping the activity that caused the pain (after getting up from a seat, cycling, sex.).

Often the pain is weaker in the morning and increases during the day.

There may be extreme pain and tenderness when the nerve is pressed when it is exposed through the vagina or rectum.

Perineal pain

Pain after orgasm

Loss of sensation with difficulty achieving orgasm

A strange feeling due to arousal without sexual desire.

Intolerance to tight trousers or tight and elastic ones.

Friction and feeling of inflammation along the nerve when walking or running for too long

The problem is to fix the stream after urination. You need to strain your empty bladder. It is more difficult to feel urine passing through the urethra

Urethra burns after urinating

Feeling as if the bladder is not empty or feeling the need to urinate even when the bladder is empty.

Painful spasms of the pelvic floor muscles after bowel movements.

Sexual problems. Men complain of decreased sensation. Pain after ejaculation is common. For women, pain during and after sexual intercourse is often reported.

There may be pain in the testicle or scrotum. The testicle itself is innervated by a different nerve, but it is difficult to distinguish the difference between scrotal/testicular pain

Sciatica of the buttocks and everything associated with it: numbness, coldness, hissing sensations in the legs, leg or buttock. This is more often due to the reaction of the surrounding muscles to pain in the pelvic area. It could also be from nerve "crosstalk".

Lower back pain as a result of irradiation of pain.

Symptoms may be unilateral or bilateral. If the nerve is pinched on only one side, the pain may also be referred to the other side.

Some people develop Complex Regional Pain Syndrome and even PTSD after prolonged or severe pain.

Possible pinching of the pudendal nerve. How to treat a pinched nerve?

Good afternoon! I am a man, 44 years old. I have the following problem: for the last 15 years I have had sudden sharp shootings from the groin to the stomach, for a few seconds, about once a month. And they immediately went away.

I worked all this time at hard physical work associated with lifting weights. Then I moved on to a much more physically easy job. 2.5 years ago I had a renovation, I carried heavy things alone.

The loads were very heavy. After the repair was completed, I suddenly had a problem - difficulty urinating and defecating. I went to the urologist.

After the examination, He said that I had an exacerbation of chronic prostatitis and prescribed an appropriate course of treatment. At the same time, I suddenly had pain in my anus, right in the center. Pain appears after lifting heavy objects and after defecation, especially when it occurs with pushing.

Also, lumbago became more frequent when standing up from a sitting position, from the groin to the lower abdomen. In a sitting position, there was often a feeling that you were sitting on a tubercle. Consistently I underwent: treatment from the same urologist - in the end, he stated that my prostatitis had gone into remission, a thorough examination by a proctologist and gastroenterologist, with all conceivable tests and examinations

None of them found any pathologies in their part, especially those that could cause such symptoms. Those. The doctors completely ruled out urology, proctology and gastroenterology. And only when I did an MRI of the lumbosacral region, did at least some new “clue” appear - spinal osteochondrosis, disc herniation L2-3 (6 mm), disc protrusion L5-L6 ( 4 mm), lumbarization of S1. I did an electroneuromyography, which said that no pathological changes in the sciatic nerve were detected.

From treatment: I received medication from my local neurologist. There was no effect. I went to exercise therapy, massage and magnetic therapy. There was no effect. Only milgamma injections helped, but only for one day. And only when I started doing exercise therapy at home every day for the lumbosacral spine, exercising the PIR of the piriformis muscle (which, as I know, also unload the spine) and had 10 sessions with a chiropractor, then the pain in the anus has decreased and reminds itself less often and not so strongly.

Simultaneously with pain relief, after these exercises. My stool, urination, erection and libido are improving. But still the pain does not go away completely, although more than 2 years have passed. It is localized in the anus, as if inside. Defecation, basically, goes away with pushing and irregularly. My exercises for the pyriformis help almost immediately, but for about half a day. In the evening I have to do them again.

I wanted to ask: what do you think I have? The chiropractor suggested that my hernia or protrusion pinched some nerve, perhaps the pudendal (genital). I looked on the Internet, according to descriptions of pinched pudendal nerve - this is very similar to my case, almost one to one.

The chiropractor told me to come to him again in half a year, but I couldn’t and now I regret it. I wanted to ask: do my symptoms look like pinched nerve (neuropathy) of the pudendal nerve and if so, how and where to treat it?

The problem is really related to damage to the lumbosacral spine, so I recommend that you undergo periodic courses of manual therapy as prescribed by your doctor until you achieve a more stable remission.

There may be several such courses. The disease is chronic, so it may take time to achieve lasting results. Sincerely, osteopathic chiropractor Evdokimov A.A.

For quotation: Repina V.V., Danilov A.B., Vorobyova Yu.D., Fateeva V.V. Chronic pelvic pain – what is important for a neurologist to know // Breast Cancer. 2014. P. 51

WHO statistics indicate that every fifth person in the world suffers from chronic pain of one location or another. Pain in the pelvic area annually forces more than 60% of women to consult a gynecologist. Chronic pelvic pain (CPP) is an interdisciplinary problem. As a rule, a patient with CPP receives consultations from a number of specialists: a gynecologist, proctologist, urologist, psychiatrist and, nevertheless, in the end, he is often left alone with his pain.

It is known that the impact of CPP on the patient’s mental sphere is comparable to the impact of myocardial infarction, unstable angina, ulcerative colitis and greater than the impact of dental and ear pain. A number of authors note that almost 20% of patients from this group had a history of suicidal attempts or intentions, which once again confirms the medical and social significance of this pathology.
There is no doubt that such a concept as “pelvic pain” (without describing other signs of the disease) is not enough for an optimal differential search. Currently, changes in the approach to the pathogenesis, diagnosis and treatment of diseases of the pelvic organs are noticeable in medical circles. The approach becomes multimodal, since the pelvic organs are a single complex with common afferent and efferent innervation, blood circulation and musculo-ligamentous apparatus. This approach easily explains why damage to one organ often involves others in the pathological process. Recently, more and more often in foreign literature, instead of the term “chronic pelvic pain syndrome”, the term “chronic perineal-pelvic pain and dysfunction syndrome” is used.
According to the definition of the International Continence Society, CPP syndrome is the presence of constant or recurrent pain in the pelvic area, accompanied by symptoms of dysfunction of the lower urinary tract, sexual dysfunction, intestinal dysfunction in the absence of confirmation of an infectious disease or other verified pathology.

The mechanisms of pelvic pain are very diverse, many of them are poorly understood. Time demonstrates the validity of A.V.’s statement. Bolotov that the number of causes of pelvic pain is comparable to the number of causes of headaches. CPP can be a separate symptom of a gynecological, urological, proctological, neurological, vascular, musculoskeletal or mental disease, or it can have a completely independent nosological significance, being the most important manifestation of pelvic pain syndrome. Data from the US National Institutes of Health are indicative, according to which CPP becomes the cause of almost 40% of laparoscopic operations on the pelvic organs, but only in 30% of cases is it possible to detect an infectious-inflammatory or other visceral cause of pain.
We have the right to call pain “pelvic” if it is localized in the lower abdomen below the navel, in the lower back and sacrum, in the perineum, in the area of ​​the external genitalia, vagina, rectum, with possible irradiation along the anterior inner surface of the thighs. Typically, patients cannot indicate the exact localization of pain and separate the epicenter of pain from the zone of irradiation.
According to the recommendations of the European Association of Urology guidelines of March 2009, the term “chronic pelvic pain” is appropriate if recurrent or persistent pain has bothered the patient for at least 6 months.

To verify the genesis of CPP, as well as any disease, a well-collected anamnesis is most important: the history of the present disease, family and social history, detailed data on concomitant pathology.
Standard examination of patients with CPP includes the following laboratory and instrumental methods:
- laboratory testing (including for herpes infection);
- Ultrasound of the pelvic organs;
- X-ray examination of the lumbosacral spine and pelvic bones;
- densitometry to exclude osteoporosis;
- X-ray (irrigoscopy) or endoscopic (sigmoidoscopy, colonoscopy, cystoscopy) examination of the gastrointestinal tract and bladder;
- laparoscopy.
In clinical practice, however, we often encounter patients with pain in the anno-coccygeal region, perineum, and genitals, whose standard laboratory and instrumental examination does not allow us to establish the genesis of the pain syndrome. Consultation with a neurologist is especially necessary if, after a thorough urological and gynecological examination, there is no doubt about the absence of local pathology of the pelvic organs.

According to D. Hough, W. Pawlina, R. Roberts (2003), one of the important and often overlooked causes by specialists is the neurogenic cause of pelvic pain, namely pudendal neuralgia. As reported by A. Shafik (1991), R. Robert (1991), compression of the pudendal nerve in men and women occurs in a ratio of 1:3.
Being the caudal part of the sacral plexus, the pudendal nerve leaves the pelvic cavity, bending around the ischial spine or sacrospinous ligament (Fig. 1).
The pudendal nerve (n. pudendus, S3-S4) provides innervation to the levator ani and coccygeus muscles, the anal sphincter, transverse perineal muscle, bulbocavernosus muscle, innervates the skin of the anterior part of the anus, the posterior side of the scrotum or labia majora, skin penis or clitoris, urethra and urethral sphincter. Compression of the pudendal nerve can develop either due to the impact of a tense piriformis muscle or due to compression between the sacrospinous and sacrotuberous ligaments. Also, the nerve can be compressed in the genital canal - Alcock's canal, which is formed by the split fascia of the obturator internus muscle. In addition to compression, the causes of neuropathy of the pudendal nerve can be its damage during childbirth, pelvic trauma and malignant neoplasms.

For pain associated with damage to the pudendal nerve, the typical localization is the rectum, anus, urethra, perineum and genitals. A characteristic symptom is increased unilateral pain in a sitting position, during defecation, or sexual intercourse. As a rule, the pain decreases when lying down. Mild sphincter disorders may also occur.
Patients' complaints can be regarded as manifestations of diseases of the lower urinary tract, and without a detailed neurological examination, the pathology of the pudendal nerve may remain undiagnosed for a long time. A logical consequence is the rather rare detection of pudendoneuropathy.
When conducting a neurological examination, the earliest and, most often, the only neurological symptom of damage to the pudendal nerve is a violation of sensitivity in the area of ​​​​its innervation.
In the diagnosis of compression of the pudendal nerve in the Alcock canal, in addition to electroneuromyography (ENMG), transvaginal ultrasound with assessment of blood flow in a. pudenda and v. pudenda, since when the nerve is compressed, these vessels are also subject to compression, which is manifested by a decrease in blood flow speed on the affected side. To exclude oncopathology as the cause of neuropathy, magnetic resonance imaging of the pelvic organs is necessary.

The exclusion of such a main etiological factor as inflammation of the pelvic organs and/or failure of treatment should prompt the doctor to think about possible damage to the musculo-ligamentous apparatus of the pelvis. According to W. Smith, (1959) G. Thiele (1963), J. Slocumb (1984), the cause of chronic pelvic pain syndrome, not associated with visceral pathology of the pelvis and traumatic changes and requiring close attention of a neurologist, can very often be myofascial pain syndrome. S. Skootsky reports that 30% of patients with CPP in specialized pain clinics were diagnosed with myofascial syndrome (MFS). Myofascial pelvic pain syndrome in most cases is recorded in a female cohort of patients, for example, in a study by W. Smith (1959) 80% of patients were women.

For long-term MFS, the appearance of characteristic trigger points and corresponding reflected pain patterns is typical. Typically, painful spasms and active triggers are found in the levator anus and piriformis muscles.
Two-way connections between MPS and anxiety and depression are often observed: it is possible that MPS can be provoked by anxiety, or that existing MPS can be aggravated by emotional disturbances. Women with CPP are significantly more likely than the healthy population of women to experience psychologically negative events such as divorce, family troubles, and sexual abuse.
Understanding the significant prevalence of pelvic floor MFS dictates the need to conduct intravaginal palpation examination of the pelvic floor muscles for every woman who has unexplained pelvic pain.
Data from domestic scientists also confirm that compression neuralgia of the pudendal nerve and painful MFS with the formation of myotonic nodes are important causes of chronic pelvic pain syndrome, not associated with infectious and inflammatory processes in the pelvic organs and vertebrogenic pathology.
Therefore, it is necessary to more carefully examine patients with treatment-resistant chronic urological and gynecological diseases to identify neuropathic and myofascial syndromes.

Effective treatment of CPP syndrome is not an easy task. Taking into account the multifactorial nature of the pathogenesis of CPP and based on the results of studies conducted in this area, an integrated treatment approach is recommended, including the following key links:
- elimination of chronic pain (antidepressants, anticonvulsants);
- psychological correction (psychotherapy);
- treatment of neuropathy, pelvic dysfunction (B vitamins, muscle relaxants);
- correction of pathobiomechanical disorders of the pelvis (manual therapy, therapeutic exercises).
Drug treatment for pudendal neuropathy includes medications for neuropathic pain such as anticonvulsants (pregabalin). Combination therapy for pudendal nerve neuropathy should include large doses of B vitamins (B1, B6, B12). A prominent representative of B vitamin complexes is Neuromultivit, a patented combined multivitamin drug created by the Austrian company Lannacher Heilmittel GmbH. Neurotropic components of Neuromultivit improve the speed of nerve impulses and activate reparative processes in peripheral nerves. The pharmacological effect of the drug is determined by the properties of the vitamins included in its composition.

Vitamin B1, as a result of phosphorylation processes, is converted into cocarboxylase, a coenzyme of many enzymatic reactions, and is actively involved in the processes of nerve excitation in synapses. Vitamin B6 in phosphorylated form is a coenzyme of amino acid metabolism (decarboxylation, transamination, etc.) and is involved in the biosynthesis of many neurotransmitters (dopamine, norepinephrine, adrenaline, histamine, γ-aminobutyric acid). Vitamin B12 is a natural organic compound that contains a metal atom - cobalt. Vitamin B12 is necessary for normal hematopoiesis and red blood cell maturation; participates in the transfer of methyl groups (and other one-carbon fragments), the synthesis of nucleic acids, proteins, carbohydrates, lipids; has a pronounced lipotropic effect and increases oxygen consumption during chronic and acute hypoxia; effectively strengthens the immune system. The diverse physiological functions of vitamin B12 are the basis for widely recommending it for dysfunctions of the hematopoietic organs, metabolic disorders, and neurological diseases. The use of vitamin B12 for tunnel syndromes promotes not only remyelination, but also a decrease in the intensity of pain.
When using a combination of B vitamins, the activity of nociceptive neurons in the central nervous system is clinically significantly reduced, which contributes to the antinociceptive effect. The potentiating effect of high doses of B vitamins during intense neuropathic pain on the antinociceptive effect of NSAIDs has been proven in a number of clinical studies. In general, we can say that B vitamins, having a metabolic effect on the processes of myelination in peripheral nerve fibers and affecting nociceptive and neuropathic pain, are a means of pathogenetic therapy.
Indications for the use of Neuromultivit are neurological diseases: polyneuropathy of various origins, neuritis, neuralgia, radicular syndrome, plexitis (including compression-ischemic nature), facial nerve paresis.

The components of the drug are water-soluble, which eliminates the possibility of their accumulation in the body. Neuromultivit film-coated tablets are intended for oral administration: 1 tablet 3 times a day for 1 month. The drug is well tolerated and intended for long-term therapy.
The treatment method used is a pudendal nerve block (for example, a combination of 5 ml of 0.5% bupivacaine and 80 mg of triamcinolone), which is performed under x-ray or ultrasound guidance. Surgical treatment is performed only when there is proven compression of the pudendal nerve that is resistant to drug therapy.

In case of verification of MFS, vaginal suppositories with diazepam and injections of local anesthetics with glucocorticoids into trigger points are used to relax muscles. In case of a positive effect, botulinum toxin is administered under the control of ENMG. To relax the pelvic floor muscles, patients with MFS are recommended to use exercises. It is proposed to contract the muscles of the perineum for 7-8 s with holding the breath as you exhale and then relax them for 7-8 s with holding the breath as you inhale. The exercises are performed in series of 10 repetitions 5-6 times during the day in a sitting or lying position. Daily physical therapy exercises, mastery of autogenic training with the ability to relax muscles are necessary conditions for effective treatment of CPP associated with MFS.

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Recently, especially in French- and Spanish-speaking medical circles, the approach to the pathogenesis, diagnosis and treatment of diseases of the pelvic organs has changed significantly.
First of all, it has become complex or, as they say in Europe, “multimodal”, since the pelvic organs are closely interconnected and often have common efferent and efferent innervation, blood circulation, and musculo-ligamentous apparatus. Thus, damage to one organ often involves others in the pathological process.
An example is the occurrence of painful bladder syndrome (not interstitial cystitis - these are different things, why will be explained below) in patients with adenomyosis or IBS.
This is due to the phenomenon of the so-called. cross-sensitization. Most of the pelvic organs receive sensory and motor innervation through the n.pudendus. In addition, in some cases these organs have representation in the same or neighboring centers of the brain. This issue will also be discussed in more detail below.
Secondly, the increasingly dominant point of view is that the role of inflammatory diseases in the pathogenesis of chronic pelvic pain syndrome is decreasing. Currently, the main role, according to French colleagues, is played by myofascial (spastic) syndromes of the pelvic floor muscles and neuropathy of the pudendal nerve, which is informally called the king of perineum - “king of the perineum”. Thirdly, the terminology has changed: increasingly, instead of the term “chronic pelvic pain syndrome,” the term “chronic perineal-pelvic pain and dysfunction syndrome” is used.
We hope that at the 1st International Congress on Pelvic Pain and Dysfunction, which will be held in Amsterdam, a common terminology will be adopted.

Within the framework of this article, it is not possible to consider all pain syndromes and dysfunctions of the pelvic organs, so we suggest paying attention to syndromes of the female pelvic organs that are relevant to practice, that is, urogynecological syndromes.

Pain syndromes:

• painful bladder syndrome;
• pudendal nerve neuropathy;
• myofascial syndromes.

Disorders of the storage and evacuation function of the bladder:

• overactive bladder with detrusor overactivity;
• overactive bladder with increased bladder sensitivity;
• and men under stress.

As for painful bladder syndrome, this, according to G. Amarenco, is a condition caused precisely by cross-sensitization of the bladder due to damage to neighboring organs, for example, the colon (IBS) or the uterus with adenomyosis. In this case, the number of C-fiber receptors also increases, and central sensitization occurs - but this is a consequence of a pathological process in another organ. Pathological changes in the lamina propria can cause umbrella cell damage similar to IC - but in this case it will be secondary.

Clinical case

The patient is 38 years old and has never given birth. She applied for long-term (3 years) dysuria, pollakiuria, nocturia, pain localized in the urethra, irradiating to the right lower limb. Repeated courses of antibiotic therapy were carried out for U. urealitycum. Urine cultures are sterile, general urine tests are unchanged. Cystoscopy revealed visual signs of leukoplakia in the area of ​​Lieto's triangle.
Pathomorphological examination: no evidence of leukoplakia was found.
The patient underwent TUR of the altered area in the area of ​​Lieto's triangle. After the operation, the condition improved somewhat, but after a month it returned to the situation before the intervention. At the time of examination, completion of the voiding diary demonstrated 41 voiding movements per day, with an average voided volume of 37 ml.
The patient was examined together with Professor E. Botrand (L’Avancee Perinneal-Pain Clinic, Aixen-Provence).
The examination revealed adenomyosis, increased tone of the right internal obturator muscle, pain in the trigger point m. obturatorius int.

According to the expert opinion of Professor Botran, in this case there is a painful bladder syndrome caused by cross-sensitization due to adenomyosis and aggravated by the myofascial reaction of the right internal obturator muscle. In addition, due to neurogenic inflammation in the lamina propria of the urothelium caused by cross-sensitization, the patient has urothelial damage.
The pathogenesis of this condition may be as follows. Adenomyosis, like any other condition that causes chronic pain, leads to a decrease in the pain threshold. This is well demonstrated in an experiment on rats called the pressure paw vocalization test.
Its essence is as follows: two groups of rats were taken, in one a chronic pain syndrome was induced by introducing a chemical reagent under the skin of the back, the other group remained intact. A month later, a test was carried out by squeezing the paw of rats in both groups with a special device. The vocalization threshold was determined, i.e. when the rats started squeaking. So, before the start of the study, the threshold in rats of both groups was the same. But after a month, in the group of rats with chronic pain, vocalization occurred with much weaker pressure on the paw compared to intact rats. This seems quite logical. Pain is a signal of tissue damage. If the pain has become chronic, it means that the brain has not taken action sufficient to eliminate the cause of the pain. Therefore, it is necessary to reduce the pain threshold in order to motivate the central nervous system to take more active actions.

The next stage is peripheral sensitization. In the affected organ, the production of nerve growth factor (NGF) increases. This leads to an increase in the number of receptors affiliated with demyelinated C-fibers. The main role of C-fibers is the transmission of chronic pain impulses. Accordingly, an increase in their number leads to increased pain in the affected organ. However, as we have already discussed, the pelvic organs have cross innervation and in this case, the number of receptors for C-fibers increases not only in the endo- and myometrium, but also in the urothelium.
In addition, this patient was diagnosed with myofascial reaction m. obturatorius int. dext. Muscle contraction is a normal response to pain. However, long-term pain leads to spastic contractions, which, in turn, cause pain due to the accumulation of lactate in the muscle and compression of nerve fibers. As an example, we can cite piriformis-syndrome, when m. piriformis causes compression of n. Pudendus.

Returning to the examined patient, she was referred to for treatment of adenomyosis. In addition, for the treatment of painful bladder syndrome, it was recommended:

1. katadolon 200 mg - for the purpose of relieving pain and central sensitization;
2. pregabalin - 75 mg 2 times a day with gradual titration of the dose - to eliminate peripheral sensitization;
3. injection of 100 units of botulinum toxin into the right obturator muscle under electromyographic (EMG) control;
4. intravesical electrophoresis 200 units of botulinum toxin;
5. intravesical injection of sodium hyaluronate (URO-HYAL) to restore the urothelium.

You should pay attention to the effectiveness, albeit short-term, of the TUR of the Lieto triangle. As is known, the main afferent innervation of the bladder is localized in the region of Lieto's triangle - apparently TUR temporarily disabled the endings of the afferent fibers.

Pudendal neuropathy

The main symptom of pudendal neuropathy is pain in one or more areas innervated by the n. pudendus or its branches.
These are the areas of the rectum, anus, urethra, perineum and genitals. One typical symptom is pain that worsens while sitting and progresses throughout the day.
The causes of neuropathy are still debated, but the most well known is compression of the pudendal nerve in Alcock's canal.
Other causes are: piriformis syndrome, damage to the pudendal nerve during childbirth, pelvic trauma and malignant neoplasms. Therefore, for any chronic pelvic pain, an MRI is advisable.
The role of the herpes virus is also actively discussed - indirect evidence is the effectiveness of acyclovir and valacyclovir in some cases of PN.

There are so-called Nantes criteria for PN, which were developed by J.J. Labat, R. Robert, G. Amarenco. Five main criteria have been identified:

1. pain in the area innervated by the pudendal nerve;
2. Predominant pain in the sitting position;
3. the pain does not cause sleep disturbance (i.e. does not cause the patient to wake up at night);
4. the pain does not cause serious sensory impairment;
5. blockade of the pudendal nerve relieves pain.

Typically, patients describe pain during PN as neuropathic, i.e. burning, paresthesia. Most often, the pain is localized on one side. The sensation of a foreign body in the rectum is very typical.
A few words about the anatomy of n. Pudendus. The pudendal nerve contains both afferent and efferent fibers, which causes sensory and motor disorders of the corresponding organs.
The pudendal nerve enters the pelvis at the level of S2-S4 and passes through f. piriformis, then through Alcock's canal and divides into 3 branches.
It is hypothesized that pudendal nerve dysfunction may lead to symptoms of overactive bladder that are predominantly sensory in origin, due to an increase in the number of C-fibers in the bladder, as well as through cross-sensitization, which we have already mentioned, in organs receiving the same innervation for the reason convergence of sensory pathways in the pelvis.
Diagnosis of PN is based on the above Nantes criteria; in addition, it is necessary to palpate trigger points m. piriformis and m. obturatorius for the diagnosis of myofascial syndromes.
Transvaginal ultrasound with assessment of blood flow in a. can help in diagnosing compression of the pudendal nerve in the Alcock canal. pudenda and v. pudenda, because when the nerve is compressed, these vessels are also compressed and the speed of blood flow on the affected side decreases.

Treatment of pudendal nerve neuropathy

Drug treatment usually includes pregabalin, starting at 75 mg twice daily and titrating up to 600 mg/day. To relax the muscles, vaginal suppositories with diazepam and injections of local anesthetics with glucocorticoids into the affected muscles are used. If the effect is positive, botulinum toxin is administered under EMG control.
For diagnosis and treatment, blockade of the pudendal nerve is used under x-ray or ultrasound control. Typically, 5 ml of 0.5% bupivacaine with 80 mg of triamcinolone is administered - 3 injections.
Surgical treatment is performed only when there is proven compression of the pudendal nerve that is resistant to drug therapy. Significant improvement is achieved only in 44% of cases. Other authors report 62% effectiveness (E. Botran), 70% (R. Robert).
Indications for decompression of the pudendal nerve and its technique require further discussion and study.

Myofascial syndromes of the pelvis

Myofascial syndromes or chronic myofascial pain are chronic pain syndromes and dysfunctions caused by chronic spasm of the musculo-ligamentous apparatus of the pelvis.
These syndromes are quite widespread, but are rarely diagnosed in urological practice. For example, Skootsky S. reports on 30% of patients with chronic pelvic pain who were diagnosed with myofascial syndromes in specialized pain clinics, while Bartoletti R. published data on 5540 patients suffering from CPPS examined in 28 Italian urological clinics - myofascial syndromes were detected only in 13.8% of cases.
Therefore, it is necessary to more carefully examine patients with chronic cystitis, chronic prostatitis, urethritis, etc. in order to identify neuropathic and myofascial syndromes.

Types of iofascial pelvic syndromes:

• levator syndrome;
• internal obturator muscle syndrome;
• piriformis syndrome;
• bulbocavernous syndrome.

Levator syndrome

Localization of pain:

• pain in the anorectal area;
• vaginal pain;
• hypogastric pain;
• pollakiuria and imperative urge to micturate;
• increased pain when sitting.

According to J. Rigaud, this syndrome occurs in 100% of cases in patients with CPPS of both sexes.

Internal obturator syndrome:

• feeling of a foreign body in the rectum;
• pain in the urethra;
• pain in the vulva area.

Piriformis syndrome:

• lower back pain;
• pain in the perineum;
• dyspareunia;
• erectile dysfunction;
• pain in the buttock and hip joint;
• pain during bowel movements.

Bulbocavernous syndrome:

• pain in the perineum;
• dyspareunia;
• sexual arousal syndrome without sexual stimulation;
• erectile dysfunction;
• pain at the base of the penis.

• analgesics (catadolon);
• gabapentins;
• benzodiazepines (if possible - vaginal suppositories);
• antidepressants (trazodone);
• transcutaneous electrical stimulation (TENS);
• injections of anesthetics and glucocorticoids into the involved muscles (naropin 0.5% + diprospan);
• injections of botulinum toxin under EMG control (Porta M.A, Grabovskiy C.);
• sacral neuromodulation.

Overactive bladder with detrusor overactivity

Enough has been written about this type of OAB; effective diagnostic and treatment methods have been developed.
The drugs of choice are M-anticholinergics, but quite often there are cases of insufficient effectiveness of these drugs. This may be due to the combination of OAB with DO and OAB with increased sensitivity of the bladder, which will be discussed below.

Overactive bladder with bladder sensitivity

Clinically, this type of OAB (which is sometimes called “OAB without OAB”) is manifested by a frequent or even constant feeling of the urge to urinate, but without urgency and episodes of urgency, as in women. M-anticholinergics are usually ineffective.

Urodynamic manifestations:

• decrease in the volume of the first sensation of bladder filling;
• decreased volume of the first urge to urinate;
• decrease in maximum cystometric capacity;
• absence of detrusor overactivity and episodes of urinary incontinence;
• positive cold water test;
• positive test with lidocaine.

Etiology:

• pudendal nerve neuropathy;
• myofascial syndromes;
• cross-sensitization of the urothelium in adenomyosis, IBS, adexitis;
• damage to the GAG ​​layer of the urothelium.

Pathogenesis

Just as with painful bladder syndrome, there is an increase in the number of C-fibers and receptors affiliated with them. Moreover, sometimes the clinical and urodynamic manifestations of both conditions are identical. Perhaps these are manifestations of the same process that differ in severity.
Central sensitization also plays an important role. This is why the use of tibial neuromodulation is effective - the tibial nerve and the pudendal nerve have the same representation in the central nervous system.

• pregabalin;
• intravesical use of anesthetics, oxybutynin;
• intravesical electrophoresis of anesthetics, glucocorticoids, botulinum toxin;
• intravesical application of vanilloids (resiniferatoxin, capsaicin);
• transcutaneous electrical stimulation (TENS) with electrodes placed at the S2-S4 level (for example, Neurotrack Pelvitone, mode 10 Hz, 200 ms, 30 - 40 minutes per day);
• sacral neuromodulation;
• tibial neuromodulation;
• treatment of pudendal nerve neuropathy and myofascial syndromes;
• laser or electroablation of Lieto's triangle (A.I. Neimark, V. Gomberg);
• hydrobougation of the bladder.

Stress urinary incontinence (stress incontinence)

Pathology deserves consideration in a separate article, so we will only touch on its relationship with pelvic dysfunctions and pain syndromes.
We are talking about complications of implantation of synthetic slings using a transobturator approach. Quite often (2-8%) after this procedure, pain occurs due to the insertion and persistence of the implant in the obturator muscle, compression of the branches of the obturator nerve and the occurrence of myofascial obturator syndrome. Sometimes, in addition to pain, OAB symptoms occur, which are very difficult to relieve.

A possible solution to the problem seems to be the use of new types of slings:

• new generation minislings (“JUST-SWING”) - they are fixed with a titanium anchor in the obturator membrane without involving the muscle;
• biodegradable mini-slings (for example, a polylactic acid matrix obtained by electrospinning technology) impregnated with fibroblast growth factors.

For the treatment of pain syndromes after TVT-O surgery, it is possible to use injections into the obturator muscle of mixtures of anesthetics and glucocorticoids. If ineffective, remove the implant.

Conclusion

Diagnosis and treatment of pelvic pain syndromes and dysfunctions seems to be a very relevant and promising area in urology. Active implementation of a modern approach to the management of patients with such syndromes will improve the quality of medical care and reduce treatment costs.
The possibility of organizing specialized rooms or departments as part of leading urological medical institutions should also be considered.

I.A. Apolikhina, Ya.B. Mirkin, D.A. Bedretdinova, I.A. Eisenach, O.Yu. Malinina.
Scientific Center of Obstetrics and Perinatology named after. Academician V.I. Kulakova, Research Institute of Urology of the Ministry of Health and Social Development of the Russian Federation, Moscow, NMTC International, New Medical Technologies LLC. Diabetes mellitus – laser treatment

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