[en] [en] AIM: Pudendal and inferior cluneal nerve entrapment can cause a neuropathic pain syndrome in the sensitive areas innervated by these nerves. Diagnosis is challenging and patients often suffer several years before diagnosis is made. The purpose of the review was to inform healthcare workers about this disease and to provide a basis of anatomy and physiopathology, to inform about diagnostic tools and invasive or non-invasive treatment modalities and outcome.
METHODS: A description of pudendal and inferior cluneal nerve anatomy is given. Physiopathology for entrapment is explained. Diagnostic criteria are described, and all non-invasive and invasive treatment options are discussed.
RESULTS: The Nantes criteria offer a solid basis for diagnosing this rare condition. Treatment should be offered in a pluri-disciplinary setting and consists of avoidance of painful stimuli, physiotherapy, psychotherapy, pharmacological treatment led by tricyclic antidepressants and anticonvulsants. Nerve blocks are efficient at short term and serve mainly as a diagnostic tool. Pulsed radiofrequency (PRF) is described as a successful treatment option for pudendal neuralgia in patients non-responding to non-invasive treatment. If all other treatments fail, surgery can be offered. Different surgical procedures exist but only the open transgluteal approach has proven its efficacy compared to medical treatment. The minimal-invasive ENTRAMI technique offers the possibility to combine nerve release with pudendal neuromodulation.
CONCLUSIONS: Pudendal and inferior cluneal nerve entrapment syndrome are a challenge not only for diagnosis but also for treatment. Different non-invasive and invasive treatment options exist and should be offered in a pluri-disciplinary setting.
Disciplines :
Surgery
Author, co-author :
Jottard, Katleen; Department of Surgery, CHU Brugmann, Brussels, Belgium
Bonnet, Pierre ; Université de Liège - ULiège > Département des sciences biomédicales et précliniques > Anatomie humaine systématique
Thill, Viviane; Department of Surgery, CHU Brugmann, Brussels, Belgium
Ploteau, Stephane; Department of Gynecology and Obstetrics, Center Hospitalier Universitaire, Nantes, France
de Wachter, Stefan; Department of UZA, Antwerp Surgical Training, Anatomy and Research Centre (ASTARC), Faculty of Medicine and Health Sciences, Wilrijk, Belgium
Language :
English
Title :
Diagnosis and treatment of pudendal and inferior cluneal nerve entrapment syndrome: a narrative review.
Hibner M, Desai N, Robertson LJ, et al. Pudendal neuralgia. J Minim Invasive Gynecol. 2010; 17 (2): 148–153.
Dellon AL. Pain with sitting related to injury of the posterior femoral cutaneous nerve. Microsurgery. 2015; 35 (6): 463–468.
Robert R, Labat JJ, Riant T, et al. [The pudendal nerve: clinical and therapeutic morphogenesis, anatomy, and physiopathology]. Neurochirurgie. 2009; 55 (4–5): 463–469.
Kinter KJ, Newton BW. Anatomy, abdomen and pelvis, pudendal nerve. Treasure Island (FL): StatPearls; 2021.
Darnis B, Robert R, Labat JJ, et al. Perineal pain and inferior cluneal nerves: anatomy and surgery. Surg Radiol Anat. 2008; 30 (3): 177–183.
Ploteau S, Salaud C, Hamel A, et al. Entrapment of the posterior femoral cutaneous nerve and its inferior cluneal branches: anatomical basis of surgery for inferior cluneal neuralgia. Surg Radiol Anat. 2017; 39 (8): 859–863.
Robert R, Prat-Pradal D, Labat JJ, et al. Anatomic basis of chronic perineal pain: role of the pudendal nerve. Surg Radiol Anat. 1998; 20 (2): 93–98.
Ploteau S, Perrouin-Verbe MA, Labat JJ, et al. Anatomical variants of the pudendal nerve observed during a transgluteal surgical approach in a population of patients with pudendal neuralgia. Pain Phys. 2017; 1 (21;1): E137–E143.
Levesque A, Riant T, Ploteau S, et al. Clinical criteria of Central sensitization in chronic pelvic and perineal pain (convergences PP criteria): elaboration of a clinical evaluation tool based on formal expert consensus. Pain Med. 2018; 19 (10): 2009–2015.
Gangadharan V, Kuner R. Pain hypersensitivity mechanisms at a glance. Dis Model Mech. 2013; 6 (4): 889–895.
Levesque A, Bautrant E, Quistrebert V, et al. Recommendations on the management of pudendal nerve entrapment syndrome: a formalised expert consensus. Eur J Pain. 2022; 26: 7–17.
Labat JJ, Riant T, Robert R, et al. Diagnostic criteria for pudendal neuralgia by pudendal nerve entrapment (nantes criteria). Neurourol Urodyn. 2008; 27 (4): 306–310.
Woo AK. Depression and anxiety in pain. Rev Pain. 2010; 4 (1): 8–12.
Sturgeon JA. Psychological therapies for the management of chronic pain. Psychol Res Behav Manag. 2014; 7: 115–124.
Tricard T, Munier P, Story F, et al. The drug-resistant pudendal neuralgia management: a systematic review. Neurourol Urodyn. 2019; 38 (1): 13–21.
Fall M, Baranowski AP, Fowler CJ, et al. EAU guidelines on chronic pelvic pain. Eur Urol. 2004; 46 (6): 681–689.
Labat JJ, Riant T, Lassaux A, et al. Adding corticosteroids to the pudendal nerve block for pudendal neuralgia: a randomised, double-blind, controlled trial. BJOG. 2017; 124 (2): 251–260.
Fang H, Zhang J, Yang Y, et al. Clinical effect and safety of pulsed radiofrequency treatment for pudendal neuralgia: a prospective, randomized controlled clinical trial. JPR. 2018; 11: 2367–2374.
Masala S, Calabria E, Cuzzolino A, et al. CT-guided percutaneous pulse-dose radiofrequency for pudendal neuralgia. Cardiovasc Intervent Radiol. 2014; 37 (2): 476–481.
Krijnen EA, Schweitzer KJ, Wijck AJM, et al. Pulsed radiofrequency of pudendal nerve for treatment in patients with pudendal neuralgia. A case series with long-term follow-up. Pain Pract. 2021; 21 (6): 703–707.
Wang CL, Song T. The clinical efficacy of high-voltage long-duration pulsed radiofrequency treatment in pudendal neuralgia: a retrospective study. Neuromodulation. 2021;1–6.
Robert R, Labat JJ, Bensignor M, et al. Decompression and transposition of the pudendal nerve in pudendal neuralgia: a randomized controlled trial and long-term evaluation. Eur Urol. 2005; 47 (3): 403–408.
Ploteau S, Robert R, Bruyninx L, et al. A new endoscopic minimal invasive approach for pudendal nerve and inferior cluneal nerve neurolysis: an anatomical study. Neurourol Urodyn. 2018; 37 (3): 971–977.
Jottard K, Bruyninx L, Bonnet P, et al. A minimally invasive, endoscopic transgluteal procedure for pudendal nerve and inferior cluneal nerve neurolysis in case of entrapment: 3- and 6-month results. The ENTRAMI technique for neurolysis. Int J Colorectal Dis. 2020; 35 (2): 361–364.
Jottard K, Bruyninx L, Bonnet P, et al. Endoscopic trans gluteal minimal-invasive approach for nerve liberation (ENTRAMI technique) in case of pudendal and/or cluneal neuralgia by entrapment: one-year follow-up. Neurourol Urodyn. 2020; 39 (7): 2003–2007.
Shafik A. Pudendal canal syndrome as a cause of vulvodynia and its treatment by pudendal nerve decompression. Eur J Obstet Gynecol Reprod Biol. 1998; 80 (2): 215–220.
Beco J, Climov D, Bex M. Pudendal nerve decompression in perineology: a case series. BMC Surg. 2004; 4: 15.
Shafik A, El Sibai O, Shafik IA, et al. Role of sacral ligament clamp in the pudendal neuropathy (pudendal canal syndrome): results of clamp release. Int Surg. 2007; 92 (1): 54–59.
Beco J, Seidel L, Albert A. Endoscopic transperineal pudendal nerve decompression: operative pudendoscopy. Surg Endosc. 2018; 32 (8): 3720–3731.
Bautrant E, de Bisschop E, Vaini-Elies V, et al. Modern algorithm for treating pudendal neuralgia: 212 cases and 104 decompressions. J Gynecol Obstet Biol Reprod (Paris). 2003; 32 (8 Pt 1): 705–712.
Possover M, Rhiem K, Chiantera V. The “Laparoscopic Neuro-Navigation”–LANN: from a functional cartography of the pelvic autonomous neurosystem to a new field of laparoscopic surgery. Minim Invasive Ther Allied Technol. 2004; 13 (5): 362–367. Dec
Possover M. Laparoscopic management of endopelvic etiologies of pudendal pain in 134 consecutive patients. J Urol. 2009; 181 (4): 1732–1736.
Erdogru T, Avci E, Akand M. Laparoscopic pudendal nerve decompression and transposition combined with omental flap protection of the nerve (Istanbul technique): technical description and feasibility analysis. Surg Endosc. 2014; 28 (3): 925–932.
Bollens R, Mjaess G, Sarkis J, et al. Laparoscopic transperitoneal pudendal nerve and artery release for pudendal entrapment syndrome. Surg Endosc. 2021; 35 (11): 6031–6038.
Heinze K, Hoermann R, Fritsch H, et al. Comparative pilot study of implantation techniques for pudendal neuromodulation: technical and clinical outcome in first 20 patients with chronic pelvic pain. World J Urol. 2015; 33 (2): 289–294.
Schmidt RA. Technique of pudendal nerve localization for block or stimulation. J Urol. 1989; 142 (6): 1528–1531.
Spinelli M, Malaguti S, Giardiello G, et al. A new minimally invasive procedure for pudendal nerve stimulation to treat neurogenic bladder: description of the method and preliminary data. Neurourol Urodyn. 2005; 24 (4): 305–309.
George AT, Dudding TC, Nicholls RJ, et al. A new minimally invasive technique for pudendal nerve stimulation. Colorectal Dis. 2012; 14 (1): 98–103.
Bock S, Folie P, Wolff K, et al. First experiences with pudendal nerve stimulation in fecal incontinence: a technical report. Tech Coloproctol. 2010; 14 (1): 41–44.
Possover M. A new technique of laparoscopic implantation of stimulation electrode to the pudendal nerve for treatment of refractory fecal incontinence and/or overactive bladder with urinary incontinence. J Minim Invasive Gynecol. 2014; 21 (5): 729.
Konschake M, Brenner E, Moriggl B, et al. New laparoscopic approach to the pudendal nerve for neuromodulation based on an anatomic study. Neurourol Urodyn. 2017; 36 (4): 1069–1075.
Possover M. A novel implantation technique for pudendal nerve stimulation for treatment of overactive bladder and urgency incontinence. J Minim Invasive Gynecol. 2014; 21 (5): 888–892.
Gregory NS, Terkawi AS, Prabhakar NK, et al. Peripheral nerve stimulation for pudendal neuralgia: a technical note. Pain Med. 2020; 21 (Suppl 1): S51–S55.
Carmel M, Lebel M, Tu le M. Pudendal nerve neuromodulation with neurophysiology guidance: a potential treatment option for refractory chronic pelvi-perineal pain. Int Urogynecol J. 2010; 21 (5): 613–616.
Peters KM, Killinger KA, Jaeger C, et al. Pilot study exploring chronic pudendal neuromodulation as a treatment option for pain associated with pudendal neuralgia. Low Urin Tract Symptoms. 2015; 7 (3): 138–142.
Jottard K, Bonnet P, Bruyninx L, et al. The ENTRAMI technique: Endoscopic transgluteal minimal invasive technique for implantation of a pudendal electrode under full visual control: a cadaver study. Neurourol Urodyn. 2019; 38 (1): 130–134.
Jottard K, Bruyninx L, Bonnet P, et al. Pilot study: pudendal neuromodulation combined with pudendal nerve release in case of chronic perineal pain syndrome. The ENTRAMI technique: early results. Int Urogynecol J. 2021; 32 (10): 2765–2770.
Rigoard P, Delmotte A, Moles A, et al. Successful treatment of pudendal neuralgia with tricolumn spinal cord stimulation: case report. Neurosurgery. 2012; 71 (3): E757–E762; discussion E763.
Buffenoir K, Rioult B, Hamel O, et al. Spinal cord stimulation of the conus medullaris for refractory pudendal neuralgia: a prospective study of 27 consecutive cases. Neurourol Urodyn. 2015; 34 (2): 177–182.
Mahran A, Baaklini G, Hassani D, et al. Sacral neuromodulation treating chronic pelvic pain: a Meta-analysis and systematic review of the literature. Int Urogynecol J. 2019; 30 (7): 1023–1035.
Hunter CW, Yang A. Dorsal root ganglion stimulation for chronic pelvic pain: a case series and technical report on a novel lead configuration. Neuromodulation. 2019; 22 (1): 87–95.
