Vulvodynia or Pudental Neuralgia -Simple Repeated Injection Breakthrough Treatment

A simple perivulvar way to do pudental like blocks, if repeated, can lead to astounding improvement in pain in perineal areas – either vulvodynia or pudental neuralgia. I have achieved control in one case of either but don’t know yet the long term story.

Weinschenk, Stefan, Markus W. Hollmann, and Thomas Strowitzki.
New perineal injection technique for pudendal nerve infiltration in diagnostic and therapeutic procedures.
293.4 (2016): 805-813.
http://link.springer.com/article/10.1007/s00404-015-3812-0

Procedure:

  • Inject local into skin prior
  • Actual injection with Injection needle 0.4 9 40 mm (27-gauge, gray) 3/4 inch
  • Inject “1–2 cm laterally to the labia majora between clitoris and anus at the level of the  caudal introitus (see Fig. 2).”
  • Injection direction was  0 lateral and 0 dorsoventral (i.e., in sagittal direction).
  • Injections were a step but step process –  after aspirating, inject small amount, then advance some and repeat. – Author during injection supported one hand with other to avoid any unnecessary movement.
  • In total, 4–5 ml of local was injected “as slowly as possible”
  • depth of  3.8–4.0 cm.”

NOTE – when your starting this technique, you  might be best to palpate the bony pelvic brim to orient yourself; if you hit it when injecting that can be painful so orient otherwise. The pic below looks like it could hit the brim in some cases.

In more diagrammatic presentation is such:

There is good and bad news – the bad news is that the first 4 weekly shots may hurt. The good news is that subsequent injection are surprisingly much better:

The degree of pain in area corresponds some to this – when it starts feeling considerably better, actual pain is down to at least 50% better.

 

Annoyingly article does not give any actual pain relief results. They do refer to articles:

For pudental neuralgia:
“Repeated blockade of the pudendal nerve with local anesthetics (LA) plays an important role in the treatment of chronic pudendal neuralgia. In former investigations, injections of LA in chronic vulvar pain have yielded positive responses in 97/112 cases (87 %) and a lasting alleviation of symptoms after 30–40 % of LA injections.”

For vulvodynia, a case report which shows relief is sporadic and requires booster shots – but ultimately succeeded:

Weinschenk, Stefan, et al.
Successful therapy of vulvodynia with local anesthetics: a case report.
Forschende Komplementärmedizin/Research in Complementary Medicine 20.2 (2013): 138-143.
http://www.karger.com/Article/FullText/350023

OK there is something to consider about above – one loses momentum if not given weekly and that I had happen with my pudental neuralgia case.

Case I – Pudental neuralgia

Pudental neuralgia with burning pain perineal spilling over into inner folds of upper thighs at times ?some obturator too?

Saw patient initially for piriformis block which went well except for one annoying spot medial inferior to piriformis -concluded to be inferior gluteal nerve – tissues were very fibrotic there and I worked to loosen up. Notice how close pudental is to that.

I could control (for several weeks at a time) inferior gluteal with injections of 5% lidocaine with small amounts cortisone but sitting was a problem with perineal pains.

Had a series of 4 weekly pudental blocks bilaterally using 0.75 ml 5% lidocaine bilaterally at which time she was ill over Christmas. Pains had returned and shots were restarted. Again the first 4 shots were painful but now burning pain is better for the moment and shots are much easier.

As a backup plan for above lady’s pudental neuropathy,  pulse radiofrequency of pudental nerve has been considered:
Ozkan, D., et al.
Ultrasound-guided pulsed radiofrequency treatment of the pudendal nerve in chronic pelvic pain.
Der Anaesthesist 65.2 (2016): 134-136.

Dr. Jason Attaman at Mayo clinic does it and he has a copy of article on his site

Pudendal Neuralgia and Pelvic Pain

both pudental and sacral stimulation are alternatives

Surgery is an option but recovery is slow. Dr. Attaman does it and some go to France for it.

It is a big topic and is discussed here:
http://www.pudendalhope.info/node/23

Doctors dealing with it in North America are listed here:
http://www.pudendalhope.info/node/58

In Europe are
http://www.pudendalhope.info/node/57

 

Case 2 – Case of Vulvodynia longstanding:

After 4 weekly shots, vulvar pain was reduced and shots were no longer all that painful.  She was having 1 ml of 5% lidocaine in each side which she found better than the other shots. Localized pain area on left was eventually injected with small amount of left over bolulinum toxin over Christmas. She was able to have sex for first time in some time.  Her pain is 50% better and she is carrying on with shots.

I do host a resource to help patients with vulvodynia:
http://painmuse.org/?p=187

For vulvodynia there is a national site to help find a physician and other help
https://www.nva.org/

Comments

  • Instead of wiping with alcohol I use wipes used when doing a urine C&S.
  • 5% lidocaine 0.75-1 ml bilaterally works for me though it is possible I do not hit the right spots on some occasions with that small a volume
  • 4 weekly injections will get one to maybe 50% better. Injections had to be frequent to sustain effect and gain further ground in my cases.
  • With vulvodynia, pains can become more localized with repeated shots and these areas can be targeted for botulinum – something that would have been more difficult to do when one was hurting all over. The lady in question will have more than small amounts injected next time…

 

I would be interested in any recommendations. Have not found someone in Canada and could use a source.

 

Addendum:

Recent article suggested pudental blocks with steroid are not helpful but was not wise enough to do more than  one block:

Labat JJ, Riant T, Lassaux A, Rioult B, Rabischong B, Khalfallah M, et al.
Adding corticosteroids to the pudendal nerve block for pudendal neuralgia: a randomised,
double-blind, controlled trial.
BJOG 2017;124:251–60
http://onlinelibrary.wiley.com/doi/10.1111/1471-0528.14222/full

Another one for evidence based medicine based on what I call Voltaire’s Bastards – a book on the dictatorship of reason:
https://www.amazon.com/Voltaires-Bastards-Dictatorship-Reason-West/dp/0679748199

wrote that one steroid shot did not seem to do much for pudental pain

Critic from specialists that know better came up with the following:
Re: Adding corticosteroids to the pudendal nerve block for pudendal
neuralgia: a randomised, double-blind, controlled trial
S Antolak, M Chung
BJOG 2017;124:1122-1123

  1. Perineal pain does not live by itself and co-exist with multiple problems. This is try I am treating a lady with the following
    – pudental neuralgia – can’t sit well- but this is not her major issue
    – piriformis syndrome so severe and unresponsive to treatment, I feel it is likely on of those that actually has a branch of the nerve that goes through the piriformis
    – Maigne’s thoracolumbar syndrome that refers to the buttock and flares everything up – flares occur during periods of increased activity like yard work
    – Buttock triggers – flare as part of piriformis and as part of thoracolumbar, and by itself
    -Inferior glueal nerve – spot on lower end of piriformis intensely sore and relieved by spot injection
    – back issues – suspect a player is the back itself
    – quadratus lumborum spasm and rib crowding- rib rubbing pains at hip crest – better now with treatments

– cluneal nerve irritation from thoracolumbar down
mostly now her pudental pain is gone with treatments but she still can’t sit because of piriformis and whatever factors are tied to them (one of them being her botulinum shot has probably worn off)

2) diagnosis of pudental neuralgia based on relief of sitting with lidocaine injection is crude

3) No one shot wonders – I cannot believe how many article I have read (tennis elbow ones are the worst) where one shot must do it for them. Well, excuse me, I am NOT GOD and that is just stupid. It is commonplace with epidural to do a series of three before deciding it is not helpful ( with there being a septum in the canal, the injection could easily end up on the wrong side). Study above found it took four shots to bring down the pain well. However with Volataire’s bastards in full swing, this study will be remembered because it was randomized and controlled – not because they had the brains to do more than one. Letter states “experience after thousands of pudental nerve perineal injections indicates the one PNPI almost nerve provides therapeutic relief”. The they say “A series of three PNPI at 4 week intervals is highly successful” though pain might seem to initially get worse ie – “subjectively, patients often not an increase in pain after week three”.

The ultimate Volataire’s bastard analysis is to check for effectiveness on one shot after 3 month – some even do it at one year – are they for real? nothing last that long. They argue that carpal tunnel injection (placement not an issue) only last one month.

4) placement – original article cited did not worry as much about placement as 4 shots seemed to overcome that. However, letter startes:
– sacrospinous ligament injections may fail
– pudental nerve compression within space between sacrotuberous and sacrospinous ligaments
– pudental compression lateral to ischial spine and occasionally over bone.

There was a randomized control trial of one shot biphosphonates for CRPS that failed – it set back its use for ?10 years – it is clear 3-4 shots are needed and it only really works in the earlier stages of CRPS – not the later cold form – still some teaching pain clinicians don’t feel comfortable discussing it.

 

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