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Case report: Conservative management of refractory perineal pain

David Schimp DC, DACNB, DAAPM, Greg Turpin DC, CNMT, ART

 

Abstract

OBJECTIVE

Describe the clinical presentation of a 72-year-old female with medically refractory post-traumatic pudendal neuralgia and her response to conservative chiropractic pain management strategies.

CLINICAL FEATURES

The patient reported chronic perineal region pain that was described as burning, throbbing, sharp, pulling, stabbing, shooting, squeezing, dull, painful pins and needles, like an electric shock, tender and spreading.  Her symptoms negatively impacted her tolerance for sitting and general activity.

INTERVENTION AND OUTCOME

A trial of conservative management utilizing various therapeutic options was provided during a four-month period.  A poor response or inadequate palliation warranted the application of other therapeutic approaches.  These included active and passive stretching, myofascial release, chiropractic manipulative therapy, Logan-basic technique, acupuncture, ergonomic modification and whole-body vibration therapy.  A gradual trend toward pain modulation was observed during the treatment period, with the most significant response occurring during the phase of care utilizing Logan-basic and ergonomic modifications.

CONCLUSION

A mild degree of pain modulation was achieved in a patient with medically refractory pudendal neuralgia utilizing manual chiropractic procedures. Logan-basic chiropractic technique and modifications to the patients sitting posture were associated with the greatest reduction in the patients reporting of Current Pain, Worst Pain and Best Pain while side-posture sacroiliac joint manipulation and myofascial release was associated with lower Average Pain scores.  Chiropractic management may offer viable therapeutic options for patients with medically refractory pudendal neuralgia. 

 

Key indexing terms: chiropractic, Logan-basic technique, pelvic pain, pudendal neuralgia, pain management, manipulation

 

Introduction

Pudendal neuralgia is an uncommon but disabling cause of perineal pain that can be refractory to medical management.  This case report describes the clinical evaluation, diagnostic guidelines and conservative pain management strategies that were provided to a patient with medically refractory pudendal neuralgia.

Case Report

Permission to publish this article was granted by a 72 year old retired female vocational nurse.  She presented to the Moody Health Center of Texas Chiropractic College with a 7 year history of pain in the perineal region.  She was previously diagnosed with pudendal nerve entrapment and described classic symptoms of neuropathic pain in the saddle region exacerbated by sitting.  The onset of symptoms occurred following a fall onto her buttocks after missing a step on a ladder.  She received medical evaluation including electrophysiological studies and advanced imaging (MRI), followed by treatment in the form of surgical release of the pudendal nerves bilaterally.  The intensity of her symptoms diminished significantly following surgical release but did not resolve entirely and required long-term use of gabapentin for adequate pain control.  Nearly seven years later, her symptoms intensified after working in her garden.  CT imaging was performed at the request of her medical provider; it identified mild edema in the subcutaneous tissues overlying the left gluteal muscle, but no evidence of hematoma or abscess and no clear explanation for the exacerbation.  A pain management physician was consulted and a prescription for methadone was provided.  Methadone is a synthetic opioid that is sometimes used in the management of chronic pain because it has a longer duration of effect than morphine.1 Co-morbidities included hypercholesterolemia, hypertension, chronic venous insufficiency, and polyneuropathy.

 

At presentation, the patient was able to ambulate normally but had obvious discomfort with sitting.  She used adjectives like burning, throbbing, sharp, pulling, stabbing, shooting, squeezing, dull, painful pins and needles, like an electric shock, tender, spreading and several other descriptors to describe her pain.  Bowel and bladder function were normal with the exception of constipation, which required the use of an over-the-counter laxative.  She did not perceive any tactile sensory changes in the saddle region such as the touch of wiping after using the bathroom.  Her symptoms did not extend beyond the region described, and she did not experience concomitant back or leg pain except for agitation of the legs and feet in the evening hours when inactive.

 

Physical examination revealed stage 2 hypertension and mild obesity.  The ankle-brachial index was slightly increased and did not suggest peripheral arterial disease, but observation of the lower limbs was consistent with chronic venous insufficiency.  Well-healed surgical scars were visible approximately 2 lateral to the gluteal crease bilaterally.  Palpation of the lumbar spine, pelvic girdle, and gluteal muscles revealed increased tissue turgor but no tenderness.  Lumbopelvic orthopedic evaluation and range of motion were non-provocative.  The lower extremity neurological examination was consistent with distal symmetric polyneuropathy.  Focused examination of the symptomatic region consisted of the parameters of the Standardized Evaluation of Neuropathic Pain, Neuropathic Pain Scale and the Leeds Assessment of Neuropathic Symptoms and Signs Pain Scale. 2, 3, 4  These studies revealed a normal response to light touch using 2 and 10 gram monofilaments with no allodynic response.   A painful response was not evoked with blunt pressure, brush movement, pinprick, warm temperature or cold temperature.  Most meaningful was the presence of temporal summation when an initially non-painful response became increasingly painful during repeated stimulation.

 

Clinical outcomes were measured using the Neuropathy Pain Scale and The Leeds Assessment of Neuropathic Symptoms and Signs Pain Scale.  The Quad-Visual Analog Scale was utilized at each visit.

 

A 4-month trial of care was provided for a total of 24 visits (quadruple VAS scores were inadvertently not collected on the 8th visit).  At the beginning of care, the patient received recommendations to follow a Mediterranean diet, supplement with Standard Process Cataplex G, walk 30 minutes on 5 days/week and perform stretching exercises for the gluteal musculature with a particular emphasis on external hip rotators (e.g. piriformis, obturator internus, and obturator externus). 

 

Bilateral sacroiliac joint manipulation using a side-posture approach, adjunctive myofascial release, and passive stretching of the external rotators of the thigh followed by whole-body vibration therapy for 5 minutes were the primary interventions during the first half of care and accounted for a total of 10 visits.  The exceptions were pelvic blocking at the initial visit, acupuncture at the 4th visit, and Logan-basic technique at the 5th visit.   Logan-basic technique (light thumb pressure at the region of the sacrotuberous ligament with concomitant paraspinal soft tissue massage for up to 20 minutes per session) was applied during the final 10 sessions.  On the 16th visit, ergonomic modifications were introduced in an attempt to improve tolerance for sitting.  This consisted of the use of firm foam padding placed on a chair to support the patients ischial tuberosities while minimizing contact at the sacrum and coccyx.  This modification resulted in an immediate increase in her tolerance for sitting. 

 

Discussion

The Nantes criteria are a validated set of diagnostic criteria for pudendal neuralgia.  These include: (1) pain in the anatomic territory of the pudendal nerve, (2) pain made worse by sitting, (3) lack of waking at night due to pain, (4) absence of objective sensory loss in the region on clinical examination, and (5) positive anesthetic pudendal nerve block. 5 

 

Medical management of pudendal neuralgia accounts for the majority of literature citations and includes pressure-relieving and analgesic approaches using laparoscopic or open decompression procedures, pudendal neuromodulation, tricolumn spinal cord stimulation, neural blockade, percutaneous pulse-dose radiofrequency, and analgesic medications. 6, 7, 8, 9, 10, 11,12  It is suggested that 30% of patients with pudendal neuralgia due to pudendal nerve entrapment remain symptomatic despite surgical treatment.13  There are few reports in the literature about the use of manual therapies for the management of symptomatic pudendal neuralgia and no known prior reports on the use of manual therapies when symptoms are refractory to surgery.14  

 

Knowledge of the anatomical course of the pudendal nerve provides insight into the possible mechanism through which manual therapies may influence the condition.  The pudendal nerve arises from the sacral plexus by separate branches of the ventral rami of S2-4.  The nerve leaves the pelvis between the piriformis and coccygeus, then hooks around the sacrospinous ligament to enter the perineum through the lesser sciatic foramen.15  It is in this region that the nerve is frequently entrapped between the sacrospinous and sacrotuberous ligaments.16, 17 There is a single report that surgical removal of a partially ossified sacrotuberous ligament was an effective strategy for a patient with refractory pudendal nerve entrapment syndrome.18  An earlier report by Durante involving a triathlete experiencing perineal pain demonstrated a favorable outcome after using Active Release Therapy intending to influence the obturator internus.14  Our response was less dramatic in this elderly patient with many confounding factors; however, our trial did include strategies to stretch external rotators of the thigh, including the obturator internus, as well as influences achieved through sacroiliac joint manipulation.  Perhaps most interesting to the authors was the palliation achieved through the application of very light pressure in the region of the sacrotuberous ligament (i.e. Logan-basic chiropractic technique).

 

Whole-body vibration therapy was selected as a treatment option because of an earlier report demonstrating pain modulation in patients with painful diabetic peripheral neuropathy.19 In this case report, the patient tolerated whole-body vibration therapy without difficulty but did not report palliation following treatment.

 

Conclusion

A mild degree of pain modulation was achieved in a patient with medically refractory pudendal neuralgia utilizing manual chiropractic procedures. Logan-basic chiropractic technique and modifications to the patients sitting posture were associated with the greatest reduction in the patients reporting of Current Pain, Worst Pain and Best Pain, while side-posture sacroiliac joint manipulation and myofascial release were associated with lower Average Pain scores.  Chiropractic management may offer viable therapeutic options for patients with medically refractory pudendal neuralgia. 

 

 

 

1.   Toombs JD, Kral LA. Methadone treatment for pain states. American Family Physician. 2005, 71(7):1353-1358

{2.   Joachim Scholz, Richard J. Mannion, Daniela E. Hord, et al. A novel tool for the assessment of pain: validation in low back pain. PLoS Med. 2009 April; 6(4): e1000047. Published online 2009 April 7. doi: 10.1371/journal.pmed.1000047

3.   Krause SJ, Backonja MM. Development of a neuropathic pain questionnaire.  Clin J Pain. 2003, Sep-Oct;19(5):306:14

4.   Bennett M. The LANSS pain scale: the Leeds assessment of neuropathic symptoms and signs. Pain. 2001 May; 92(1-2):147-57

5.   Labat JJ, Riant T et al.  Diagnostic criteria for pudendal neuralgia by pudendal nerve entrapment (Nantes criteria). Neurourol Urodyn. 2008;27(4):306-10

6.   Heinze K, Nehiba M, van Ophoven A. Neuralgia of the pudendal nerve following violent trauma: analgesia by pudendal neuromodulation. Urologe A. 2012 Aug;51(8):1106-8. Doi:10.1007/s00120-012-2949-8.

7.   Hibner M, Castellanos ME, Drachman D, Balducci J. Repeat operation for treatment of persistent pudendal nerve entrapment after pudendal neurolysis. J Minim Invasive Gynecol. 2012 May-Jun;19(3):325-30. doi: 10.1016/j.jmig.2011.12.022. Epub 2012 Feb 4.

8.   Rigoard P, Delmotte, A, Moles A et al. Successful treatment of pudendal neuralgia with tricolumn spinal cord stimulation: case report. Neurosurgery. 2012 Sep;71(3):E757-62; discussion E763. doi: 10.1227/NEU.0b013e318260fd8f.

9.   Vancaillie T, Eggermont J, Armstrong G, et al. Response to pudendal nerve block in women with pudendal neuralgia.  Pain Med. 2012 Apr;13(4):596-603. doi: 10.1111/j.1526-4637.2012.01343.x. Epub 2012 Mar 5.  Kim SH, Song SG, Paek OJ et al. Nerve-stimulator-guided pudendal nerve block by pararectal approach.  Colorectal Dis. 2012 May;14(5):611-5. doi: 

10.Cok OY, Eker HE, Cok T et al. Transsacral S2-S4 nerve block for vaginal pain due to pudendal neuralgia.  J Minim Invasive Gynecol. 2011 May-Jun;18(3):401-4. doi: 10.1016/j.jmig.2011.02.007.

 

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