Pudendal nerve entrapment syndromes : Physiotherapy Treatment, Exercise

What is Pudendal nerve syndrome ?

• It is also known as the Pudendal neuralgia & Alcock syndrome.
• It is an unusual of the condition which is arises from to the compression of to the pudendal nerve (S2) .
• It is a chronic & severely disabling neuropathic pain syndrome.
• It is a presents in to the pudendal nerve region & affects to the both of the males & females.
• It is a mostly inappropriately treatment & underdiagnosis and also affect to the impairment of the quality of the life.
• In this condition patient feel to the pain, discomfort & numbness in the pelvis ,genitals , perineal, perianal area.
• It is happen when to the major nerve of the lower body is damage or irritate & it is make to it hard for the use to the bathroom ,during sex & In the sit to down.
• This pain is come & go.
• This syndrome is one of form to the vulvodynia which is mostly common in women.
• This syndrome is also affect to the men.

Anatomy of the Pudendal Nerve :

• This nerve is in paired, meaning to there are to the two nerves, one for the left & one for the right side of to the body.
• This nerve is emerges from nerve roots to the S2, S3, S4 roots of the ventral rami of to the sacral plexus.
• It is carries to the sensory, motor, & autonomic fibers .
• So that in this an injury to this nerve sensory is more affected than the motor.
• Courses of this nerve is between the two muscles, the piriformis & coccygeus muscles.
• It is departs to the pelvic cavity through to the greater sciatic foramen ventral to the ligament sacrotuberous .
• It is pass to the medial side to & under to the sacrospinous ligament to the level of the ischial spine for to the re-enter of the pelvic cavity through to lesser sciatic foremen.
• In This nerve courses also a pudendal canal, which is also to the Alcock canal.
• The last three branches of this nerve terminate in to the fossa of ischioanal .
• In three branches include the perineal branch, inferior rectal branch, perineal branch, & the dorsal sensory nerve of to the penis / clitoris.
• Sensory fibers = it is innervates in to the external genitalia of the both of the sexes & to the skin around of the anus, anal canal & perineum
• Motor fiber = it is innervates to various to pelvic muscles, to the external urethral sphincter & the external anal sphincter.
• Autonomic fibers = it is carries to sympathetic nerve fibres of the skin of to the S2-S4 of the dermatology region.

• This nerve compression is based on to the anatomy .

• This syndromes is subdivide into the four types based on to the level of compression.

• Type I – Entrapment is below to the piriformis muscle when the pudendal nerve is exits form the greater sciatic notch.
• Type II – Entrapment is between to the sacrospinous & sacrotuberous ligaments , it is the most common cause of the nerve entrapment.
• Type III – Entrapment is in the Alcock canal.
• Type IV – Entrapment is of the term inal branches.

Etiology of the Pudendal Nerve syndrome:

• It is arise from to the non-mechanical or mechanical injury.
• Mechanical injury is due to the compression, stretching or transaction,.
• In the mechanical causes compression is the most common cause of this symdrome .
• Non-mechanical causes is in this symdrome
• Viral infections such as HIV , herpes zoster
• Multiple sclerosis
• Diabetes mellitus

Epidemiology of the Pudendal Nerve syndrome:

• This is to a rare syndrome
• This prevalence is to unknown.
• This condition is may be occurs to 1 per 100,000 .

Pathophysiology of the Pudendal Nerve syndrome:

• Exact mechanism of this nerve dysfunction & damage is to dependent on to its etiology.
• It is may be to the unilateral or the bilateral.
• Patient is feel the stretch & compression .
• This nerve is compressed to during prolong sitting & cycling.

Clinical Presentation of of the Pudendal Nerve:

• In this situation include to pelvic pain with the sitting which is increases throughout to the day & decreases with to the standing or to lying down.
• Sexual dysfunction & difficulties with the urination & defecation.
• To confirm this syndrome by the Nantes criteria.
• This pain & sensations are to similar to the other entrapment nephropathy.

Causes of the Pudendal Nerve syndrome:

• There are to many several things which can damage the pudendal nerve.

• It is happen due to when the if any is injured,
• In past clear to the surgery,
• During to the birth.
• Tumor & any infection which is squeeze or irritate to it
• Sometimes some exercise, like as to spending a lot of the time on to the bicycle, it is produce to the problem.
• Genitoanal surgical scarring
• Mishaps in to the pelvic region,
• Trauma to the pelvis,
• Pregnancy,
• Anatomic abnormalities.
• Vaginal birth is also reason of the damage & stretch of this nerve
• Cesarean section,is also cause of the nerve injury.
• In the cyclists, is present to this symdrome due to the both of the reason [compression + stretching ]
• If use the inappropriately shaped or the incorrectly position of the bicycle seat
• Repeated of to the mechanical injury
• Trauma of to the pelvic area, for example during childbirth
• Any cause of the development of the peripheral neuropathy such as the diabetes or vasculitis .

Symptoms of the Pudendal Nerve syndrome :

• Patient feel the neuropathic pain feel the cutaneous dysaesthesia
• Burning or sharp pain [ dysaesthesia ]
• Increase to sensitivity
• patient feel to the Numbness , pins & needles feeling, like when the leg falls in a asleep
• A feeling of swelling
• This feelings is become to worse when the patient sit down.
• This symptoms is feel on to the both sides of the body & they this pain is go into the belly, buttocks, /legs.
• Need to go sudden or frequent in to the bathroom
• Feel the trouble or pain during the sex
• Patient feel the Genito-anal numbness,
• Gecal & urinary incontinence is occur in the patient .
• People feel the burning pain in the perinatal or the genital areas.
• May be Pain is present is during the sitting and also relieved by in the standing, lying down or the sitting to the toilet seat.
• In the systematic symptoms of this syndrome implicated in the various sexual dysfunctions such as to PGAD = persistent genital arousal Disorder
• Erectile dysfunction,
• Premature ejaculation,
• Vestibulodynia.
• Sexual dysfunction by to the disturbing of to the testosterone signaling
• Constipation
• Painful of the bowel movements,

Diagnosis of the Pudendal Nerve syndrome :

Physical examination :-

• In this examination doctor is put the finger into the vagina / rectum & apply the pressure on to the nerve for check this symdrome .

High-frequency ultrasonography :-

• It is helpful in to the detection of the site [ location ] of this compression.
• Compressed nerve is appear to the flat, when to the inflamed nerve is appear edematous.

Doppler ultrasound :-

• It is a most of the use of for the diagnosis of this syndrome .
• As of the pudendal nerve & vessels course together to in a become to neurovascular bundle & the assumption is produce due to if there is a Present to nerve compression & also present of the vein compression .this is diagnosis by the Doppler ultrasound

MRI (magnetic resonance imaging) :-

• It is help into the running out of the other causes of the chronic pain.
• The advancement of the MRI techniques is to evaluating of the peripheral nerves which is provides to a detailed description of to the anatomy,
• Fascicular details,
• To the blood supply of the nerve & to the 3-D anatomy.
• It is also help to for the diagnosis in to the localizing the site of entrapment.
• Functional MRI is assesses to nerve integrity based on to their biological properties.
• There are to no specific & consistent radio logical findings of in the patients with this syndrome so that the further research is to necessary.

Pudendal nerve blocks :–

• This blocks is used to for confirm of this nerve
• In this procedure patient is feel to pain relief .This blocks is also used to during delivery in place of the spinal anesthesia.
• In This procedure given to a shot in the pelvis to the numb of the nerve & check the symptoms is relief or not .

Quantitative sensory threshold testing :-

• It is used in to the detect of the inability of sense temperature changes.

Skin rolling test :-

• It is a helpful for the clinical sign.
• In to this test , a thick roll or fold of skin is just below & lateral to the anus is to the pinched & then rolled to forwards.
• If the patient feel the pain is to elicited, so that the this syndrome is compressed.

Nerve studies :-

• Small device is to the inserted into to the rectum .
• In these study stimulate to the nearby nerves with the mild electrical impulses to the check how to it react .

Nantes Criteria for diagnosis :

• This syndrome is difficult for the diagnose & there are no a viable of specific exams which is clearly to confirm of the diagnosis.
• So that the Dr Roger Robert posted to the “Nantes Criteria” , which is help & guide to the physicians in to the diagnosis of this syndrome .
• It this Criteria consists of the inclusions, exclusions, & complementary characteristics of this syndrome.

Inclusion of this criteria :-

• Pain is produce to anatomically associated with to the pudendal nerve .
• Patient feel the Pain in a sitting position .
• Pain is not to cause of the nocturnal awakenings .
• Function of sensory is to intact .
• Pudendal nerve block is used to for diagnosis test of the in pain relief .

Exclusion of this criteria :-

• This Imaging results is used for the exclusion .
• Pain in Unilateral .
• This test results is of an abnormal diagnostic .
• In this criteria pain is acute .

Complementary of this criteria :-

• Nerve to pain is associated with the extreme sensitivity to the touch .
• It is described to burning or shooting pain .
• Defecation following to the posterior pain .

Associated signs:-

• Pain in the buttock .
• Referred sciatica pain .
• Pain in the medial thigh (indicates obturator nerve) .
• Pain in the supra pubic region .
• Increased frequency of urine or pain with a full bladder .
• Pain after ejaculation .
• Pain worsens hours after sexual intercourse.
• Erectile dysfunction .
• A normal result on electrophysiological tests .

Differential Diagnosis of the pudendal nerve syndrome :-

• A tumor & metastasis in the external source
• Superficial infections of to the skin in the dermatomes which is covered to in this nerve
• Sacral region of this neuropathy which is due to damage to this sacral nerve plexus.
• During Childbirth to a stretch of to the perineum
• Pain syndrome in complex regional , chronic pain in to the limbs .
• Interstitial cystitis.
• Prostatitis in males,
• Uterine diseases in females,
• Abacterial chronic prostatitis in male
• Idiopathic proctalgia in male
• Vulvodynia in female
• Endometriosis in female
• Endometriosis in female

Function measurement of the pudendal nerve syndrome :-

• Visual Analogue Scale (VAS)
• McGill Pain Questionnaire(MPQ)
• DN4 (which stands for Douleur Neuropathique 4)
• Brief Pain Inventory – Short Form (BPI-sf)

Visual Analogue Scale (VAS) :-

• It is used for the check the pain intensity of the patient .
• First all give the all the information about this scale to the patient .
• In this scale tell the patient give to the number how many number like their feel the pain .
• All see the face of the patient .

McGill Pain Questionnaire(MPQ) :-

• It is used for the check the pain of the patient .
• First all give the all the information about this scale to the patient .
• In this scale ask to question the patient about to the pain .

Douleur Neuropathique 4 (DN4) :-

• It is a screening question naire to the help for the identify neuropathic pain (NP) .
• It is used to the in clinical practice & research.

The Brief Pain Inventory (BPI) :-

• It is rapidly assesses to the severity of the pain & its to impact on to the functioning.
• In this scale ask to the patient 9 question for the pain relief .

Treatment of the pudendal nerve syndrome :

Medical treatment :-

• Give to the patient analgesics, anticonvulsant & muscle relaxants
• Give to the patient anti-epileptics drug = gabapentin ,
• Antidepressants drug = amitriptyline & palmitoylethanolamide.
• Tricyclic antidepressants = amitriptyline
• Anticonvulsants = carbamazepine & sodium valproate
• Nerve stabilizers = gabapentin & pregabalin.

Conservative treatment :–

• Avoidance of to the painful stimulus is one of the most important parts of this treatment.
• If the cycling is produce to the pain so that the patient is use to proper padding or the cease of the activity.
• Do the lifestyle modifications for the minimize of sitting.

Surgical treatment :-

• This treatment is decompression is the best treatment for this symdrome .
• Four different approaches are used for this symdrome .
• Transperineal,
• Transgluteal,
• Transischiorectal
• Laparoscopy.
• Superior retrosciatic
• Medial transgluteal
• Inferior retrosciatic
• Superior transgluteal
• Transischial entryinferior transglutealand.

• in all tenchinque remove to the nerve fiber .

Pudendal nerve block :

• In to the other treatment of the modality is to infiltration with to local anesthetic or to a steroid in to this area encircling the pudendal nerve.
• This block is given to unguided or with to the aid of the ultrasonography, computed tomography (CT) scan & fluoroscopy,.
• Mostly used this technique is with to the use of the CT scan.

Neuromodulation:–

• In the latest treatment includes to the using a peripheral nerve stimulator
• Which is stimulat the pudendal nerve in to the ischioanal fossa.

Pulsed radiofrequency:–

• It is a relatively to new neuromodulation technique &
• It is a considered to safer than the continuous radiofrequency .
• It is also useful for the chronic refractory neuropathic of the pudendal neuralgia.
• It is manage to chronic pain & give to the long-term benefits

Lipofilling:–

• It is a relatively to new technique of the treatment of the pudendal neuralgia.
• In this techinqe give to the patient autologous injection of the adipose tissue along with the stem cells in to the pudendal canal.

Nerve protection :-

• It is a form of the self treatment to the keep pressure off to the pudendal nerve.
• In this involves to avoiding the any activities which is increase to pain in the pelvic area.
• If the remove the seat cushion of the center area is help to provide relief & prevent form the further pain.
• Used to a wider seat when do the cycling ; which is prevent to damage of the nerve.
• For use to the cycling include to having soft & wide seat in to a horizontal position & setting to the handlebar height lower than to the seat.
• For the bicycle used to seat designed for to the prevent of this nerve compression so that the seat is usually to a narrow channel in the middle of to them.
• For the other recommendations include to wearing padded during bike shorts, standing on to the pedals, periodically, shifting to the higher gears & take to frequent breaks.
• Avoid to the prolonged periods of the sitting, particularly in to the in cyclists who have to this condition.
• Use to a foam ring-cushion which is no apply to pressure on to the center when to the sitting
• Avoid to straining when to the passing the urine or opening of the bowels

CT-guided nerve block Injections :-

• It is used to in to identify & alleviate pain associated with to the pudendal nerve .
• During in this procedure bupivacaine hydrochloride drug which is a long-acting local anesthetic & a methylprednisolone [ corticosteroid ] are give to as injected for to the provide a immediate pudendal anesthesia.
• This nerve blocks inserted from several to different anatomical locations like as the : transvaginal, transperitoneal& perirectal.
• A reduction of the pain following to this injection is typically felt to quickly.
• Side effect of this block injection is site irritation.
• This is also Relief the chronic pain , by the reduced of the inflammation around the nerve .

Physiotherapy treatment of the Pudendal nerve syndrome :

• Pelvic floor exercise is works for the patients in the pain & muscle spasms.
• Exercise is helps in to the relaxation of the pelvic floor muscles by the releasing of spasm & muscle lengthening.
• It is give to the stretches the muscles of the lower end of the pelvis, which is known as the pelvic floor muscle .
• This stretch is also give to easy pressure on that to irritate by to this nerve.
• It is also help in control of the bladder or bowels by the exercise.
• Give to the patient neural mobilization for the nerve entrapment by the therapist .
• Goal of this mobilization is to the restore the functionality of to the nerve & muscles through to a variety of exercises .
• Do the strengthening exercise of the muscle .
• Apply to TENS (trans-cutaneous electrical nerve stimulation) machine for relieve of the pain but apply to electrode in correct position .

Exercises of the pudendal nerve syndrome :

1. Wide leg bridges
2. Standing backward leg lifts
3. Side-lying hip abduction and extension
4. Hip extension in the quadruped position
5. Cobra pose
6. Arch Backs

Wide leg bridges :-

• It is strengthens to the glutes & hamstrings muscle while enhancing to core stability.
• Tighten to the abdominal & buttock muscles by the pushing the low back in to the ground.
• Raise to the hips to the create a straight line from to the knees to the shoulders.
• Squeeze the core and pull the belly button back toward the spine.
• Hold for the 20 to 30 seconds.
• Do the Lower the hips and return to in the starting position.

Standing backward leg lifts :-

• Starting position of the standing .
• Then the left the leg in the backward .
• Do this exercise for the 10 times in one session .
• Repeat this exercise 3 session per a day .

Side-lying hip abduction and extension ;-

• Starting position is the side lying
• One leg is bend and other leg to raise .
• It is called the abduction .
• For the extension other leg is extended form the hip .

Hip extension in the quadruped position :-

• Starting position is the quadruped position
• Then the extended the leg form this position
• Hold for the 10 second .
• Repeat this exercise for the 10 times & 3 times per a day .

Cobra pose :

• Lie prone on to the floor.
• Stretch the legs , back, tops of to the feet on to the floor.
• Spread to the hands on to the floor under the shoulders.
• Hug to the elbows back into the body.
• Then Press to the tops of to the feet & thighs & the pubis firmly in the floor.
• During the inhalation, begin to the straighten the arms for to lift the chest off to the floor.
• Go to the height at which the maintain a connection through to the pubis to the legs.
• Press to the tailbone toward to the pubis & lift to the pubis toward to the navel.
• Narrow to the hip points.
• Lift through to the top of the sternum & avoid to pushing the front ribs to forward
• Hold this pose anywhere from to the 15 to 30 seconds breathing to easily.
• Release to back the floor with the exhalation.

Arch Backs :-

• This all exercise perform to the relive to the back pain .

Complications of the pudendal nerve syndrome :

• Infection .
• Laceration of to the vaginal mucosa .
• Intravascular injection of to a local anesthetic is cause to cardiovascular & CNS toxicity.
• Hematoma of the injury of to the pudendal artery .
• Urinary problems like as the frequency & urgency .
• Sexual dysfunction including to a painful sex .
• High levels of the stress .
• Anxiety & depression .
• Difficulty to opening the bowels .