Publication Abstract - A Must Read!

[nonsequitur]

nyt wrote:
I have read the full paper and no where in this paper does it state "an entrapment of the pudendal nerve by hardened connective tissue in the cadavers they examined." 

I downloaded again the publication. You are right they don't talk about hardened connective tissue but use the term "dense" instead. What they describe is much worse. They describe finding what PNE surgeons describe as "entrapment of the pudendal nerve both at the alcock's canal and at the ligaments".

The study says: Traction on the nerve(s) within the pudendal canal did not result in displacement of the pelvic section of the nerve, and similarly, traction on the pelvic portion of the PN did not result in movement of the nerve(s) within the canal.
The PN was not freely mobile until the SSL was transected from its attachment to the IS, and the nerve was dissected off its surrounding connective tissue fibers.

It is entrapped. It is entrapped in "dense" connective tissue. The nerve is completely stuck. Yet those subjects did not suffer from CPPS while alive as far as we know!
Normal healthy connective tissue does not entrap the nerve.

Let's review how a nerve in healthy connective tissue behaves (like you claim the authors in this article found):

Peripheral nerve injuries
Evidence-based Manual Medicine: A Problem-oriented Approach
By Dr. Michael A. Seffinger and Dr. Raymond J. Hruby

A nerve has flexibility within its connective tissue to glide. The nerves have a loosely adherent outer connective tissue sheath known as the epineurium. The epineurium and associated blood vessels along with intraneural gliding surfaces of the fascicles permit the nerve to move about 1cm during flexion.

The nerve is loosely attached and can glide. It is not entrapped rigidly. It is not at all the situation in this paper. They found the pudendal nerve entrapped in dense connective tissue.

Authors' conclusion:
This finding has potential implications in the surgical treatment of pudendal neuralgia, and it may be misleading to attribute pudendal neuralgia to nerve entrapment. Thus, procedures seeking to decompress the PN may not address the true etiology. In fact, these procedures may potentially result in significant complications, given the complexity of surrounding nerve and vascular anatomy.

Conclusion: pudendal pain may not be connected to pudendal entrapment/adhesion!

I have contacted the authors of this article directly and will report back

[Violet M]

Normal healthy connective tissue does not entrap the nerve.

What about unhealthy connective tissue that is hardened and sclerosed? Also, how was traction applied to the nerve in this study? How can you apply traction in a cadaver the same way it would be applied in a live person?

I see problems with this study. There are too many variables that we don't know about -- whether these people had hardened ligaments, whether they exercised heavily, whether they had any history of pelvic surgery or trauma, etc. Also, it was a very small sample. And just because one person doesn't have pain from adhesions doesn't mean someone else won't, even if they are "normal" adhesions as you say (whatever those are).

Conclusion: pudendal pain may not be connected to pudendal entrapment/adhesion!

I actually agreed with this statement, even prior to the publication that is under discussion having been published. I think there are numerous cases of pudendal pain that are not connected to pudendal entrapment/adhesion. But it does not follow that there is never a case of pudendal pain caused by pudendal entrapment. To draw that conclusion would be a non sequitur.

Violet

[Violet M]

It seems to me that you are the one denying PNE exists.

Yes, until we have some proof of entrapment, it's a completely bogus diagnosis.

2) I have never said the nerve is "never" entrapped. That's a straw man argument. A straw man is a common form of argument and is an informal fallacy based on giving the impression of refuting an opponent's argument, while actually refuting an argument which was not advanced by that opponent

First you say entrapment is a completely bogus diagnosis. Then you refuted yourself and denied saying the nerve is never entrapped. Which of your two statements do you believe? First you advance the argument that PNE is a bogus diagnosis and then your say you never argued that.

I am appalled to see how many posters here have case histories that do not suggest PNE at all, but still the moderators and site owners do not raise a red flag or suggest that other conditions be investigated.

Flat out lie, CPPS. Please see our diagnosis page. http://www.pudendalhope.info/node/69
We clearly state near the top of the page to investigate other possibilities.

I can point to numerous threads where the poster described vanilla CPPS or IC symptoms, yet the assumption is made that this is a pudendal nerve problem, and CPPS/IC are never mentioned. So it's not a lie.

Once again, incivility and threats of banning only undermine your position. Banning opinions you don't like, as you did with Ezer, is a sign of weakness.

Wrong again. We never assume anyone has a pudendal nerve problem. We aren't doctors and we don't diagnose so your accusation is completely false. And wrong again about Ezer. He was not banned for his opinions. We allowed him to freely state his opinions.

However, from my own experience running a similar forum, I find that people who are cured (or so much improved that their symptoms are not front of mind) almost invariably move on with life and leave the forum. It is instructive that many of the PNE surgery "cures" are still here, on this forum, posting advice.

Wrong again, CPPS. I am one of the few people who is much improved who continues to post here. My goal is not to post advice. My goal is to provide information to people. My life would be much easier if I moved on but I remember how lost I was when I first came to the forum and that the information I received on tipna and pudendal.info saved my life. That's why I stay around. I have another full-time job and I take no medication for pudendal nerve pain. I am essentially cured of PGAD. I want to help other people find the same relief I have. HOPE does not advertise any products. We are a non-profit 501c3 tax exempt organization and we are all volunteers. None of us receives a dime from running this website but in fact we have put a lot of unpaid time and money into this organization.

Violet

[nonsequitur]

I see problems with this study. There are too many variables that we don't know about -- whether these people had hardened ligaments, whether they exercised heavily, whether they had any history of pelvic surgery or trauma, etc. Also, it was a very small sample. And just because one person doesn't have pain from adhesions doesn't mean someone else won't, even if they are "normal" adhesions as you say (whatever those are).

You probably did not read the full study. Many of the questions you are raising are answered in the publication. Why don't you ask the publisher to allow you to post it?

What about unhealthy connective tissue that is hardened and sclerosed?

Yes, that is what they found. What about it?
Because of it, the nerve was found to be stuck. Entrapped by the definition of PN surgeons. You can probably pick random people that have a sedentary life (office jobs) and submit them to PNE surgery. They would all be deemed entrapped. That's worrisome.

And just because one person doesn't have pain from adhesions doesn't mean someone else won't

Therefore adhesion of the pudendal nerve does not prove anything? Yet you define adhesions (the nerve tethered) as a proof of PNE:

Pudendal nerve entrapment (PNE) is a more specific term describing a neuropathy or neuralgia that is associated with the nerve being tethered by fascia, compressed by ligaments, enlarged muscles, and/or other structures.

http://www.pudendalhope.info/node/8

[nyt]

nonsequitor, you forget the authors raised the some of the same questions and limitation of their study that Violet has ie sample size. Please go back and reread either what I posted from their discussion section or the discussion section in the paper.

The authors seem to use the same wording to describe their observation " pudendal nerve was fixed to the SSL" which is typical of what authors do when they are not totally sure of the physiological significance of their finding. In the figure legend they even use the words "appears fixed" which the word "appears" puts a tentativeness to their observation. Let's all be careful to accurately describe what these author state. In their discussion they raise the potential concerns, that is what the Discussion Section of a paper is for, is to raise interesting questions and potential implications of your findings but doesn't carve it in stone which I'm finding some members have done.

Let's not forget these are cadaver's. Rigamortis sets in right after death. We have no idea how this natural occurrence after death effected the mobility of the nerve. Personally, I found their method to determine mobility not scientific and they didn't reference anyone else that has used their method.

[cpps-admin]

In the figure legend they even use the words "appears fixed" which the word "appears" puts a tentativeness to their observation.

That's typical of scientific discussion. Words like "appear" and "may" are routinely used because there is always a (usually small) chance that things are not as they seem.

Let's not forget these are cadaver's. Rigamortis sets in right after death.

"Rigamortis"? I think you mean "rigor mortis". Rigor mortis affects muscles, not nerves, so it is not material here.

[cpps-admin]

Yes, until we have some proof of entrapment, it's a completely bogus diagnosis.

2) I have never said the nerve is "never" entrapped. That's a straw man argument. A straw man is a common form of argument and is an informal fallacy based on giving the impression of refuting an opponent's argument, while actually refuting an argument which was not advanced by that opponent

First you say entrapment is a completely bogus diagnosis. Then you refuted yourself and denied saying the nerve is never entrapped. Which of your two statements do you believe? First you advance the argument that PNE is a bogus diagnosis and then your say you never argued that.

It is a bogus diagnosis as long as the definition of pudendal nerve entrapment includes words like "does not slide freely", "attached" etc. Nerve compression syndrome or compression neuropathy, also known as entrapment neuropathy, is a medical condition caused by direct pressure on a single nerve. Symptoms include pain, tingling, numbness, and muscle weakness. I would suspect a trapped or compressed nerve in a patient who had one-sided tingling, numbness, pain, incontinence, and weakness, and had a dramatic difference in symptoms when sitting on a toilet seat vs sitting on a chair. Studies back up these observations. These patients are rare, so the current fad for diagnosing PNE in run-of-the-mill pelvic pain patients is ill-advised and yes, "bogus".

I am appalled to see how many posters here have case histories that do not suggest PNE at all, but still the moderators and site owners do not raise a red flag or suggest that other conditions be investigated.

Flat out lie, CPPS. Please see our diagnosis page. http://www.pudendalhope.info/node/69
We clearly state near the top of the page to investigate other possibilities.

Um, I was not referring to your nodes, I was referring to threads in the forum.

Wrong again. We never assume anyone has a pudendal nerve problem. We aren't doctors and we don't diagnose so your accusation is completely false.

I don't have the time to point to all the many threads where new members are taken into a PNE discussion before CPPS and/or IC are discussed (if they are raised at all), but anyone reading this can go check for themselves. It's everywhere.

And wrong again about Ezer. He was not banned for his opinions. We allowed him to freely state his opinions.

Did you (or another mod) ban him or not? He told me he'd been banned. If so, why?

Wrong again, CPPS. I am one of the few people who is much improved who continues to post here.

Your improvement allows you to sit on "some chairs" now. That is not a cure, is it? So you are not the sort of cured patient (who moves on) that I am talking about.

I am essentially cured of PGAD.

Be completely and totally honest and describe your exact remaining symptoms.

[nonsequitur]

First of all nyt, thanks for posting this article.

Your stance on the significance of that study however keeps morphing.

1) In your first post, you bolded what you found of great interest:Fixation of the pudendal nerve to the dorsal surface of the sacrospinous ligament is a consistent finding; thus, pudendal neuralgia attributed to "nerve entrapment" may be overestimated.

2) You then said later that what those researchers found is just plain connective tissue. What they found is completely normal and therefore of no interest.

3) Now you write that they indeed seem to have found the nerve stuck but that the research is of such poor quality that it should be ignored.

You need to pick. It cannot be all true. 1) Very interesting: Entrapment over-diagnosed & 2) No Interest: Completely normal findings, just plain connective tissue & 3) Nerve found indeed entrapped but the study is flawed and should be discarded because of poor quality.

[Violet M]

You probably did not read the full study. Many of the questions you are raising are answered in the publication. Why don't you ask the publisher to allow you to post it?

I don't have access to the full study. Could you email it to me? I think you have my email address.

You can probably pick random people that have a sedentary life (office jobs) and submit them to PNE surgery. They would all be deemed entrapped. That's worrisome.

Obviously that would be worrisome if the person wasn't having any pain. No one in their right mind would do that. I still maintain, that even for a person in pain, surgery remains a last resort option after other therapies have failed. So it's not a matter of submitting people to PNE surgery. People have surgery because they choose to and one of the purposes of this forum is to help people make an educated choice. Which is why we are having this discussion.

And just because one person doesn't have pain from adhesions doesn't mean someone else won't

Therefore adhesion of the pudendal nerve does not prove anything? Yet you define adhesions (the nerve tethered) as a proof of PNE:

Pudendal nerve entrapment (PNE) is a more specific term describing a neuropathy or neuralgia that is associated with the nerve being tethered by fascia, compressed by ligaments, enlarged muscles, and/or other structures.

http://www.pudendalhope.info/node/8

Why do some people have severe pain with arthritic joints and others don't? BTW, I don't see the word adhesions in our definition. Like I said at the beginning of this thread, compression of the nerve is what I have always understood to be the most likely cause of PNE. I have been told by surgeons that the nerve can be stuck in fascia. The medical community may be in disagreement about whether that can cause pain but I don't think this study definitively disproves it. Even if it did, compression by ligaments would still remain an issue.

Violet

[Violet M]

I am essentially cured of PGAD.

Be completely and totally honest and describe your exact remaining symptoms.

Regarding PGAD, I honestly can't remember the last time I had symptoms of PGAD. I've described my symptoms elsewhere on the forum and I'm not going to again. It's just too personal. It was the worst PNE symptom I had. Rarely, maybe a couple of times a year, if I have been really active, such as doing a lot of yard work, I might have symptoms that last for a few minutes. So going from symptoms 24/7 when awake, I would say a few minutes a couple of times a year is close to cured, but completely cured is kind of elusive when it comes to PN. I can sit for many hours a day, in lots of different chairs without cushions, including driving a car. I have no reason to stay on the forum other than to try to help other people.

BTW, what are your symptoms, CPPS? Have you ever told your story on this forum? I would be interested to hear it.

I am in agreement with you that PNE can be caused by compression of the nerve. My symptoms were much worse on one side than the other which is consistent with the Nantes criteria.

Violet