Health Organization for Pudendal Education

chuck wrote:
As for the question of pelvic varices causing PNE symptoms, this is something that has interested me for a long time. During Callie's pregnancies, she had the most God-Awful varicose veins (in her legs) that any of her doctors had ever seen! They ended up thrombosed; she had to be on daily heparin therapy, etc, etc. After delivery of our last child, the veins becaome much improved, but she eventually had sclerotherapy done to shrink the last ones away.

I only mention this because knowing that she had a propensity for varices always caused me to wonder if pelvic varices were somehow involved in her PNE symptoms. It makes sense to say that the varices are so "soft" that they couldn't cause nerve compression, but when you remember that nerves often travel alongside blood vessels, and that they often travel in enclosed areas (like Alcock's canal), you begin to wonder if a dilated vein running next to a nerve, in a confined space COULD cause a problem...

Just ran across this article:

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2117410/

J Neurol Neurosurg Psychiatry. 2006 January; 77(1): 88.
doi: 10.1136/jnnp.2005.069278.
PMCID: PMC2117410
Copyright © 2006 BMJ Publishing Group
Pudendal nerve compression by pelvic varices: successful treatment with transcatheter ovarian vein embolisation
T Moser, M‐C Scheiber‐Nogueira, T S Nogueira, A Doll, C Jahn, and R Beaujeux
T Moser, M‐C Scheiber‐Nogueira, T S Nogueira, A Doll, C Jahn, R Beaujeux, CHU Strasbourg, Strasbourg, France
Correspondence to: Dr T Moser
CHU Strasbourg, Strasbourg 67000, France; moser_th@yahoo.fr
Keywords: embolisation, pelvic varices, pudendal nerve


A 37 year old woman complained of chronic perineal pain and numbness for three years. Physical examination was unremarkable, but perineal neurophysiological testing revealed isolated abnormalities of the left pudendal nerve. The distal motor latency and the left bulbocavernous reflex latency were both lengthened (5.3 ms; normal <3.5 ms and 48 ms; normal <42 ms, respectively). Previous laparoscopy for tubal ligation also described bilateral ovarian varices more prominent on the left side, which were confirmed at pelvic CT (fig 1A​1A).

Figure 1 37 year old woman with left pudendal nerve compression by pelvic varices successfully treated with transcatheter ovarian vein embolisation. (A) Contrast enhanced CT scan through the ischial spine shows left ovarian varices (arrow). (B) (more ...)
Diagnosis of Alcock syndrome was rejected because pain was not exacerbated while seated, but rather in the upright position.1 Although perineal pain has not been reported in pelvic congestion syndrome,2 the possibility of venous compression resulting in nerve damage was raised. The patient was then referred to undergo an ovarian phlebography with possible subsequent embolisation.3 The phlebogram disclosed an enlarged left ovarian vein with congestion of the ovarian plexus (fig 1B​1B)) and selective left ovarian vein embolisation was performed with coils and glue (fig 1C​1C).). Three months later, our patient began to notice marked reduction in perineal pain and numbness. Neurophysiologial examination performed eight months after embolisation demonstrated normalisation of the left pudendal nerve distal motor latency.
This report suggests for the first time the possible compression of the pudendal nerve by pelvic varices, and should be analysed in line with other recently reported nervous compression cases of venous origin.4,5 It also demonstrates the dramatic relief obtained after ovarian vein embolisation.

I have been diagnosed with having a varicose vein in the vaginal vault but have been told on numerous occasions that it is unlikely to cause PN symptoms. Just woneringif that's entirely true.
I don't think I'd be considered for another MRI. Would a vaginal probe ultrasound show varices in the pelvic floor?

Catherine

I also have a vericose vein in the perineum in a vein that runs right along where the course of the pudendal nerve runs (was seen on the mri i had with dr kalinkin). This is very interesting. Dr hibner had told me that it's a chicken and egg question in my case about whether the vein contributes to the pne or if the vein is entrapped in the same place the pudednal nerve is and that what is causing the vericosity.

Merrie

Hi, I also have a Dr. Potter MRI showing enlarged veins (Varices) on both sides of my pelvis along the path of my dorsal nerve, which is where my pain is the worst. I had an expert on Dorsal Nerves look at my MRI and this is what he said. It seems possible to me that you can have an enlarged vein compressing the nerve or a compression of a nerve can also in turn cause an enlargement of the vein.

Allright- just had a look into your MRI with my radiologist. Excellent images, as ususal from Hollis Potter. The sequences show impressive varices at the base of the penis reaching into the distal canal on both sides! The nerve itself is difficult to visualize, since the signal of the veins is so intense. However, the ischiocavernous bodies and pubic bone are well delineated so that one can see the canal where the nerve is very well. So I suppose that the varices inflict continuous pressure on the nerve at the distal canal. That explains also why the problems arise when you do yardwork or other activities, since then the veins automatically bulge forward with quite some pressure. This phenomenon is known in this region. In some patients this “venous congestion” is even more prominent and extends all the way into the small pelvis. Fortunately with you this stops at the urogenital diaphragm. The vascular anatomy in the ischiorectal fossa and further up is normal!

So I am convinced that ligation and resection of these veins to decompress the nerve there will do the job.



Best regards,

I'm now confused again because Dr. Dellon has never heard of anybody doing a ligation and resection of enlarged blood vessels (Varices) in this area of the dorsal nerve and does not recommend it, and said he could take care of the veins during surgery if they were a problem by removing them, so I guess I am sticking with the dorsal nerve surgery now. I wish there was more evidence to support this possible Varices as the cause, but so far I have not been able to get a whole lot. Oh well . I will let you know if I find anything new out.

Hallo Shawn
do you have any news regarding your veins?
I have enlarged vein in the right Alcock canal, waiting till 21st December for consultation with prof. Aszmann, hope that he will be able to interprete my 3T MRI more thoroughly as my radiologist who is not a specialist in PNE.
Is there any other way how to treat enlarged veins in the Alcock?
Matt