Health Organization for Pudendal Education

Here is an update from Prof. Thierry Vancaillie ( Sydney Australia) I've also posted this in the 'Australia & New Zealand' forum.


Our pain clinic is expanding steadily. We welcomed Amy Corcoran, osteopath, as a member of the team this past April. She is already a fully fledged member contributing immensely to the management of our patients. Soon we will also be joined by Jeni Saunders, a sports physician with an interest in the sacro-iliac joint, an often overlooked source of pelvic and perineal pain.

In terms of research, we finished an interesting trial on the ‘natural history of the pudendal nerve block’ showing that 40+% of patients have a lasting effect from a simple block. Following on from that research, we have developed a technique to visualize the Alcock canal on X-Ray which ensures that the anaesthetic is indeed reaching the pudendal nerve in the canal. This may also one day become a test to identify compression unequivocally!

Recently, I was elected Fellow of the Pain Faculty of the College of Anaesthesia (FFPMANZCA) and have been working diligently to introduce electro-stimulation to the treatment of chronic pelvic and perineal pain. I went to the states several times to attend workshops and cadaver labs to familiarize myself with the technology. We now have three patients who successfully passed the trial of treatment ( = placing electrodes with an external controller). Two of them have so far received their permanent ‘pain pace maker’ and are doing well. There is a host of information on neuro-modulation on the Boston Scientific website. Their technology is called ‘Precision Plus System’.

We continue however to use Botulinum Toxin and trigger point injections as well as topical ointments, in addition to physiotherapy, osteopathy and psychotherapy, as treatment modalities. Our next project with Botulinum Toxin is to develop a dose-response curve for individual muscles. This will assist physicians, interested to use this modality, in applying the Toxin in the proper amount.

Queensland x Ray MRI technique:

Information on MRI technique. Queensland XRay Brisbane Australia

With regards to imaging the pudendal nerve with MRI - it is possible. MRI can definitely image nerves and their course through anatomy. We have been imaging with MRI to diagnose piriformis syndrome for a considerable time and have extrapolated this technique for imaging the pudendal nerve.

We have just recently imaged 3 cases of suspected PNE for Peter. We did not find evidence of PNE on these cases. What I would like is a positive case of entrapment to verify the technique that we are using. We are using a 3T system, MRN sequences, diffusion sequences and 3D datasets to track the course of the nerve. We have been able to track the course of the nerve from S2 down into the perineum in normal patients as well as these 3 patients, looking at the two common areas of entrapment - alcocks canal and between the SS ligament and ST ligament.

With the MRN technique you are looking for increased fluid and thickening within the nerve sheath, and by using this technique (sensitive to increased water content in nerves) you are making everything else dark (using heavy fat suppression), making the abnormal nerve 'stand out'.
What is essential for optimal imaging of PNE - site with experience in interpreting and imaging PNE, MRI imaging on a 3T platform is preferred, utilising 3D, MRN, and diffusion sequences.

I think with more cases in this area (and hopefully show some positive cases) we will be able to provide a viable option for imaging PNE patients.

| MRI Coordinator | Queensland X-Ray