Health Organization for Pudendal Education

There's been some discussion of MRI's showing pelvic varices impinging on the pudendal nerve and whether varices could put enough pressure on the nerve to cause pudendal neuralgia. I ran across Marc Possover's publication in which he mentioned vascular entrapments. Here is the abstract:

Possover M.
Source
Department and Gynecology and Neuropelviology, Hirslanden Clinic, Zürich, Switzerland.
Abstract
PURPOSE:
The feasibility of the laparoscopic transperitoneal approach to the pelvic somatic nerves was determined for the diagnosis and treatment of anogenital pain caused by pudendal and/or sacral nerve root lesions.
MATERIALS AND METHODS:
The records of 134 consecutive patients who underwent laparoscopy for refractory anogenital pain were retrospectively reviewed. All neurosurgical procedures, such as neurolysis/decompression of the pudendal nerve and the sacral nerve roots or neuroelectrode implantation to the sacral plexus for postoperative neuromodulation, were done via the laparoscopic transperitoneal approach to the pelvic nerves.
RESULTS:
A total of 18 patients had Alcock's canal syndrome and decompression was successful in 15. Due to failed decompression 3 patients underwent secondary sacral laparoscopic neuroprosthesis implantation with a decrease of at least 50% on the pain visual analog scale. Sacral plexus lesions or radiculopathies, most commonly postoperative lesions and retroperitoneal endometriosis, were found in 109 patients who underwent laparoscopic neurolysis of the sacral plexus. The final outcome depended on the etiology. Of patients with postoperative nerve damage 62% had a decrease in the mean +/- SD preoperative visual analog scale score of from 8.9 +/- 2.9 (range 7 to 10) to 2.4 +/- 2.3 points (range 0 to 4) at the time of article submission at a mean followup of 17 months (range 3 to 39). Because of failed decompression, 8 patients underwent secondary sacral laparoscopic neuroprosthesis implantation and a decrease in the pain visual analog scale score was achieved in 5. Of patients with an endometriosis lesion of the sacral plexus 78% had a decrease in the mean preoperative visual analog scale score of 8.7 +/- 1.9 (range 8 to 10) to 1.1 +/- 0.7 points (range 0 to 2) at the time of article submission at a mean followup of 21 months (range 2 to 42). All 6 patients with vascular entrapment of pelvic nerves achieved complete relief. The last 7 patients underwent primary sacral laparoscopic neuroprosthesis implantation with at least a 50% decrease in the pain visual analog scale score in 4.

Here is a quote from the article:

exploration of the pelvic nerves permitted confirmation of suspected diagnosis such as extensive endometriosis or a postsurgical fibrosis of the retroperitoneal space, but also permitted discovery of anatomical situations never suspected before such as the compression of the sciatic nerve by an atypical superior gluteal vein, the entrapment of the sacral nerve root S2 between the inferior gluteal vessels...

Thankyou Violet, that is really interesting.

It is of particular interest to me because laparoscopy is what I am hoping can be done in my case. I wonder, do you think that by 'patients with post-operative nerve damage' they mean patients with damage that occurred during a surgery? It couldn't be known about until post-operatively, of course. Damage that actually occurred post-operatively is basically all damage other than during surgery, so why mention 'post-op' at all. I think it must mean surgical damage?

Anyway it is encouraging to see that 62% of nerve damage patients had a decrease in pain, and that some went down to zero pain. And also quite encouraging to see that for 8 of these patients where decompression failed, they tried a different approach and were successful in 5 cases.

Maybe the doctors who did these surgeries should be added to our list of PN doctors. Or at least the details of the clinic in Switzerland.

That study could answer a lot of questions Violet, but that information is not widely accepted by surgeons. I remember showing Dr Filler my MRN scan and asking what to me looked like thick threads wrapped around my sciatic nerve was, he confirmed that they were veins but said they wouldn't be significant for compression on a nerve.
Admittedly this probably is the case for the sciatic nerve but obviously smaller nerves as discussed in this paper can be affected.

Thanks for the post Violet.

Calluna, over 1 year ago I contacted Dr. Possover because Dr. Howard thought I would be a good candidate for his decompression of the sacral roots, decompression of hypogastric plexus and implantation of a peripheral nerve stimulator. These are procedures he developed and when I contacted him he is the only one in the world doing them and at that time he had not trained anyone else. At one point in time Dr. Howard thought about getting trained in the technique but he has recently gone part-time (semi-retired) so I doubt he will at this juncture. Dr. Possover use to practice in Germany so I contacted a surgical friend of mine and he told me even though he didn't know Dr. Possover personally knew that Dr. Possover was an outstanding surgeon. Dr. Possover got interested in pelvic nerve damage because his wife had pudendal nerve damage during a C-Section. I have been in contact with one woman who had a consult with Dr. Possover when he was visiting in the states and was very impressed with him. If she had the money she would have gone to Switzerland for surgery. Last I knew the sacral root decompression (done laprascopicaly) with implantation of peripheral nerve stimulator was about $50,000. Last I knew Dr. Possover was willing to see patients for a consult here in the states when he comes for conferences. Might be a good option for individuals who have failed pudendal surgeries. Something I have considered because of my RSD. The good news is there are lots of options still available when the pudendal surgery doesn't give someone the pain relief they would like.

That's good to know, nyt.

Going to Switzerland is out of the question for me, there is no way in the world I could afford it, let alone the clinic fees. I will see what Mr Dixon says when I see him next month. Dr Greenslade has told me that in his opinion Mr Dixon is the best pelvic floor surgeon in the UK.

Thank you so much for posting this article, Violet. You really find the best things to post here!

I will see what an MRI with Dr. Potter shows in my pelvis before I pursue this further, but I have long-suspected endometriosis in myself, so I'm interested to have this information.

I know people compare PN to carpal tunnel syndrome, but I think a much better comparison is to trigeminal neuralgia. (Like PN, trigeminal neuralgia can be difficult to treat, with less successful surgical outcomes, and involves complicated anatomy -- the trigeminal nerve is in the skull and face.)

Anyway, it has long been theorized that vacaular compression on the trigeminal nerve is a cause of that pain.

Hi, My Hollis Potter MRI done on 7/13/2011, showed varices (enlarged veins) bilaterally with left side greater than right along dorsal nerve and not any pudendal nerve scarring. The dorsal nerve area is the area of pain I have the most, so I am trying to figure out what to do next since the MRI kind of confirms this. It seems as if either fixing the enlarged vein or dorsal nerve decompression surgery are the options. I have had this for over 1 year. II have pain in my extreme upper perineum (dorsal nerve area) when sitting upright, occasional pain/burning in scrotum area, sometimes urinary problems when pain is high, and pain after sex. I guess my first option would be to try to fix the enlarged veins along the dorsal nerves and see if it helps. Any suggestions. Take care.

Shawn

shawnmellis wrote:Hi, My Hollis Potter MRI done on 7/13/2011, showed varices (enlarged veins) bilaterally with left side greater than right along dorsal nerve and not any pudendal nerve scarring...... I guess my first option would be to try to fix the enlarged veins along the dorsal nerves and see if it helps. Any suggestions. Take care.

Sounds like a reasonable plan, Shawn but maybe it's good to get a couple of PN doc opinions and then go into whatever treatment you choose with your eyes wide open --- being positive but knowing that there are no guarantees with whatever treatment you decide on. Best of luck with what you decide!

susibee wrote:I know people compare PN to carpal tunnel syndrome, but I think a much better comparison is to trigeminal neuralgia. (Like PN, trigeminal neuralgia can be difficult to treat, with less successful surgical outcomes, and involves complicated anatomy -- the trigeminal nerve is in the skull and face.)

Yes, this is brilliant, Susibee and from now on I am going to take your suggestion on this!

calluna wrote:Maybe the doctors who did these surgeries should be added to our list of PN doctors. Or at least the details of the clinic in Switzerland.

Calluna, Dr. Possover is on the list at this link: http://pudendalhope.org/node/57#SW It's unfortunate that he's the only doc in the world doing this and I hope that some others will become interested in learning his procedure.

Shawnmellis, Dr. Hibner has just started injected a sclerotizing agent into enlarged dorsal veins. Not sure how many he has done so probably doesn't have any outcome data yet but it is something to consider.

I just received another opinion from Dr. Aszmann which said when he looked my MRI that the dorsal veins were extremely enlarged (varices) on both sides of my pelvis and that this is likely the cause of the compression of my dorsal nerves. He said that this phenomenon is known in his area. This is very interesting as another possible cause of pudendal nerve entrapment and goes along with what Violet stated as a possible cause. This is what he said below in the email:

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,

OCA


Has anybody else just had a Potter MRI showing only varices (enlarged veins) along the area of their nerve pain?