Australia Update

[catherine a]

I've also posted this in the Australia section. Below is email from Prof. Vancaillie with an update of the Pudendal Nerve Diagnostic & Treatments.

Hi Catherine,

Thank you for your e-mail. Sorry to hear I have caused controversy, but that's probably not the first time in my life.
Let me explain what is happening at our Pudendal Nerve Diagnosis and Treatment Centre at WHRIA.

The main themes are:
1] we have made significant progress with non-surgical treatment
2] the results of the surgery are good, but often below the patient's expectations
3] pudendal nerve entrapment is rarely a stand-alone condition

A study on the 'natural history of pudendal nerve block' which we recently finished (a manuscript has been submitted for publication last month) shows that there is substantial improvement in at least 40% of the patients. And that is after a single injection of anaesthetic alone. This has convinced me to continue improving the injection technique first and then to look into using different substances to improve the outcome.

Improvement in injection technique was aimed at making sure the injected medication is actually delivered into Alcock's canal and the infra-piriformis canal. We achieved that by introducing dynamic fluoroscopy: radio-opaque dye is used to localise Alcock canal and we observe how the dye as well as the anaesthetic spreads along both canals toward the perineum as well as toward the sacrum. Patients who received blocks prior to introduction of that technique and are now getting a repeat block with dynamic fluoroscopy, report a marked difference in result.

Parallell to this development, we have started working with Dr. Toos Sachinwalla from Northside Imaging and have developed a specific pudendal neuralgia protocol for MRI (neuro-MRI). We have now realised that combining the MRI and the neurography (=dynamic fluoroscopy) technology gives us a far better understanding of the anatomy. We can now see the true dimensions of Alcock canal and abnormalities such as compression by the falciform ligament, narrow canal etc. We also believe (but can't prove yet) that we can actually visualise true compression of the pudendal nerve along its course. The most common site for compression, at least identified by this new combination of techniques, appears to be between the sacro-spinous and sacro-tuberous ligaments. We have however also observed that the anatomy is not 'fixed' over time. We are able in some cases to 'unblock' a compression, using large volumes of injected fluid in combination with cortisone.

Our team has also increased to include: 1] Sherin Jarvis, physiotherapist, who you already know; 2] Bernice Lowe, acupuncturist specialising in pain management (Bernice spent several weeks in the US and Canada to learn new techniques specifically aimed at dealing with chronic pain); 3] Amy Corcoran, osteopath, who deals with frequently associated pathology such as unstable sacro-iliac joint; 4] Kate O'Flynn, naturopath, who deals with the frequently associated gastro-intestinal issues; and 6] Margaret O'Brien, psychologist, who provides instruction in coping techniques.

Last year we introduced neuro-stimulation for the treatment of various conditions involving the sacral plexus. We favour this approach if there is additional issues, for instance with urinary or fecal incontinence. Associated pathology is the rule rather than the exception unfortunately.

In summary, we have a 'holistic' approach to the patient and exhaust all conservative measures prior to recommending surgery. The majority of patients do well with conservative management. Surgery does not eliminate the need for additional measures in most patients and patients need to be aware of that prior to committing to surgery. We offer both the trans perineal and trans gluteal (with Dr. Andreas Loefler, orthopaedic surgeon) approach, depending on anatomic findings. Dr. Loefler, Sherin Jarvis and myself spent a week in Nantes this year to learn the trans-gluteal approach from the master himself.

And unfortunately I am not going to Las Vegas, but I will be in Nimes next year.

I hope I answered your question,

Regards

Thierry



Thierry Vancaillie MD (Belgium), FRANZCOG, FFPMANZCA
Gynaecologist and Pain Specialist
Conjoint Professor, UNSW
Director, Women's Health and Research Institute of Australia