Health Organization for Pudendal Education

I would like to ask you those who had it> Where is exact location of the injection to dorsal nerve block?
Is it after the end of Alcok canal or is it in pubic area?
Next question is> do you think that ultrasound with high resolution is able to visualise tthe dorsal nerve itself?
I think it is possible because dorsal is pretty superficialy located /although it is very thin nerve.../
any opinions?

http://www.biomedsearch.com/article/Ult ... 96841.html

Basically it should somehow like described here.

But dorsal nerve block might leave unaffected ischiocavernosus muscle, which is often responsible for penile pain.

The anesthetic is injected by the pubic bone. Whether one can actually see the nerve is controversial. Some dr.'s believe if the frequency of the US is high enough (say 17 Hz) then they say you can see the nerve. However, some dr.'s don't believe you actually see the nerve itself but rather the neurovascular bundle (nerve, artery and vein complex).

Update to my case:

Today (6 hours ago) I had ultrasound guided dorsal nerve block made by prof. Bodner in Vienna. Unfortunately it did not help much, the only change was that my skin on the penis on the right side was numb for maybe 2 hours, but the pain was still there.

Prof. Bodner and prof. Aszmann decided not to add the steroids because there is very tight space in dorsal canal and steroids might irritate it considerably. The procudeure was smooth, 17Mhz ultrasound device is able to see the nerve, so no hitting the nerve. I felt maybe twice some painful impulses, but nothing excruciating.
But prof. Bodner assured me that he did not touch the nerve itself and ultrasound guided procedure is quite safe.
Now the pain is more prominent, hope that it will not be a major flare-up.

We discussed my situation, both on 17Mhz ultrasound as well as on my 3T MRI, there was visible huge pelvic congestion on the right side, in the pubic ramus and dorsal canal ("on typical spot" - said dr. Aszmann). I have bilteral pain but right side is definitely worse. Prof. Aszmann said, that there are huge pelvic varices, which are maybe more obstructive than the fibrotic tissue itself. These varices (and some fibrotic changes as well) are inflicting the pelvic congestion. So my situation similar like Shawn has, if I remember correctly.

Alcock and higher did not show up any pathology, so no need to intervene there. This varices aspect is in concordance with my worsening of symptoms after some specific conditions: sex, physical labour, lack of sleep etc. - these are situation when varices are more pressing the overall entirely tight space.

So I dont think that injections will help me considerably. More injections means more scars in the ligaments etc. Physical therapy is only partly effective - I have always more benefitted form long rest than from any form of physical therapy. Next logical step should be that PSST testing and when there will be some significant result, I am leaning to operation at dr. Aszmann. The future seems pretty grimm right now.

Matt

Sorry you didn't get a positive result Matt. . . . you do seem to be in good hands however as the Dr's are discussing what may be the cause with regard to the shot and MRI results and what to do next.
Take care,
Helen

Hi Matt,

I'm sorry it doesn't sound good for you. So basically you believe your problems are distal to Alcock's then? What about the ligamental grip at the ischial spine? Is there any pathology there? It's my understanding the ligamental grip is the "typical spot" so I'm not sure I understand what Dr. Aszmann meant -- whether the pathology is at the ligamental grip or distal to Alcock's. Before heading into a dorsal nerve surgery I would certainly want an honest assessment of the success rates because we are not hearing of good results here on the forum.

Take care,

Violet M

I think that the problem is surely distal to Alcock, because I dnot have sitting pain, and there is no pain in rectal area, and only small discomfort in perineum. The pain is radiating from the pubic ramus region forward. 3T MRI shows some pathology only in that area, nothing to find upper.
But- if the dorsal nerve block failed to stop the pain, it might be true, that it is no entrapment at all - but a clasical case of CPPS, transmitted sympathetically. /I had in past hypogastric plexus block which was partly succesful/.
So all in all> having bilateral pain at the base of penis and penile ligament, without any relation to sitting - it excludes to have some pathology up in sacrospinous/sacrotuberous ligament.
I will probably try to have that PSSD test at prof, Aszmann and then decide.

Yesterday block resluts were also for me surprising- dorsal nerve block was approached by 17Mhz ultrasound very precisely, I could see the nerve and the needle - and still no alternation of pain.

One more result - I did not have Tinel sign on any of examined places - neither ischial spine, nor Alcock, nor dorsal canal.

Still searching.

Brief update after 2 days:

Bad news: I feel certain flare-up after the block 2 days ago, My pain is more prominent and typically raw, exactly like Budgie wrote about his case several days ago. Fortunately no new spots of pain, only the highlighting of the "old" ones. Pretty burning neuropathic pain at the base of penis, both sides (although only one side was infiltrated).Dont know if this flare up might be dealt like confirmation of the hypothesis that dorsal nerve is surely involved (and probably main culprit). hope that this flare up will last only some days and not the whole summer. The nerve itself was not injured, thats pretty sure, I saw both the nerve as well as the needle on the screen.

Good news: I briefly communicated with one of my internet friends from Czech republic (he is not active on our forum) who had dorsal nerve decompression surgery 2 weeks ago by prof. Aszmann. My and his symptoms were 80% similar (location, type of pain, duration od symptoms). Even prof. Aszmann admitted that our cases are somehow similar (at laest clinical signs and 3T MRI pictures). He is feeling very good and is reporting significant progress. he is taking only some ordinary anti-inflammatory pills, so no heavy medication. I keep fingers crossed for him, we could build up United CzechoSlovak PNE Veterans Team

Hey Matt, I hope your increased pain settles down soon. It's pretty early to conclude anything with your friend because some of the guys who had the dorsal nerve surgery felt better at first but eventually relapsed. I hope his will continue to improve.

Good luck to you on figuring out what to do next.

Best,

Violet

Whole week after injection the flare-up somehow subsided. back to baseline pain.
Contemplating infiltration of Alcock but prof. Aszmann thinks that there is no reason to play with Alcock if there is no sign of problems being there.
Dorsal injection was applied to distal end of dorsal canal, so failure of the block basically point out to the fact that problem is inside dorsal canal (dont interchange it with Alcock canal).
Thick fibrosis there, sensitivity, and this is the place from where pain started almost 3 years ago. I intuitivel y feel that there is a problem - combination of varices and scars (mainly probably from that unlucky ECSW wave attempt, I would kill that orthopedist....).

here is the opinion of prof. Aszmann:
"From what Dr. Bodner told me, we can suppose that there is compression at the distal course of the pudendal nerve. I would not suggest a more proximal injection, since there the MRI does not show any irregularity, but rather a distal decompression. Both the ultrasound and MRI shows more fascial thickening on the right than on the left.
Best regards,OCA".

So things are pretty simple right now: Last attempt to eliminate the pain by increased Neurontin, physical therapy and relaxation in our weekendhouse in the mountains and when it fails, I will probably undergo the surgery.

Yesterday I took vacation from my job and will have holidays till Monday, 20th August.

Matt