Health Organization for Pudendal Education

So I came back from Dallas this week. I think the whole trip was well worth it. Let me start by saying that Dr. Avneesh Chaabra and his staff at the UT Southwest Medical Center were great and very friendly. I can say that of the multiple MRI scans I’ve tried in my humble experience with my pelvic woes (4 MRI’s before this one, one was 3T also), this was definitely the one with more resolution. The scan itself took quite more time than the ones I’ve tried in the past. About 1 ½ hours probably. It did not matter to me as I can sleep pretty well during the process, but for those with tight space issues, this one might get tedious. The whole staff was awesome. They even put me some smooth jazz while I was on the machine (the only place where I’ve had this), so I felt asleep easier. At the end, I thought I was not going to see the Professor at all, don’t know if it was because I came from out of town or what, but to my surprise he received me at his office, then we went to the screening room and he went through the whole analysis of the scan with me, the neurography part and all. That was just awesome and I really appreciate that he took time to answer all of my questions.
So basically, there’s no sign, at least on the scan, that the pudendal nerve is irritated. I saw it with my own eyes on the screen. There is however some mild irritation on sciatic and superior gluteal nerves, and some hamstring tendinosis at the side of the butt cheeks. Piriformis and obturator internus seem to be involved. This came somewhat of a shock to me, since I was almost assured in my last trip to Houston, that I was going to need PNE surgery. That is all that I will mention on that regard.
Anyway, to my scan results:

EXAM: MR LUMBAR PLEXUS WO IV CONTRAST
HISTORY: 36 years old Male with pelvic pain
TECHNIQUE: High resolution MRI of the lumbosacral spine and MRI of the pelvis
was performed for the purposes of lumbosacral plexus evaluation employing MR
neurography techniques on a 3.0 Tesla system using multiplanar 3-D anatomical
and fluid sensitive sequences. Contrast material was not administered.
3-D imaging - Independent work station 3-D imaging system for reconstructions
was utilized under concurrent supervision
COMPARISON: None.
FINDINGS:
Nerves
Lumbosacral plexus: Size: Normal. Signal: Normal. Course: Normal.
Sciatic nerve: Size: Normal. Signal: Mild hyperintensity on the left. Course:
Normal.
Femoral and obturator nerves: Size: Normal. Signal: Normal. Course: Normal.
Other specific nerves in question: The pudendal nerves are normal. Mild left
superior gluteal neuropathy, as it traverses under the greater sciatic notch.

Muscles/Tendons
Psoas major: Bulk: Normal. Intramuscular signal: Normal.
Piriformis: Bulk: Normal. Intramuscular signal: Normal.
Gluteal: Bulk: Bulk: Normal. Intramuscular signal: Normal.
Hamstring tendon: Mild tendinosis bilaterally.
Mild fatty infiltration of the left obturator internus.

Bones
Sciatic notches: Normal.
Marrow signal: Otherwise normal.

Joints
Lumbosacral spine:
Alignment: Normal
Spinal Canal: Developmental stenosis absent.
Minimal left facet arthrosis at L3-L4, L4-L5, and L5-S1.
L1-L2: Central canal: Patent Neural foramina: Right Normal Left Normal
L2-L3: Central canal: Patent
Neural foramina: Right Normal Left Normal
L3-L4: Central canal: Patent
Neural foramina: Right Normal Left Normal
L4-L5: Small left foraminal disc protrusion.
Central canal: Patent
Neural foramina: Right Normal Left Normal
L5-S1: Central canal: Patent. Small central disc protrusion
Neural foramina: Right Normal Left Normal
Sacroiliac joints: mild degenerative arthritis.
Pubic symphysis: Normal.
Vessels: Within normal limits
Masses: None

Other: 3-D imaging, thick slab MIP reconstructions were generated from
anatomic and diffusion-weighted imaging on independent workstation and sent
to PACS showing the peripheral nerve abnormalities..

IMPRESSION:
1. Mild left sciatic neuropathy changes. Mild left superior gluteal
neuropathy at the greater sciatic notch. Patient might benefit from
piriformis Botox injection and left sciatic perineural injection.
2. Mild fatty infiltration of the left obturator internus.
3. Minimal bilateral hamstring tendinosis

No wonder the previous blocks I’ve had didn’t work. I did not try the upright MRI, according to Dr. Chaabra, the resolution is very poor, unlike this scan and its findings.
Now I have homework to do back home, hopefully this study will shed some light to my Doctors to plan a better course of treatment.
For all interested, my symptoms are pain almost exclusively while sitting, on the butt, sometimes along the rectum, and butt cheeks, but does not travel down my leg. Sometimes I do get the foreign object in the rectum kind of feeling. No pain in perineum, scrotum or penis. I do not have incontinence either. My symptoms are more prominent on my left side.

Bikelover,

Nice to see that the MRI matches up with your symptoms. Sounds like your symptoms are not in the distribution area of the pudendal nerve so it's surprising that you received a diagnosis of PNE.

So could you actually see the nerves on the MRI? I've heard conflicting reports on whether nerves can be seen with the 3T MRI or the MRN.

I hope your doctors will be able to figure out the right treatments for you. Any ideas where this might lead you now?

Violet

Hi Violet!
No, there seems to be some confusion. From what I understood, I could be wrong....but all the data comes from the same 3 tesla MRI machine, some of the data is taken to another workstation where some kind of image filtering, or post processing takes place, I guess the neurography part. I do think that there could be some additional special resonant sequences added during the scan, because as I mentioned, the scan took more time than usual.
Anyway, we were looking at 2 screens all the time. The left screen showed what I think were the usual images we see from any MRI machine. Here the Professor showed me things like the piriformis muscle, the tendonitis on the hamstrings, and checked a bunch of other usual stuff, like the lumbar area, sacrum, joints, soft tissue, etc etc. The filtered images were on the right screen. On this screen, from what I understood was that if a nerve shows up with significant intensity, then its supposed to have some issue, irritation, inflammation, etc. The pudendal nerve showed up with very low (or normal) intensity, while the sciatic and superior gluteal nerves were indeed more intense. Hope I explained myself correctly.

In my own opinion, some of these conditions (and symptoms) seem to overlap with each other, its really hard to say, let alone as a simple civilian, and then for the doctors to interpret what we feel inside our bodies. During my visit to Houston, when I mentioned the golf ball in the rectum feeling, I was told that this was a classic textbook symptom of PNE. I was also told they have had people with only rectal problems, and that pain at other sites could be referred, etc. Go figure...
My own very personal opinion, is that these kind of tests (clinic history, electromyography, PNLT, etc) do not seem, or should not be taken as the main basis for the diagnostic. My particular impression of this MRN study that I did at Dallas, is that it surely has potential to become a great diagnostic tool for these kinds of things, as it pinpoints exactly where potential problems are occurring. I still have to find out if the technology is right though .

Next step, going to start inquiring about botox injections on the piriformis, and possible analgesic injection near the irritated nerve sites. Profesor Chaabra strongly recommended some Yoga or Pilates influenced PT as well, I will start as soon as I find a good one. Will keep reporting as I go, until hopefully, I'm able to sit and ride a motorcycle again

As a side note, remember that when we look at MRI images, you're looking at particular "slices" or "cuts" through the inside of your body, so its not like you can expect to see the whole nerve in one still as it goes through your body, you actually see cross sections of the nerve in question, at different spots while the radiologist moves through the different slices of your body. This is why I think, at first its hard to picture what is going on for the common folk, but for the radiologist is a piece of cake

Change of plans. Trying to do less invasive therapies, want to avoid more needles in my body. Going to start ESWT therapy today, with my Doctor friend who did shoulder surgery in the past. He owns the machine. I already know its wonders, he removed a big calcium deposit on my left shoulder once, that was leaving my shoulder useless. We are going to experiment a bit, I'm his first patient with sciatica through piriformis syndrome. We'll see how it goes. He will also use the machine on the hamstrings.
I can definitely feel now that pirifomis syndrome is the source of my woes. Today I woke up doing some light piriformis stretches and was able to bring some discomfort, including the golf ball in the rectum feeling. Maybe the piriformis is pushing against the 3 nerves, PN, Sciatica and the superior gluteal. The 3 of them seem to come out from behind the muscle when I look at anatomy pictures. Lord I wish I had found about the MRN study at Dallas before...

I'm going to move (copy) my thread to the case updates. Those who want to follow can do so there.

Today I woke up doing some light piriformis stretches again. I triggered the golf in the rectum sensation very easily again. Not painfull, just an uncomfortable sensation..

This is interesting...http://www.jaoa.org/content/108/11/657.full

"Some symptoms of piriformis syndrome occur as a result of local inflammation and congestion caused by the muscular compression of small nerves and vessels—including the pudendal nerve and blood vessels, which exit at the medial inferior border of the piriformis muscle.13"

"Spasm of the piriformis muscle and sacral dysfunction (eg, torsion) cause stress on the sacrotuberous ligament. This stress may lead to compression of the pudendal nerves or increased mechanical stress on the innominate bones, potentially causing groin and pelvic pain.6,9,22 Compression of the fibular branch of the sciatic nerve often causes pain or paresthesia in the posterior thigh.1,6,8,9,11,21,23"

Could this be why I get these PNE like rectal symptoms?

Scheduled for my first ESWT session later on today.

Hi Bikelover,
Wow, very interesting. Best of luck with the ESWT, yes do keep all of us informed.
Your fortunate to have a doctor friend willing to experiment a bit.

Thank you,
Debbie

Bikelover, it's nice to know there is another good place to get some good imaging done. Thanks for your detailed post.

Hope you have good success with ESWT and don't need to consider a surgical route which can be pretty nerve-wracking (no pun intended). Please let us know how it goes for you.

Violet