Publication Abstract - A Must Read!

[nyt]

Below is an abstract from a brand new publication on the anatomical variation in pudendal nerve anatomy. What is of great interest I have bolded. The authors found that in ALL cases the pudendal nerve was "fixed" to the dorsal surface of the sacrospinous ligament.

Am J Obstet Gynecol. 2015 Jun 9. pii: S0002-9378(15)00592-X. doi: 10.1016/j.ajog.2015.06.009. [Epub ahead of print]

Anatomic Variations Of Pudendal Nerve Within Pelvis And Pudendal Canal: Clinical Applications.
Maldonado PA1, Chin K2, Garcia AA2, Corton MM2.
Author information
Abstract
OBJECTIVES:

To examine the anatomic variation of the pudendal nerve in the pelvis, on the dorsal surface of the sacrospinous ligament and in the pudendal canal.
STUDY DESIGN:

Detailed dissections of the pudendal nerve were performed in unembalmed female cadavers. Pelvic measurements included: distance from the origin of the pudendal nerve to the tip of ischial spine and nerve width at its origin. The length of the pudendal canal was measured. The inferior rectal nerve was identified in the ischioanal fossa and its course documented. Lastly, the relationship of the pudendal nerve to the dorsal surface of the sacrospinous ligament was examined after transecting the lateral surface of the sacrospinous ligament. Descriptive statistics were used for data analyses and reporting.
RESULTS:

Thirteen female cadavers (26 hemi pelvises) were examined. A single pudendal nerve trunk was identified in 61.5% of hemi pelvises. The median distance from the point of pudendal nerve formation to the ischial spine was 27.5 mm (range 14.5-37 mm). The width of pudendal nerve in the pelvis was 4.5 mm (range 2.5-6.3 mm). The length of the pudendal canal was 40.5 mm (range 20.5-54.5 mm). The inferior rectal nerve was noted to enter the pudendal canal in 42.3% of hemi pelvises; in these cases, the nerve exited the canal at a distance of 32.5 mm (range 16-45 mm) from the ischial spine. In the remaining specimens, the inferior rectal nerve passed behind the sacrospinous ligament and entered the ischioanal fossa without entering the pudendal canal. In all specimens, the pudendal nerve was "fixed" by connective tissue to the dorsal surface of the sacrospinous ligament.

CONCLUSIONS:

Great variability exists in pudendal nerve anatomy. Fixation of the pudendal nerve to the dorsal surface of the sacrospinous ligament is a consistent finding; thus, pudendal neuralgia attributed to "nerve entrapment" may be overestimated. The path of the inferior rectal nerve relative to the pudendal canal may have implications in the development of anorectal symptoms. Improved characterization of the pudendal nerve and its branches can help avoid intraoperative complications and enhance existing treatment modalities for pudendal neuropathy.

[ezer]

Very interesting. In short there is no correlation between entrapment and pain. Every person having a sedentary lifestyle is "entrapped". It does not mean they experience pain.

PNE a myth?

Exactly what I suspected. So much for some of the French surgeons almost always finding an entrapment at the ligaments that explains pain. It is meaningless just like my surgery reports.

[nyt]

It is a finding that is of utmost importance to this group and to PN doctors. It will be interesting to see what the doctors have to say.

Have their been surgeons who would say they have done surgery and not find someone entrapped. I know one patient told me they were not entrapped when they had their surgery which then raises the question how is entrapment defined. What I do not know if there is something about how the cadavers were prepared prior to their dissection that could have caused it to be "fixed" to the sacrospinous ligament. I am not sure what the authors mean by "fixed." Also, it states the dorsal surface of the sacrospinous which is a specific location.

Anyway, all and all, this is a subject everyone should start asking their PN specialist prior to surgery. If you can get a full copy of the article take it with you. Even though Dr. Carrillo (he replaced Dr. Howard) does not do surgery it will be something I will bring to his attention at my next appointment.

[ezer]

PNE surgery not better than a placebo.

http://en.wikipedia.org/wiki/Sham_surgery

[Violet M]

Interesting article but I don't see how we can conclude from it that PNE is a myth.

Where is entrapment defined as the nerve being fixed to the SS ligament? My understanding is that entrapment is due to the space between the SS and ST ligaments being tight causing the nerve to be constricted, or an entrapment may be due to other reasons.

From Robert: http://www.pudendalhope.info/sites/defa ... Robert.pdf

"Our anatomic findings have led us to define conflictual relations that may be encountered in their course by the pudendal n. and
its branches. Starting from the clinical study of a group of patients suffering from chronic perineal pain in the seated position, we
have defined, beginning with the cadaver, three possible conflictual settings: in the constriction between the sacrotuberal and
sacrospinal ligaments; in the pudendal canal of Alcock; and during the straddling of the falciform process of the sacrotuberal
ligament by the pudendal n. and its branches."

From Hibner: http://www.pudendalhope.info/sites/defa ... Hibner.pdf

"Pudendal neuralgia can be caused by mechanical injury to the nerve, viral infection, or immunologic processes. In the case of mechanical injury to the nerve, most practitioners will refer to the condition as pudendal nerve entrapment. This "entrapment" may be caused by pelvic floor muscle spasm (levator any or obturator internus), pressure from surrounding ligaments (sacrospinous, sacrotuberous), or scar tissue from trauma or surgeries involving the surrounding areas. In patients who have undergone surgery, entrapment may be caused by mesh or suture directly injuring the nerve. "

In my case I think the pathology could be explained by pelvic instability due to strained ligaments leading to a misaligned pelvis with the nerve being compressed between the SS/ST ligaments and an impingement with the nerve rubbing against the falciform process. This could explain why shaving off some of the ST ligament at the falciform process and severing the SS ligament to release the compression between the ST and SS ligaments worked for me. That's not to say some people aren't misdiagnosed and that unnecessary surgeries occur. I think we all know it's difficult to come up with an accurate diagnosis when it comes to chronic pelvic pain. The authors' conclusion that PNE due to entrapment may be overestimated is not the same as saying PNE is a myth. Can we please keep our comments reasoned here?

Violet

[ezer]

Pudendal neuralgia fact or fiction?

http://www.ncbi.nlm.nih.gov/m/pubmed/19238769/

[Violet M]

Ezer, the article you posted above is a review of the literature and summarizes what can be found in the literature about PN/PNE, concluding that PN, although rare, exists as a syndrome and can be caused by pudendal nerve entrapment.

The article states that PN exists as a clinical syndrome and that pudendal nerve entrapment may be one of the causes of PN. (definition of etiology being "the cause of an abnormal disease or condition." http://www.merriam-webster.com/dictionary/etiology) I'm not sure how it supports your argument, Ezer, that PNE is a myth.

Violet

[ezer]

Violet, I had a question mark after PNE a myth. It is a question. The article says that the etiology (etiology = cause to effect) is not clear. Please note that they claim the diagnosis is unreliable. When an article is titled "fact or fiction" you know it is a controversial topic. You cannot brush lightly the naysayers.

"CONCLUSIONS: PN does seem to exist as a clinical syndrome rather than a specific diagnosis. It is important to note that it does not have definite etiological implications, and there is no evidence to support equating the presence of this syndrome with a diagnosis of pudendal nerve entrapment"

Some surgeons find most people entrapped at the alcock's canal while others claim the majority of patients are entrapped at the ligaments. Dellon said the pudendal nerve cannot be entrapped at both ligaments. He said it is attached to one or the other.

With such unreliable observations how do you believe anything those PNE surgeons say?

You can produce yet again the same couple of poorly written papers, it does not make their claims reliable. The fact that so few papers have been written on the subject is highly suspicious.

The description you make about your own case above is pure speculation. You show absolutely no proof.

After all Mayo and Stanford have discontinued PNE surgery. They are 2 prestigious medical institutions. Why do you think they abandoned it?

But that's fine. You have the right to believe in that surgery that produces awful results in the majority of cases. The sad part is that patients have pudendal surgery not because they have carefully analyzed the pros and cons. They do surgery because they are desperate.

Again, if you want PNE surgery you will get it. Pretty sad

I agree that PN pain is due to the pudendal nerve being irritated. But what about if the nerve is compressed by muscles that spasm for some reason or another (be it the brain, posture, infection, or what not), you can have as many PNE surgeries as you want, the muscles will still spasm afterward and keep the patient in pain.

[Violet M]

Violet, I had a question mark after PNE a myth. It is a question.

And then you answered your own question in the affirmative by saying, "Just as I suspected." So do you suspect it's a myth or not? You said you do.

The article says that the etiology (etiology = cause to effect) is not clear. Please note that they claim the diagnosis is unreliable.

It says the cause is not always clear. Of course you could say that about other diseases too such as multiple sclerosis, cancer, and type 1 diabetes. That doesn't mean they don't exist.

It says the neurophysiological tests have low diagnostic efficacy which I would agree with. I think we have said numerous times on this forum that it is difficult to diagnose pudendal nerve entrapment accurately. That doesn't mean it doesn't exist.

"CONCLUSIONS: PN does seem to exist as a clinical syndrome rather than a specific diagnosis. It is important to note that it does not have definite etiological implications, and there is no evidence to support equating the presence of this syndrome with a diagnosis of pudendal nerve entrapment"

Oops, you left out the end of the sentence. If you add the end of the sentence, it actually says that pudendal nerve entrapment may be one of the etiologies (causes of) PN.

The description you make about your own case above is pure speculation. You show absolutely no proof.

So do you think Bautrant was lying that the SS ligament was hardened and sclerosed and lying about what he did during the surgery-- shaving off some of the falciform process of the ST ligament? You want proof that I am better and that surgery worked for me. Can you produce absolute proof that you are better and that mindbody is what cured you? What if I were to say "Mindbody a myth? Just as I suspected." How would that make you feel?

you can have as many PNE surgeries as you want, the muscles will still spasm afterward and keep the patient in pain.

I did have PNE surgery, my muscles are much more relaxed now and I actually have a life. Muscle spams are listed in Hibner's article as one of the possible causes of PN. No one is denying muscle spasms as a possible cause of PN.

Violet

[ezer]

Violet in short, the article says that it is unclear.

Fact or fiction? Response: Unclear. Not exactly an endorsement of your PNE theories. Certainly not an endorsement of the studies that you keep referring to.

"there is no evidence to support equating the presence of this syndrome with a diagnosis of pudendal nerve entrapment" In clear there is no correlation between PN pain and a PNE diagnosis. Probably those cadavers (in the original article) that were asymptomatic while alive would have been diagnosed with PNE via imaging.

Oops, you left out the end of the sentence. If you add the end of the sentence, it actually says that pudendal nerve entrapment may be one of the etiologies (causes of) PN.

It "may be one", Wow. "May" that is a very strong word. May = unclear.

So do you think Bautrant was lying

Violet, Bautrant is not lying. He is maybe seeing normal puny abnormalities in patients. Things that come with aging or lifestyle.

* Why were all the surgeons that adopted Bautrant's technique completely unsuccessful? Does it only work (sometimes) when the charismatic Dr. Bautrant himself is the surgeon?
* What do you make of my conflicting surgery reports (surgeon 2 saying that surgeon 1 was completely wrong)?
* What do you make of all the reports from failed surgeries? Yes, they found abnormalities --yet irrelevant.

Then when failure occurs we get into the voodoo explanation where the nerve gets mysteriously "re-entrapped" or "the nerve was too damaged in the first place". Sure, sure, that makes perfect sense.

Can you produce absolute proof that you are better and that mindbody is what cured you? What if I were to say "Mindbody a myth? Just as I suspected." How would that make you feel?

You told me exactly that multiple times on this forum. I am not offended by it Violet. I don't need constant validation.

I did have PNE surgery, my muscles are much more relaxed now and I actually have a life. Muscle spams are listed in Hibner's article as one of the possible causes of PN. No one is denying muscle spasms as a possible cause of PN.

Yes, but Hibner administers PNE surgery regardless. Look at all the failures.