Prostatitis-like pain: Surgical decompression of the pudendal nerves can improve or cure symptoms

Prostatitis-like pain:
Surgical decompression of the pudendal
nerves
can improve or cure symptoms
Stanley J. Antolak, Jr., MD
Christopher M. Antolak, MD
AUA. Orlando, FL, USA , May 17, 2008
OBJECTIVES
• Define CPPS
• Acknowledge Pudendal Neuralgia as an
etiology of CPPS
• Review symptoms and diagnosis of
pudendal neuralgia
• Identify effective conservative and surgical
treatments
Male pelvic pain
• Chronic pelvic pain syndrome
– NIH Category IIIB (non-inflammatory
prostatitis)
• Prostate Pain Syndrome (EAU)
• Prostatitis-like pains (Nickel)
• Prostatodynia
• Prostatosis
• Prostatitis is a waste basket diagnosis.
• NIH new focus is on neuropathic etiologies.
Pudendal Neuropathy
• Recognized by the European Association of Urology
(EUA)
– as a mononeuropathy that causes pelvic pain.
Neuropathic Pain: a Tunnel Syndrome
• Treat in a similar fashion as CTS
•
Fall; European Urology 2004; 46:681
Robert, et al. Surg-Radiol Anat. 1998; 20:93
Pecina MM. Tunnel Syndromes: peripheral nerve
compression syndromes. 3rd edition Pages 191-4
Chronic Pelvic Pain Syndrome NIH IIIB
(CPPS)
“lower genitourinary symptoms,
– particularly pain in the perineum or genitalia,
– voiding symptoms, such as dysuria or frequency,
– and sexual dysfunction…”
– absence of bacteria in urine or prostate secretions
Krieger; JAMA 1999; 282:236
Study Population: Prospective case series
70 men ages 18-73 (avg 47), seen in 2005 with pain in the
.
following areas:
•
•
•
•
•
•
•
•
Perineal
Scrotal/“testicular”
Penile/urethral
Perianal
Suprapubic
Ejaculatory pain
Inner thigh / inguinal
Absence of prostatic infection
Diagnosis of pudendal neuropathy
HISTORY: typical pain (sitting, driving, relieved on toilet seat)
May have bladder, sexual, bowel dysfunction
SENSORY EXAMINATION: changes
to pinprick;
Examine for other pelvic neuropathies
WDT; Warm Detection Threshold test
(a Quantitative Sensory Test).
PNTMLT; Pudendal Nerve Terminal Motor Latency Test
Smith ARB Br J Obstet Gynaecol 1989;96:29.
Bleustein CB J Urol 2003; 169: 2266
Pudendal Neuralgia (Robert)
Pain in perineum
...aggravated by sitting
...reduced by standing
… not present
when
recumbent, and...
Relieved sitting on a lavatory
Bladder, rectal and sexual dysfunction may occur as non-pain
components of pudendal neuropathy (Shafik)
Robert R Surg-Radiol Anat 1998;20:93
Pudendal Neuropathy:
-A “tunnel syndrome” causing pain due to nerve compression
• Compression commonly
occurs at two locations:
•The “CLAMP” or lobster
claw, between the
sacrotuberous and
sacrospinous ligaments.
(>90%).
•The Alcock canal (pudendal
canal. (<10%).
Three sequential treatments may relieve
pelvic pain due to pudendal neuropathy
• I. “Self-care”, a Nerve protection program. (All patients)
Avoid exercise, cycling. Use “suspension pad”.
Amitriptyline 10 mg and increase at 5 day intervals
• 2. Three Pudendal Nerve Perineural Injections (PNPI)
needed in (80 to 90% of patients).
Monthly x 3.
Steroids and bupivacaine.
• Decompression Surgery (in 30 to 40% of patients).
We monitor responses with Symptom Scores
NIH-CPSI = the National Institutes of Health-Chronic
Prostatitis Symptom Index
AUASI = American Urological Association
Symptom Index (International Prostate Symptom Score)
SHIM = Sexual Health Inventory in Males (IIEF-5).
SF – 12
Decision for surgery ( ) after failure of self care
and 3 Pudendal nerve perineural injections (PNPI)
PNPI
Transient response to PNPI; surgery
recommended
NIHCPSI
AUASI
C
on
PN s
PI
2
3m
os
pr
e
O
p
35
30
25
20
15
10
5
0
KmbrWd
Anatomic landmarks for a transgluteal
decompression.
• On left
– Incision site marked
• On right
– Ischial tuberosity
– Sacrum with
prominent inferior
lateral angle
TPApr12008
Case 1
Nerve exposure left pudendal nerve.
*
• Rectum retracted. *
• Inferior rectal nerve
• Scissors at ischial
spine ( )
• Anterior to
(underneath) scissors
is fascia of the Alcock
canal
TerePoiAPR12008
Case 1
Alcock canal is opened.
Portion of obturator fascia is removed.
Fibers of
S-Sp ligament
IRN
Rectal vessels
Main trunk
Case 1
Pudendal Nerve Pathology
• Pudendal nerve is in
the vessel loops
• Nerve flattened
superiorly
• Nerve is significantly
compressed between
S-T and SSp
ligaments.( )
TerePoiAPR12008
Case 6
PN anterior to obturator fascia (Alcock canal).
Nerve is flattened, splayed over obturator internus muscle
Individual fascicles are apparent (significant compression).
Pallor of compressed nerve suggests ischemia.
WS10208
Results of Pudendal Nerve
Decompression Surgery
• N=70
• Follow-up available at 12 months in 47
• 23 patients lost to follow-up or with
inadequate patient data
• 25 patients showed improved symptoms
scores with self care and/or PNPI
• 22 patients with advanced disease
required operation
Results of Pudendal Nerve Decompression
Surgery at 12 and 24 months Postoperatively
n=22 at 12 months; n=14 at 24 months
Cumulative NIH-CPSI averages
30
25
20
15
10
5
26.1
19.7
19.3
16.1
18 mos
24 mos
0
PreOP
12 mos
Results of Pudendal Nerve Decompression
Surgery at 12 and 24 months Postoperatively
n=22 at 12 months; n=14 at 24 months
Cumulative NIH-CPSI averages
_
30
25
20
15
10
5
26.1
19.7
19.3
16.1
18 mos
24 mos
0
PreOP
12 mos
Results of Pudendal Nerve Decompression
Surgery at 12 and 24 months Postoperatively
n=22 at 12 months; n=14 at 24 months
_averages
Cumulative
NIH-CPSI
_
_
_
30
25
20
15
_
_
10
5
11 of 22
improved
26.1
19.7
_
_
9 of 14
improved
19.3
16.1
18 mos
24 mos
0
PreOP
12 mos
Results of Pudendal Nerve Decompression
Surgery at 12 and 24 months Postoperatively
n=22 at 12 months; n=14 at 24 months
Cumulative NIH-CPSI averages
30
25
20
15
10
5
26.1
19.7
19.3
16.1
18 mos
24 mos
0
PreOP
12 mos
Results of Pudendal Nerve Decompression
Surgery at 12 and 24 months Postoperatively
n=22 at 12 months; n=14 at 24 months
Cumulative NIH-CPSI averages
30
25
20
15
10
5
26.1
19.7
19.3
16.1
18 mos
24 mos
0
PreOP
12 mos
Pudendal Neuralgia: Treatment results.
Males; n = 47 @ 12 months, 39 @ 24 months
Cumulative NIH-CPSI Responses
30
25
20
Self-care
PNPI
Surgery
15
10
5
0
Prior
12 mos 18 mos 24 mos
Summary
•Chronic pelvic pain: a disease with multiple causes.
•Prostatitis comprises only 5% of male CPPS.
•Neuropathic causes include:
• Pudendal neuralgia
• Several other peripheral neuropathies
• PN is a clinical diagnosis with simple confirmatory tests.
• A sequential treatment program can successfully improve
neuropathic symptoms due to pudendal neuropathy.
•Pudendal nerve decompression surgery is an effective
treatment for refractory neuropathic disease.
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