dr. mark conway md facog v.p. society for pudendal neuralgia · dr. mark conway md facog v.p....

Dr. Mark Conway MD FACOGV.P. Society for Pudendal Neuralgia

Published on www.pudendal.com the 5th February 2009

About 60 Kilometers North of BostonCommunity HospitalPopulation of surrounding area 150,000Several Teaching and University hospitals within one hour driveStill a tremendous lack of treatment options for these patients


Neuropathic pain condition involving the areas enervated by the Ilioinguinal nerve.Often seen in conjunction with neuropathies of the Iliohypogastric and Genitofemoral nerves


PainLancinatingBurningIncreased with hip flexion or activation of abdominal muscles

Hypo and Hyper-esthesiaTemporal relationship to surgeryPelvic floor dysfunction,Myofacial pain


IliohypogastricVentral Rami L1 and small contribution T12Between int. oblique and transversalisPierces ext. oblique 2-3 cm cephalad to superficial inguinal ringEnervates skin superior to pubis


Ilioinguinal NerveFusion of T12 and L1 nerve roots,similar course to ilioinguinalPierces the transversalis and int.oblique adjacent to iliac crest. Then runs on the anterior surface of the internal oblique. Sensory branches to pubis,superior and medial aspect femoral triangle,base of penis and anterior scrotum or labia majoraOverlap with other nerves


GenitofemoralVentral rami L1 and L2Decends on the ventral surface of psoas muscle. Then splits into Femoral and Genital Branch.Femoral Branch runs lateral to femoral artery and inferior to inguinal ligamentGenital Branch inguinal canal usually inferior to spermatic cord.

Labia majora or scrotum and adjacent thigh


Starling J.R. 1989


Ndiaye A. 2007Published on www.pudendal.com the 5th February 2009

Ndiaye A. 2007


Several authors have shown significant variationRab M. 2001

4 major groups of variation A-DNdiaye A. et al 2007

100 disections great color pictures


Ndiaye A. 2007


The majority of cases result from surgical injury

Inguinal hernia repairMesh,laparoscopic,staples

Pfannenstiel incisionsAppendectomyLaparoscopy (lower quadrant port placement)Iliac bone harvestingNode dissection etc.

Non surgicalMuscle tear,Sportsman Hernia


Nerve damage from direct surgical traumaInflammation and scar formationInflammation and retraction from permanent meshSuture encirclementTack impingementFascial tear (external oblique aponeurosis)


Pathological Study ShowedGranuloma formationInflammationDemyelination

Also up stream from entrapmentFindings may be exacerbated by mesh

Miller et al 2008


Pfannenstiel Incision8.8% had moderate-severe painOdds ration increased by 2.95 > 2 incisions70% patients had pain at corners of incision

Loos M.J. et al 2008

Inguinal herniaMultiple studies ranging from 0.35%-10% for moderate to severe pain


Primarily ClinicalHistoryExam

Iliohypogastric: pain and tenderness at the scarIlioinguinal: pain and tenderness at exit of inguinal canal,and medial to anterior iliac crestGenitofemoral: hypo-esthesia anterior thigh below inguinal ligamentCarnett’s Sign

Abdominal wall flexion increases or does not change pain. With intra-abdominal pathology flexion will decrease pain.


EMG ilioinguinal nerveDescribed by Ellis et al 1992

Limited published dataSpecificity and Sensitivity is lowIf used must be interpreted along with clinical data


Ellis R.J. 1992


Nerve BlocksOffice procedureAnterior abdominal wall just medial to anterior superior iliac spineAlso can use point of maximal tendernessPatient will feel radiation to affected areas

Ultrasound guided described Gofeld 2006Possibly safer to avoid femoral block


Re exam after block to confirm benefitIf no benefit from anterior block consider Genitofemoral neuropathy and proceed with L1L2 nerve root block to confirm diagnosisSignificant overlap can make differentiation difficult

Starling J. 1989


HerniorrhaphyLaparoscopic approach widely abandonedAvoid fixation of mesh with tacks,?avoid plugs and flat mesh.Careful disection,anatomy matters,preserveposterior aspect of spermatic cord where the genitofemoral n. usually lies. Described by Lichtenstein 1998Several studies on prophylactic neurectomy

Meta analysis no benefit for pain, increased paresthesiaGravante et al 2008

RCT showed significant decreased pain and no change in paresthesia

Mui et al 2006 Published on www.pudendal.com the 5th February 2009

PfannenstielIncision length is risk factor

Avoid extending incision beyond rectus borderPosition of incision

The higher above the pubis the betterNumber of incisions is risk factor

After two incisions risk increasedWould a vertical incision work?

Only close the external oblique aponeurosis when incision extends beyond the lateral border of the rectus.


Physical TherapyLittle published dataTissue mobilizationEarly intervention may help prevent scar entrapmentHelpful for associated myofascial pain and muscle dysfunction


Neuropathic pain modulatorsTricyclic antidepressantsNeurolepticsCase reports on Gabapentin

Very effective and well toleratedBenito-Leon J. 2001


If a diagnostic block is effective a series may provide chronic relief

Marcaine +/- anti-inflamatoryEffects can be cumulativeAnywhere from 4 -7 blocksIntervals varyMay require retreatment


Open post herniorrhaphyMost reports involve mesh removal with genitofemoral and or ilioinguinal neurectomiesResults overall were favorable with low complication rateStudies can’t be compared due to poor design

Aasvang E. 2005


Starling et all 198917 of 19 patients curedFlank incision for genitofemoral neurectomy

Loss of cremasteric reflex and Hypo-esthesiaInguinal incision for ilioinguinal

Hypo-esthesia


Amid P.K. 2004Triple neurectomy from anterior approach

Genitofemoral hard to find but usually could be accessed at the lateral crus of the internal ring,withinthe ring or along the spermatic cord89 % success rate


Kim D. et al 2005Ilioinguinal and iliohypogatric

Anterior approach91% success rateNo significant complications


Post PfannenstielAnterior approachComplete scar excisionLoos et al 2008

73% good to excellent14% moderateNo significant complications


LaparoscopicMost reports use a retroperitoneal approachLateral incision and retroperitoneal space is created with a balloonGenitofemoral and ilioinguinal nerves are identified and divided

Both branches of the genitofemoral


Krahenbuhl L. 1997Published on www.pudendal.com the 5th February 2009

Krahenbuhl et al 19973 patients all curedNo complications

Muto et al 20056 patientsAll cured

No complications


Pulsed radiofrequency nerve ablationRozen D. 2006

5 patients post inguinal herniorrhaphyVertebral T12,L1,L2 nerve root

42 degrees C for 120 seconds per level4 of 5 patients with pain relief lasting 4-9 months


NeuromodulationSeveral case reports publishedMost using a peripheral placementTwo eight contact leads placed parallel above and below inguinal scarAll patients had significant reduction in painSmall numbers and limited follow up

Rauchwerger et al 2008


Rauchwerger J.J. 2008


Laparoscopic Placement of Neuroprothesis(LION) ProcedurePossover M. et al 2007

3 patients with different neuropathiesIlioinguinal +pudendalSciaticSacral nerve root


Conventional LaparoscopyRetroperitoneum accessed medial to cecum and incised up the level of the ovarian origin from the inferior vena cavaSingle contact lead placed near the origin of the nerves(ilioinguinal ,iliohypogastric and lateral femoral cutaneous)Same approach to place leads at S2-S4 and the sciatic


Operative time 2.5 hoursNo complicationsAll three patients report excellent results

Small numbersLimited follow up


These disorders are much more common than are recognizedWe now have a variety of effective treatmentsChallenges for the future is comparing these alternativesExpanding availability for treatment


Finis


dr. mark conway md facog v.p. society for pudendal neuralgia · dr. mark conway md facog v.p....

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