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  • 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

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

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

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

  • PainLancinatingBurningIncreased with hip flexion or activation of abdominal muscles

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

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

  • 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

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

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

  • 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

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

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

  • 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

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

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

  • Starling J.R. 1989

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

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

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

  • Ndiaye A. 2007

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

  • Ndiaye A. 2007

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

  • Ndiaye A. 2007

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

  • Several authors have shown significant variationRab M. 2001

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

    100 disections great color pictures

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

  • Ndiaye A. 2007

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

  • 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

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

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

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

  • Pathological Study ShowedGranuloma formationInflammationDemyelination

    Also up stream from entrapmentFindings may be exacerbated by mesh

    Miller et al 2008

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

  • 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

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

  • 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 ligamentCarnetts Sign

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

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

  • EMG ilioinguinal nerveDescribed by Ellis et al 1992

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

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

  • Ellis R.J. 1992

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

  • 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

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

  • 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

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

  • 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.

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

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

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

  • Neuropathic pain modulatorsTricyclic antidepressantsNeurolepticsCase reports on Gabapentin

    Very effective and well toleratedBenito-Leon J. 2001

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

  • 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

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

  • Open post herniorrhaphyMost reports involve mesh removal with genitofemoral and or ilioinguinal neurectomiesResults overall were favorable with low complication rateStudies cant be compared due to poor design

    Aasvang E. 2005

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

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

    Loss of cremasteric reflex and Hypo-esthesiaInguinal incision for ilioinguinal

    Hypo-esthesia

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

  • 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

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

  • Kim D. et al 2005Ilioinguinal and iliohypogatric

    Anterior approach91% success rateNo significant complications

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

  • Post PfannenstielAnterior approachComplete scar excisionLoos et al 2008

    73% good to excellent14% moderateNo significant complications

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

  • 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

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

  • 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

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

  • 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

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

  • 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

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

  • Rauchwerger J.J. 2008

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

  • Laparoscopic Place