Advice re: labral tear or other PN treatment

[winged_cent]

Dear all:

I posted here in the welcome center a year ago - thought I would check in again to see if I could get some advice on my current situation.

I am a 27 y/o male in NYC who has been having PN symptoms for about 2 years now. At first, I definitely had a tight pelvic floor/clenching situation going on, that was resolved through physical therapy at Duffy & Bracken and with Stacey Futterman in NYC. The last time I went to pelvic floor PT, I was told that my trigger points are largely resolved, and I feel this way myself.

However, my PN symptoms continue largely unabated. They consist of a tingling/burning sensation in the perineal region radiating forward into the scrotum, as well as painful muscles around the coccyx. I also feel some loss of sensation (not numbness, just a question of degree) in the distribution of the pudendal nerve, especailly on the left side. They are clearly made worse by sitting and better with standing. A cut-out cushion helps marginally; it seems that it is the posture of sitting that puts pressure on the nerve as opposed to the surface that I am sitting on. At present, the symptoms are overwhelmingly on the left side. Peculiarly, as I haven't heard anyone mention this before, sitting on a very hard object (like a golf ball) on the area where the muscles are sore around the coccyx partially relieves symptoms.

I have gotten an MRI of the pelvis (3T, but not Hollis Potter), and it should "increased T2 signal" signifying irritation bilaterally in the pudendal nerves. I went up to see Mark Conway who did his nerve signal testing - the right side was normal and the left side was delayed, though he said the delay was marginal and not necessarily clinically significant. He sent me for pudendal nerve blocks.

I have received two sets of pudendal nerve blocks at Alcock's Canal - one bilaterally, and one on the left side only. The results were positive - the anesthetic immediately resolves all symptoms. Unfortunately, as is the case for many people, the steroid was entirely ineffective both times.

I take 20 mg of nortriptyline nightly -- I've been on it for so long that I am not sure if it is helping, but I have no side effects whatsoever so I am continuing it.

My physical therapist Stacey Futterman's leading theory is that the pudendal nerve compression is due to problems with my left hip. She finds that I have extremely "open" hips with very loose internal rotation coupled with a lack of strength in the surrounding muscles. This makes sense to me -- I have always sat in strange, contorted positions since my youth, and was a yoga aficionado -- and began to notice that my left leg in general was weaker than my right some time ago, and there has been a lot of soreness in the front part of my hip as well over the last year. It is sore when I run and it is uncomfortable to sleep on my left side. However, there are no sharp pains or pains while walking -- I am not limping. She sent me for a hip MRI and reoriented the PT away from the pelvic floor towards strengthening my hip.

The hip MRI showed moderate tendinosis of the illopsoas as well as "fissuring of the anterior labrum" in the left hip. I have been dutifully doing the hip PT for a number of months, and while it does seem to be making the hip somewhat stronger, it has had little effect on the PN symptoms. I went to an orthopedic surgeon to discuss these results, and he told me that after looking at the film, he does consider the labrum to be (mildly) torn on the left side. He said that it is peculiar to have hip symptoms for so long as a young person without a pathology of the labrum, and encouraged me to get a diagnostic anesthetic injection into the hip joint to see if it has any impact. If it does, he said that I could be a candidate for surgery.

While my PN is not as severe as some others (I never have sharp pain) it still impedes my ability to study and eventually will no doubt be a great impediment to my working life which will involve a lot of sitting (I am a law student). I have gone through the "conservative treatments"-- seating modifications, physical therapy and PN blocks, and they have not provided me with sufficient relief.

On the other hand, I am aware of how serious PN surgery is, and at this point I do not believe that I am a candidate.

As such, I would like guidance and wisdom on the following questions:

(1) I know that numerous board members have improved after labral tear surgery. Indeed, the side of 90% of my PN symptoms is also the side which has the mild hip pathology. It could be a coincidence, but it could be not. However, I am wary of rushing in to get what might be an unnecessary arthroscopic hip surgery.

One of the reasons for this wariness is that I read (and the doctor mentioned) that pudendal symptoms can actually be a complication of the surgery itself, because of the traction that they need in order to access the hip joint. If healthy people get pudendal numbness from the procedure, I imagine that i may be particularly risky for someone with pre-existing PN.

Moreover, I understand that people complain of weakness of the hip muscles and require fairly aggressive PT in order to strengthen them up post-operation, and sometimes the muscles get irritated and begin "firing". It seems that this could exacerbate my symptoms further, especially given that the original MRI showed a tendinosis of the illiopsoas.

When I was discussing my hip with the doctor, I mentioned the months of PT and my symptoms with the hip, but I omitted discussion of the PN symptoms, under the theory that he would not take me seriously if I come at him with some hip-pelvis theory with which he is unacquainted. I certainly would not get the surgery for the hip symptoms alone. However, the left-sidedness of both the hip and the PN symptoms does make me think. If I had any confidence that the PN symptoms would improve significantly as the result of such a surgery, I wouldn't think twice about it.

My PT has been extremely ambiguous on this question - "I am hesitant for you to have surgery BUT I do see people that do get better after they have surgery and with lots of PT. I wish I could give you more advice on it and our research has shown better results. "

(2) If not the hip route, what is the next step? I am not interested primarily in modulation of the tingling and burning pain, but rather (and I know that this is difficult) attempting to remedy whatever the mechanical cause of the compression may be. I know that some people have had great success with the ESWT therapy in Cornwall, Canada with Dr. Andrew. I think that might be out of my price range and also seems frighteningly experimental. Are there any more affordable treatments that I should be looking in to?

Thank you very much for any advice; I really appreciate it.

[nyt]

These become very complicated questions to sort out. I have had pudendal surgery on both sides and it did take away a couple of my symptoms but not all and never changed my sitting tolerance. I do not have a labral tear so no surgery but others on this forum have had it done and hopefully can respond regarding their experience. Recovery from both is slow with no guarantees. I wish I felt like I could give you some magical advice and solution. The one suggestion I do have is the possibility of Restorative Exercise. It is not your typical exercise and focuses on biomechanical alignment. There are some Youtube videos, a website with a blog and DVDs you can purchase (I have not purchased any videos), and a Facebook group that focuses on individuals with pelvic pain. I have been using some of the techniques to pay closer attention to how I stand and my posture. After a discussion with my PT regarding my anterior pelvic tilt and the inability of my glutes to fire we totally changed our approach. I have found what we are doing helpful as it has slightly decreased my butt ache. Just a thought if you are trying to avoid surgery.

[ezer]

If Restorative Exercise is helpful, why don't you un-ban DaveM that is the only RE instructor as far as I know that addresses pelvic pain? His ban for violation of the terms and conditions seemed a bit excessive to me.
Having just visited Facebook, I see that the RE-Pelvic pain forum that seems to benefit you is his.

[stephanies]

Winged_cent,

I understand your desire to find the cause of your PN and address it. I don't know the numbers of patients with PN who have had resolution/reduction in their pain after labral tear surgery, but you can search for that information here on the forum. Maybe your PT can put you in touch with some similar patients? I know one person personally (not through the forum) who had labral tear surgery that did not change her PN pain and created some new problems for her. My opinion is that often there is no one mechanical fix to PN pain and every decision must be weighed very carefully.

Sincerely,
Stephanies