Pudendal Nerve block did it help?

[JeanneJ]

I had my first Pudendal Nerve block at 7:30 am yesterday. The Dr said to pay close attention as to whether it helped. In the morning, it wasn't painful, but I had some numbing in my butt and thighs. No vulvar pain. In the late after noon/evening the pain was all back. Does that mean it was successful? It is so intermittent anyway. This is so discouraging. I was referred to a neurologist. She ordered a MRI of my lumbar spine and EMG tests, but said she thinks nothing will show and to keep treating it symptomatically.

[Violet M]

Hi Jeanne,

I'm not sure what medications were in your nerve block but typically there is an anesthetic for diagnostic purposes. It is meant to numb the areas innervated by the pudendal nerve (the saddle area). If those areas lose sensation temporarily (a few hours) and if your pain is significantly less in the saddle area for a few hours, that is an indication that your pain is most likely caused by a problem with the pudendal nerve and that you have pudendal neuralgia.

The other medication that is often in a pudendal nerve block is a steroid to reduce inflammation over time. Often the steroid in the nerve block can cause a pain flare for several days after the anesthetic wears off. Recently some major medical organizations have indicated that there is no evidence that steroids in pudendal nerve blocks are beneficial.

Twenty-some years ago when I had my nerve blocks they included an anethetic and a steroid. I initially had partial symptom relief for several hours but then a pain flare-up for a few days. I did not get any long-term relief from pudendal nerve blocks and there have been very few people who have posted on this forum stating that they had any long-term relief.

So, I see pudendal nerve blocks as primarily valuable for diagnostic purposes. Since you had some temporary relief in the vulvar area I'm assuming your nerve block is positive for a diagnosis of pudendal neuralgia but to be sure, your doctor should explain all of that to you. If your symptoms point toward pudendal neuralgia that is caused by a nerve entrapment, you probably wouldn't want to pursue pudendal nerve decompression surgery unless you had a pudendal nerve block that indicated a diagnosis of pudendal neuralgia. See the following article: https://www.pudendalhope.info/wp-conten ... iteria.pdf

I understand your discouragement because the pain of PN can be exhausting. I wish you the best as you pursue the right treatments.

Violet

[cannicholl@gmail.com]

What research do you suggest. I've had 3 failed nerve blocks, one unguided and one CT guided plus a CT hydrodisection injection with no relief. My MRN shows hyperintensity of the pudendal nerve at entrance to Alcocks canal. Neurosurgeon wants to do decompression and guno/pain specialist dual qualified thinks ot will make me worse.

[Violet M]

What research do you suggest. I've had 3 failed nerve blocks, one unguided and one CT guided plus a CT hydrodisection injection with no relief. My MRN shows hyperintensity of the pudendal nerve at entrance to Alcocks canal.

Some suggestions of research you can do is to read up about all of the different doctors who treat PN and what treatments they use. Read up on what treatments are available and how they apply to your case. For instance, what is your history? If your pain started after say, genital herpes, then a diagnosis of nerve entrapment and surgical treatment might not make sense for you. If your pain is one-sided and meets the Nantes Criteria, then surgery might make sense for you. Read the publications section of our website and of this forum, and any recent publications about pudendal neuralgia and pudendal nerve entrapment that you can find in pubmed. Read up on the different surgical approaches for PN if you are considering surgery and which approach makes the most sense for your case, and what the surgical success rates are for that approach. Here are some studies on hyrodissection of the pudendal nerve.
https://pubmed.ncbi.nlm.nih.gov/31793050/
https://pubmed.ncbi.nlm.nih.gov/38714513/

You say your nerve blocks failed. Could you elaborate on what that means? Did you have any loss of sensation in the distribution area of the pudendal nerve, even for just a few hours after the nerve block? If so, that would mean your nerve blocks were delivered accurately to the pudendal nerve. Did you also obtain complete or partial symptom relief even for a few hours after the injection? If so, that would mean the pudendal nerve is most likely the problem. We rarely hear of permanent pain relief from nerve blocks, unfortunately, even if they were given accurately, but they can be a valuable diagnostic tool in determining a positive diagnosis for pudendal neuralgia. Some major medical organizations have new guidelines that there is no evidence for steroids in pudendal nerve blocks, so I see them as primarily a diagnostic tool.

Neurosurgeon wants to do decompression and guno/pain specialist dual qualified thinks ot will make me worse.

Not sure what you mean by "ot". According to the Nantes Criteria, an anesthetic nerve block delivered accurately and providing temporary pain relief is one of the essential criteria for determining , if you have a nerve entrapment. https://www.pudendalhope.info/wp-conten ... iteria.pdf
Here is another article that has a similar conclusion: https://pubmed.ncbi.nlm.nih.gov/31090184/
If your nerve blocks were delivered accurately but provided no pain relief, even for a few hours, then you might want to ask what would be the rationale for doing pudendal nerve decompression surgery.

All the best,

Violet

[JeanneJ]

I had a 2nd nerve block on May 6. My pain was slightly improved and I debated canceling it. The block didn't help. I actually feel worse now, but it might not be because of the block. I doubled my Gabapentin?Baclofen suppositories. I am going pack to the Pain specialist in 4 days. I am so discouraged and struggle with feelings of hopelessness. Does anyone have any suggestions? Thank you.

[eraser]

I had a 2nd nerve block on May 6. My pain was slightly improved and I debated canceling it. The block didn't help. I actually feel worse now, but it might not be because of the block. I doubled my Gabapentin?Baclofen suppositories. I am going pack to the Pain specialist in 4 days. I am so discouraged and struggle with feelings of hopelessness. Does anyone have any suggestions? Thank you.

I would ask about switching to Pregabalin. It is not much better than Gabapentin but is more centrally acting so lasts longer and you only need to take it twice a day which is much easier to manage from a medication perspective. They will be able to do a direct switch using a ratio, which the pain specialist will know.

I am struggling to understand when you have said your pain slightly improved when you had the 1st block. Violet has given you some really useful links below and has asked you a few questions that might help you as to where to go next.

I think it might be worth taking a looking and considering whether your symptoms correlate with pain in the distribution of the pudendal nerve (i.e. pudendal neuralgia). If "yes," then consider whether you meet the Nantes criteria for pudendal nerve entrapment.
If you have entrapment, you need to consider surgery as this will be the only effective intervention.

Even if you think you have pudendal nerve entrapment, you need to consider whether you have have any medical or non-mechanical causes that could explain your symptoms. There are a number of medical conditions or even conditions that give similar symptoms that may require different surgery or medical treatment. If there isn't a medical cause that can be found, then you need to consider pudendal nerve decompression surgery if you have excluded all other symptoms and meet the Nantes criteria.

Ideally, your pain specialist should support you whilst the cause of your symptoms are being worked out. Pain specialists do not tend to do this on the whole and often have biases, so you may have to be quite pushy.
You may find that you are asked to do a number of investigations to rule out other conditions - which is completely appropriate. However, a lot of these investigations, may come back normal but that does not necessarily exclude pudendal nerve entrapment.
Often clinicians these days diagnose based on investigations but unfortunately pelvic pain is not like that and they need to rule out conditions that can be identified on scans etc. Think Sherlock Holmes style.


I am very sorry to hear that you are feeling hopeless, we have all felt that way but there are treatments and there is hope but you need to find it. Solving this puzzle isn't impossible but it will be challenging.
Keep pushing forward, as the key is not to give up and not be fobbed off in your search.

When you say your pain specialist has suggested treating your symptoms. My suggestion would be to go back but tell to them that you need them to find out what the cause of the pain is, so that you can consider your treatment options.
I would say to them that it is well known that treating symptoms alone will not work but obviously you want some relief whilst you work out what you would like to do next - I am not saying this to scare you.....it is more to empower you and show to your doctor that you will not be fobbed off with nonsense (e.g. nerve block after nerve block or repeat botox injections).

I hope this in some way helps, rather than scares you. Ask more questions along your journey and fact check what doctors tell you as unfortunately very few doctors are actually familiar with the evidence incl. pain specialists.

I was feeling probably how you are right now but I am hoping that in six months time, I will feel like a new person.