Health Organization for Pudendal Education

A patient who just had an MRI done by Dr. Hollis Potter asked me to post this on the forum. They had transgluteal PNE surgery but have not seen the improvements they had hoped for. They are in too bad of shape to come on the forum but would appreciate your comments and advice. You will have to use the scroll bar on the right to read the whole thing because I'm not very good at this tech stuff. Thanks.

I would be interested to know the patient's symptoms. But it seems to me that either new scar tissue formed post-op or not all the scar tissue was removed during the surgery and this is why the patient did not receive relief of symptoms. It seems that all the scarring noted is more posterior (SS/ST level, not involving perineal/dorsal branches) and their coccyx is deviated to one side so I wonder if perhaps there is some SIJD going on. I am starting to wonder if more people have SIJD than realize it and that is why some of the surgical outcomes are not better. While the PN should be released during decompression if the pelvic dysfunction is not corrected the muscle imbalance continues and I think could possibly lead to more strain/scar tissue build up around the ST/SS ligmaments. Others will not agree, but I hold to the belief that these ligaments are important for pelvic stability. Juse my thoughts. I obviously don't have any research to back it up. I would also be interested to know who the surgeon was for this case if they are willing to share.

Faith wrote:I would be interested to know the patient's symptoms.

The patient's symptoms before surgery were vaginal burning and severe PGAD. Post-op she is still having PGAD although maybe not quite as severe.

Violet have you seen any research that correlates PGAD with pubic symphesis instability? Something I've been wondering/thinking about, but haven't looked into much. I guess there would be other pain though than just PGAD if it was caused by joint instability.

Faith, I haven't seen anything published on a correlation between PGAD and pubic symphasis instability. I didn't have pelvic symphasis instability but I did have SI ligament strain with pelvic instability.

I wish I had something useful to contribute, but all I've got is a few questions:
1. When did this patient have surgery?
2. When did this patient have the MRI?
3. Surprised to see this patient had a clitoral branch neurectomy, but still experiences PGAD. Was this also done bilaterally?
Violet - please extend my best wishes to this patient. Is she experiencing any ill effects from the ST & SS scarring?

Karyn, the surgery was about 9 months ago -- the MRI was in December. I don't think the patient had heard of Dr. Potter before surgery.

Yes, the clitoral neurectomy was bilateral. Since she still has symptoms, it's hard to say if she is experiencing ill effects from the ST/SS scarring. What the patient is trying to figure out is whether or not she is still entrapped because Dr. Potter did not come right out and say as she does on some MRI reports. What does it sound like to you?

What is the surgeon telling the patient? Wondering what his thoughts are...........

cari

Hi Violet,
Thanks very much for your response. The time line was helpful.

Violet M wrote:What the patient is trying to figure out is whether or not she is still entrapped because Dr. Potter did not come right out and say as she does on some MRI reports.

Yes, I can certainly understand her concern. You're right - Dr. Potter did not come right out and say her PN was "entrapped", but I do find several statements from her report rather curious:

The coccyx is deviated slightly to the right
The right SS ligament tethers to the coccygeus muscle

Faith wrote: It seems that all the scarring noted is more posterior (SS/ST level, not involving perineal/dorsal branches) and their coccyx is deviated to one side so I wonder if perhaps there is some SIJD going on. I am starting to wonder if more people have SIJD than realize it and that is why some of the surgical outcomes are not better. While the PN should be released during decompression if the pelvic dysfunction is not corrected the muscle imbalance continues and I think could possibly lead to more strain/scar tissue build up around the ST/SS ligmaments.

I agree, Faith. I also wonder if her coccygeus muscle could be pulling the coccyx out of alignment? Which would then shift her sacrum, putting undue strain on her SS & ST ligaments? I have no proof, but in my case; I think it's possible the SIJD caused the "prominent thickening" of my SS & ST ligaments, entrapping the PN in that area.

Scar encasement adjacent to the ischial spine is seen at the expected course of the ligament, R>L.
Does the patient have sit bone pain? I'm unclear about which ligament she's specifically referring to. ST ligament? Is there a ischial ligament? "Scar encasement" would indicate entrapment to me.

There is scar surrounding both ST ligaments but some of this may reflect the effects of prior release
There is a linear segment of scar extending anteriorly from both ST ligaments, much more prominent on the right than left, surrounding the vicinity of the PN.

"MRI of the pelvis demonstrates postoperative changes around the SS & ST ligaments with geographic and linear areas of scar formation, much more prominent right than left, around the expected course of the pudendal nerves."
I wish I knew what she was really trying to say by this last bit. Scar formation around the expected course of the PNs????? Surrounding the vicinity of the PN????
What I don't understand is ... why is Dr. Potter using words like "expected course" and "vicinity of the PN". I really don't understand what "linear scar formation" means, either.
At first glance I thought it might be the ST incision, itself, but now I'm thinking differently and have no explanation as "this linear scar formation is around the expected course of the PNs."

Violet M wrote:What does it sound like to you?

Well, when someone uses terms such as Surrounding, Encasing, Scar formation AROUND ..... it sounds like to me - entrapment. I'm not a radiologist and have no medical degree, but that's my interpretation.
I also find it interesting that Dr. Potter notes her neurectomy at the top of the report, yet there really isn't any specific info regarding that particular branch.
I know she makes mention of there being no scar formation of the dorsal nerve to the clitoris. This may seem like a stupid question, but, did it grow back? Was she not able to visualize it?
I'm sorry I wasn't much help. Only more questions. And I have another one - is this patient willing to post her op report?

Thanks Karyn -- your reaction to the wording is the same as mine.