Health Organization for Pudendal Education

Hello everyone.. I am very new to the Site, and this is like my 4th post but I would really appreciate all of your expert opinions on my summary from DR POTTER. Here it is :

MRI of the Pelvis

Mri of the pelvis with attention to the pudendal nerve was performed utilizing coronal oblique axial inversion recovery followed by coronal, sagittal and axial fast spin echo techniques. Clinical concern is right and left sided peri-rectal and anal discomfort as well as bilateral testicular, scrotal, and urethral discomfort. There is no history of surgery to the region.

There is no presacral or precoccygeal soft tissue mass. The coccyx is slightly deviated to the left.The coccygeus muscle is symmetric. The sacrospinous ligaments are symmetric. There is asymmetric thickening of the left sacrotuberous ligament noted on series 2 images 25-30 but no defined scar entrapment of the pudendal nerve is appreciated. The dorsal nerves to the penis appear symmetric. Bulbosongiosus and ischiocavernosus muscles also appear symmetric. No scar entrapment of the pudendal nerves is seen either proximal to or within the obturator canals. Levator ani muscle appears symmetric. There are varices of the pelvic floor , extending posterior to the pubic symphysis and into the anterioinferior margin of Alcock's canal, noted on series 3 images 21-30. These efface inferior perineal branches of the pudendal distribution surrounding the urethra. There is a small varix coursing with the left dorsal nerve of the penis.

The sciatic nerves lie anterior to the piriformis muscle and do not pierce the piriformis muscle. There is no pelvic adenopathy. Anteriorly there is no scarring of the inguinal canals. There is no bullky synovitis in the hip joints. Thickening of both greater trochanteric bursae is seen with abductor tendinosis, affecting the anterolateral footprint of the gluteus medius as well as the gluteus minimus. There is no psoas tendinosis. There is no ischial bursitis. Mild hamstring tendinosis is seen. There is no scarring of the sciatic nerve.

Impression:
MRI of the pelvis demonstrates asymmetric thickening of the left sacrotuberous ligament but without scar entrapment of the pudendal nerve. At the pelvic floor, there are prominent varices posterior pubic symphysis, around the urethra and effacing the inferior perineal branches of the pudendal distribution at the anteroinferior margin of Alcock's canal. Levator Ani muscle is symmetric.


Thanks to anyone who might have any insight on this... my Pain doctor has no idea what she(Dr Potter) is talking about. I am suffering pretty bad - you can read my initial post in the Welcome thread for more info on me. thanks

Matt

Does anyone know if she scans up closer to the sacrum? I get deep rectal pain and intense lower mid back pain which I think is more sacral? When I went for this exam last August I didnt have the intense back pain as much like I do now... So I had my pain doc write the MRI script using the exampe listed here at the Site. Hence I am worried I probably need another type of MRI like a lumbro sacral or something.. Any tips??
Matt

A pelvic MRI does include some views of the sacrum. I was diagnosed with S2 pathology with a pelvic MRI, so I know they go at least that high, although maybe not to S1 (?) Once my sacral pathology was identified, my surgeon insisted on a full sacral MRI for diagnostic purposes, because it includes images of the sacrum from more vantage points. Also they sometimes want a sacral MRI with contrast to get more info. I have found that not every imaging center does full sacral MRI's, so you have to check carefully ahead of time. For my surgical follow up, I wasted a whole morning at an imaging place that went so far as scheduling the procedure for full sacral MRI...Then when I got there, they realized that they only image the sacrum partially as part of a pelvic or lumbar MRI. So I had to reschedule with another facility. Lumbar MRI's are easier to access, but you do need one ordered because the pelvic MRI you already had does not look at the lumbar at all.

Thanks HerMajesty..

Actually, I forgot that in the midst of all the initial waves of testing, that I did have a MRI of my lower spine... But it wasnt a 3T or anything, and I am not sure how low they scanned with that one. I see in the report from potter that the word sacral is used so I suppose some images were taken, but I think I need to talk to my doctor and get his opinion on my pain points and maybe see if he will do a more dedicated scan of that sacral area. Also, wouldnt the same concept apply in that the nerves in the Sacrum will only show up using specialized equipment such as Dr Potter uses?

Matt

You could ask your health care practitioner if there is anything to be gained by more detailed imaging of the sacrum. If the sacral canal appeared normal when screened with a pelvic MRI, I kind of doubt it. Tarlov cysts and Cauda Equina Syndrome are the two pathologies I can think of that originate within the sacrum, and you could enquire whether these have been ruled out based on the imaging you already had. If you are able to get ahold of Dr. Potter, she could probably tell you definitively whether or not she was able to view the sacrum well enough to rull out pathology of the sacral spinal cord and nerve roots.
Sacral pain can be a result of sacral torsion or other sacroiliac joint dysfunction, which is a hands-on Physical Therapy diagnosis. Further imaging would not be useful for joint dysfunction; the deviated coccyx is a subtle hint of the presence of SIJD but you will not confirm it with more imaging studies. Joint dysfunction is a problem of restricted movement, and will not show up in a still picture taken in a neutral position, no matter how many imaging studies you get done.