Diagnosis and treatment of pudendal nerve entrapment

1 Although entrapments affecting the distal peripheral nerves, such as carpal tunnel syndrome and cubital tunnel syndrome, are well understood by virtually every neurosurgeon and neurologist, there has been little interest in perineal neurology and neurosurgery. Urologists and gynecologists are focused on end organs so that neurological conditions affecting the perineum have been effectively relegated to orphan status. Entrapment of the pudendal nerve is an area with extremely few practicing specialists. The medical and surgical management of PNE syndrome has an extended history,10,45 but no rigorous studies with significant patient numbers were published until 1998.38 And although there are now a number of reports covering various aspects of diagnosis and treatment,3,6,25,34,35 the success rate in treating pudendal neuralgias has been limited.5,29,37 One problem has been that there appear to be several subtypes with different anatomical sites of entrapment and clinical presentations.4,23,27,33,39,40 Furthermore, the surgical anatomy of the pudendal nerve itself is complex (Fig. 1) and subject to significant individual variation.28 Targeting of the pudendal nerve for diagnostic or therapeutic injection at the ischial spine by using an electrodiagnostic technique,32 C-arm fluoroscopy,1,9 and CT scanning has been described.7,21,43 Diagnosis has also relied on pudendal nerve latency testing,2 but imaging has played very little role in diagnosis. Recently, advances in Diagnosis and treatment of pudendal nerve entrapment syndrome subtypes: imaging, injections, and minimal access surgery