SILENT SUFFERERS: IT'S TIME TO TALK ABOUT PELVIC PAIN
If you thought that pain only causes bodily suffering, then let us take a glimpse into the world of pelvic pain. Have you heard of someone who has to write exams lying down as he cannot ever sit because of pain or someone who cannot wear full pants in cold winters as tight clothes hurt or someone who cannot travel by bus or train because he does not know when he may need to use the toilet or someone who cannot think/see anything erotic as arousal is painful. These are true patient experiences and yes this is the world of pelvic pain. It may not take much for one to appreciate how this can destroy careers, families and adversely impact on the quality of life.
One of the causes of pelvic pain is Pudendal nerve pain. It is also addressed as cyclist syndrome, Alcock’s canal syndrome, and pudendal nerve entrapment. Pudendal nerve
It is not always easy to pin point the root cause behind the problem.
is one of the main nerves in the pelvis and is closely involved with genital sensation, urinary and bowel functions. Irritation or damage of this nerve often presents with pain or altered sensation in the genital, rectal region or deep inside the pelvis. Though the condition is not gender specific, it is more common in young and middle aged women. Mimicking a plethora of symptoms, the patients may present to a number of different specialties including urologists, neurologists, colorectal surgeons, gynaecologists, general physicians and general surgeons, but the condition often remains undiagnosed due to low awareness about the condition. It's not uncommon for sufferers to feel dejected as specialist after specialist tells them that they cannot find anything wrong.
Pudendal Neuralgia symptoms and diagnosis
The most common complaint of patients suffering from this condition is pain in the areas supplied by the pudendal nerves. This is generally described as burning, shooting, aching, prickling or itching sensation that worsens on sitting and may resolve when lying or standing. Pain is often accompanied by increased sensitivity, pins and needles sensation in the affected area. Other symptoms include the feeling as if one has a urinary infection with increased urinary frequency and pain on passing urine; rectal pain with an urge to open the bowels more frequently and pain during sex, arousal or ejaculation.
Due to lack of specific tests, the diagnosis of this condition remains a challenge. Investigations are requested to support the diagnosis and rule out other conditions which may present similarly. These may include MRI scans and nerve tests. Resolution of pain a diagnostic nerve block, even if temporary, supports the diagnosis of pudendal neuralgia. Pudendal Neuralgia is known to be associated with many other conditions such as dysfunctional voiding, painful bladder syndrome, Chronic Pelvic Pain Syndrome, chronic prostatitis etc.
What causes Pudendal Neuralgia?
It is not always easy to pin point the root cause behind the problem. It may arise as a result of compression or entrapment of pudendal nerve due to simple activities such as cycling, prolonged sitting or intense exercise of pelvic floor and neighbouring muscles. Stretching of the nerve during childbirth or injury to the nerve due to trauma or various surgeries such as gynaecological, colorectal, orthopaedic and urology procedures have been associated with the development of this condition. Anatomical variations in the path of the nerve can predispose the nerve to compression or injury, as can biochemical factors such as diabetes and herpes infection in the area.
How is PN treated?
Management of this condition requires active patient participation and use of a combination of lifestyle changes, and medical interventions. Lifestyle changes are aimed at protecting the nerve and at reducing the irritation of the nerve. Patients are advised to avoid activities such as cycling, bike riding, prolonged sitting etc. Avoiding constipation and tight clothes is frequently suggested.
Multidisciplinary approach involves using a combination of lifestyle changes along with combines with medications, physiotherapy and psychological support and pain relieving interventions such as injections. Special type of painkillers (neuropathic medicines) which work on nerves can help in reducing the symptoms although these painkillers generally need time to work.
Supervised specialist physiotherapy aimed at pelvic floor muscles and can help with muscle spasms, imbalances and in correcting other dysfunctions.
Psychological support is often required to address maladaptive behaviours, beliefs and for developing self management techniques. This may include cognitive behaviour therapy, meditation, mindfulness and relaxation techniques. Pain reliving Interventions have an important role in confirming the diagnosis and providing symptom relief. Commonly used options include pudendal nerve block, radiofrequency treatment and pelvic floor injections. These injections are performed using ultrasound, X–rays or CT guidance to improve accuracy and chances of providing relief. Often these can reduce symptoms and help in controlling pain for long duration.
In specific cases with disabling symptoms which remain unresolved with above modalities, options such as neuromodulation or pudendal nerve release surgery is considered if indicated.