Pudendal Nerve Block
A pudendal nerve block, commonly called a pudendal block, is a medical procedure used for pain management, primarily to alleviate nerve pain stemming from the pudendal nerve. This nerve provides sensation to the pelvic region, including the perineum, rectum, and genitals. In cases where there is nerve compression or damage, patients can experience debilitating neuropathic pain. This discomfort can manifest in various ways, including perineal or vaginal pain. It can be linked to conditions where the pelvic floor muscles exert excessive pressure on the nerve or other localized traumas. The pudendal block involves the injection of a local anaesthetic near the pudendal nerve, often using ultrasound guidance to ensure precision. The primary aim is to temporarily numb the nerve, thereby interrupting pain signals. This offers immediate pain control and provides valuable diagnostic insight: if the pain is alleviated post-injection, it reaffirms the pudendal nerve’s role in the pain experienced by the patient.
While the pudendal block offers temporary relief, it is crucial in the broader treatment overview for patients grappling with pudendal nerve pain. The procedure provides a therapeutic window for patients to engage in other treatments like physical therapy, which aims to address the root causes of nerve compression, often involving exercises and stretches for the pelvic floor muscles. Furthermore, more targeted interventions can be devised by identifying the specific branches of the pudendal nerve causing the pain, such as the dorsal nerve, perineal nerve, or inferior rectal nerve. In cases where conservative treatments don’t yield lasting results, surgical decompression may be considered. This surgical approach focuses on relieving the pressure on the nerve, often by addressing structures like the internal pudendal artery that may be contributing to the nerve compression. Ultimately, the pudendal block acts as both a diagnostic tool and a temporary solution, guiding the subsequent steps in a patient’s comprehensive pain management plan.
Pudendal neuralgia is defined as pain in the area of innervation of the pudendal nerve. In men, areas affected can be the penis, scrotum, perineum, and rectum. Pudendal nerve entrapment is described as compression of the pudendal nerve from ligaments, scar tissue, or surgical materials which leads to pudendal neuralgia. Some patients with pudendal nerve entrapment experience burning pain but others may have the sensation of numbness. It may be present on one or both sides and some patients experience problems with erection and pain with ejaculation. Penile numbness is one of the frequent signs of pudendal neuralgia in men.
Pudendal nerve entrapment is less common in men than in women and the exact incidence is not known. It is usually related to a traumatic or painful event in the pelvis, penis, scrotum, or anus. It has also been noted in men who masturbate excessively or who insert objects in their rectum. Pain or numbing sensation may occur after one significant trauma or multiple repetitive smaller traumatic events. An example of repetitive smaller trauma is bike riding where a narrow bicycle seat may crush the nerve against ischial tuberosities (sitz bones).
The Pudendal Nerve in Men
Pudendal neuralgia is the pain that a patient feels in the area of innervation of the Sciatic nerve, dorsal nerve, and pudendal nerve. If the patient is a male—the areas affected can be the penis, scrotum, perineum, and rectum (dis colon rectum). If the patient is a female—the pudendal nerve runs from the lower back—along with the pelvic floor muscles to the perineum. This can cause the patient not just perineal pain, but also great pelvic pain—such as chronic pelvic pain and vaginal pain.
In addition—the pudendal nerve crosses between two muscles. These two muscles are called the coccygeus and the piriformis muscle. Piriformis muscle spasm may also affect the pudendal nerve—controlling our bladder and bowel.
Pudendal neuralgia is less common in men compared to women. The perineal pain and pelvic pain—such as chronic pelvic pain and vaginal pain caused by pudendal neuralgia in a female are commonly related to a painful or traumatic event in the sciatic nerve, pelvis, or anus. While for males—their pudendal neuralgia or the dis colon rectum—is related to painful or traumatic events in the penis, scrotum, anus, or the dorsal nerve.
Symptoms of Pudendal Nerve Involvement
There are some areas along the pudendal nerve’s path (pudendal canal)—where it can be squeezed by other structures—which causes it to become irritated. When the pudendal canal is compressed—that is when pelvic pain and chronic pain in the pelvic area happen.
The pain signal that a patient with pudendal neuralgia is usually described as stabbing and burning or chronic pain in the pelvis. Sometimes—the pain signal can be a tingling sensation or numbness. A pain signal can be worsened by any activity—involving bending your hip—such as squatting or sitting down for too long.
For pain relief—aside from injection with a numbing medicine—the patient can try standing or lying down. There are also some cases where sitting on the toilet gives pain relief to the patient. Since the perineum nerve has so many functions—pressure on the perineum nerve may contribute to a similar pain signal such as— erectile dysfunction, or the pain during ejaculation or urination—as well as—urinary urgency or frequency, bowel or bladder incontinence—and the like.
If any pain medicine doesn’t give any pain relief anymore—then it is the best idea to call a doctor right away. Pain medicine should be able to give pain relief to the patient. Otherwise—pudendal nerve blocks might be necessary.
Pudendal Nerve Blocks
Pudendal nerve blocks are historically a common regional anesthesia technique or also known as the local anesthetic technique. This local anesthetic technique provides perineal anesthesia during an obstetric procedure—such as vaginal birth during the second phase of labor, vaginal repairs—as well as—anorectal surgeries—which include hemorrhoidectomies.
Pudendal nerve blocks are less commonly utilized local anesthetic techniques to provide anesthesia for urological procedures. Nevertheless—this local anesthetic technique is very safe and effective for the patient. The pudendal nerve blocks are used in comforting pain associated with pudendal neuralgia.
Pudendal nerve blocks are more helpful than pain medicine in evaluating—as well as—managing both pelvic and groin pain around the anus, perineum, and genitals. A pain physician gives an injection with numbing medicine with a needle placement on the pudendal artery to determine what is causing your pain.
A pain physician just doesn’t give out an injection with a numbing medicine injected anywhere on your body. A proper needle placement—specifically on the pudendal artery is necessary. Pudendal nerve blocks can be executed via a perirectal approach with the use of a nerve stimulator. A nerve stimulator can stimulate contractions of the outer anal sphincter
The aim of pudendal nerve blocks is to block the nerve as it enters the lesser sciatic foramen—1 cm inferior and a medial comparative to the extension of the sacrospinous ligament to the ischial spine. The sacrospinous ligament is a very thin ligament that is attached to the ischial spine. On the other hand—the sacrotuberous ligament is a stabilizer of the sacroiliac joint. The sacrotuberous ligament also connects the bony pelvis to the vertebral column.
What Conditions Can Pudendal Nerve Blocks Treat?
A pudendal nerve block is used in treating conditions characterized by symptoms of genital/rectal pain (pudendal neuralgia)—which is caused by pudendal nerve entrapment while passing through the pelvic region. It may also become inflamed caused by local trauma—including stretch injury. However—the most common for its inflammation is due to skin-tight clothing, pregnancy, weight gain—or obesity.
How is it Performed?
A team of health professionals will help the patient to be in the proper position to make sure the procedure is done properly and can be completed with the smallest amount of discomfort for the patient. The patient’s skin is cleansed using a sterilizing solution (chlorhexidine). Next—a local anesthetic medication will be given to numb the skin. To find the target—fluoroscopy (x-ray) or ultrasound is done next.
A very thin needle is then directed to the desired location. Then—a local anesthetic and/or steroids are injected. During the entire process—the patient will be constantly monitored by a team of health professionals. A small badge is then placed on the skin after the injection. The patient will be given time after the procedure to ensure that the patient feels fine and is not experiencing and side-effects before leaving the clinic/hospital.
What Kind of Medication is Injected?
The medication inside the injection includes a combination of anesthetic ( bupivacaine or lidocaine) and steroid (dexamethasone, cortisone, or Kenalog). The local anesthetic will be the one responsible for the immediate relief—while the steroid is used to supply more long-term relief.
Does the Entire Procedure Hurt?
The procedure is normally well-tolerated. The most common and uncomfortable part of the procedure is a localized burning sensation from the anesthetic. During the procedure—patients often experience a pressure sensation—which typically resolves within a few minutes. The patient may also feel a minor soreness for a week after the procedure—which is totally normal.
How Long Does Usually the Procedure Take?
The procedure normally takes about 15 minutes. We advise patients to arrive at the hospital/clinic 1 hour prior to allow pre and post-procedural protocols.
For more details on pudendal neuralgia, you may refer to the page on pudendal neuralgia in women. Treatment of pudendal neuralgia in men is similar to treatment in women and surgical decompression of the pudendal nerve (transgluteal pudendal neurolysis) is also done in a similar manner since the anatomy of the nerve in men and women is virtually identical.