Part II in the “Demystifying Pudendal Neuralgia” Series
After Thanksgiving we will be publishing the third blog in our pudendal neuralgia series that will focus on the pudendal nerve entrapment diagnosis and the decompression surgery that’s associated with it. For this post, we have interviewed the two top surgeons in the country that perform the aforementioned surgery, Dr. Michael Hibner and Dr. Mark Conway. Stay tuned for this groundbreaking post! In the meantime, take a look at the second blog in the series, “The Role of PT in Treating PN”.
In the previous post in our “Demystifying Pudendal Neuralgia” series, I talked about the difference between PN and PNE. In addition, I reviewed a list of treatment options for PN. Physical therapy was at the top of that list. Today, in this second post in the series, I will delve deeper into the role of PT in treating PN.
So what is the role of PT in treating PN?
For one thing, a pelvic floor PT is in one of the best positions to uncover the possible underlying causes of PN.
That’s because a leading cause of PN is myofascial dysfunction. Indeed, hypertonic muscles (too tight muscles), myofascial trigger points (MTrPs), joint dysfunction, and connective tissue restrictions can cause pudendal nerve irritation and the symptoms of pudendal neuralgia: sharp, shooting, or burning pain in the territory of the nerve. Pelvic floor PTs are specifically trained to identify and treat these issues.
Another reason a PT can best identify the underlying causes of PN has to do with the amount of time spent with the patient. A typical PT appointment is one-hour in length and patients generally see their PT one-to-two times per week. Spending so much time with a patient allows the PT to take a detailed history and perform a very thorough physical examination to identify the collection of impairments at the root of the patient’s pain and/or dysfunction.
Besides being in the best position to uncover the cause behind a patient’s pain/dysfunction, an important role of a PT treating PN is to help the patient sort through all past tests, interpret the responses to various treatments, and make informed choices about diagnostic tests and interventions going forward.
In our clinic, time and again we have seen patients struggle through the complexity of this diagnosis because they do not have a medical professional willing or able to “steer their ship.” Having a provider in place to spearhead the patient’s healing can go a long way toward establishing a multimodal treatment plan to treat the underlying causes of PN.
So what are some of these underlying causes?
PN pain can be caused by a combination of several factors, and that’s why there is no one-size-fits-all treatment protocol. So every patient that walks through the door of a PT’s office bringing with them a PN diagnosis is going to have a different reason or combination of reasons for their pain and symptoms.
That said, with a diagnosis of PN—and remember, “PN” is simply pain anywhere along the territory of the pudendal nerve—any of the typical suspects for pelvic pain can be involved. Those usual suspects include: hypertonic muscles that compress or irritate the nerve, trigger points, biomechanical dysfunction, connective tissue restrictions, or any combination thereof that can alter neurodynamics, which is basically the ability of the nerve to move without irritation.
For example, it is possible for a patient who has certain types of SI joint dysfunction to have less space between the sacrotuberous and sacrospinous ligaments. This space deficiency can influence the nerve’s ability to glide and move freely, and the end result may be neuralgia. Another issue that has the potential to alter neurodynamics would be a trigger point in the obturator internus muscle. This trigger point can result in a narrowing of Alcock’s Canal and irritate the nerve. (Alcock’s Canal is the structure through which the pudendal artery, veins and nerve pass.
Incidentally, both of these patients likely have the same symptoms—burning at their sit bones that worsen with sitting. However, the treatment plan for each of these scenarios will be quite different. Indeed, many patients with the exact same symptoms will have very different objective findings. Often I have to explain to my patients that having pain with sitting does not mean that they have entrapment. Numerous impairments cause pain with sitting.
While any of the usual suspects or a combination of the usual suspects might be the cause of a patient’s PN, there are a handful of very specific issues that are strongly associated with pain along the course of the pudendal nerve that should be considered when a PT does his or her evaluation.
- Sacroiliac joint dysfunction—The pudendal nerve runs out of the sacrum and through the sacroiliac joint ligaments. The space between those ligaments could be affected by a positional change of the joint, which in turn could compress the nerve. Changes in the mobility of the SI joint can also negatively impact the nerve at different locations along its course.
- Trigger points in the obturator internus muscles—As was touched on above, the aponeurosis of the obturator internus muscle forms Alcock’s Canal, through which the perineal branch of the pudendal nerve travels. (An “aponeurosis” is a layer of flat, broad tendons whose primary function is to join muscles to other muscles or bones.) If a patient develops trigger points in the obturator internus muscle it can cause the muscle to become hypertonic. In turn, this hypertonic muscle will compress the nerve.
- Connective tissue restrictions in the dermatomal distribution of the pudendal nerve—This is often the case when patients say they feel as though they are sitting on a golfball or cannot tolerate wearing underwear. What’s happening is the connective tissue in the area is tight and is irritating the superficial nerve branches.
- Hypertonic pelvic floor muscles—Too tight pelvic floor muscles can cause compression along the course of the nerve and thus result in neural inflammation.
- Neural sensitivity and ischemia – Aggravating factors such as repetitive yeast or bacterial infections can sensitize the nerve. In addition, there has been shown to be a correlation between PN and Endometriosis, Vulvodynia, and IC. To be sure, we know visceral disease states can affect peripheral nerves and it is plausible that nerve irritation can irritate visceral structures.
What the list above shows us is that the pudendal nerve itself is rarely the sole driver of the symptoms of PN, such as sitting pain. But rather, is one impairment of a myofascial syndrome comprised of many parts. This is one reason why interventions directed at the nerve alone, such as nerve blocks, often provide limited or no relief.
Take Peggy for instance, Peggy was a 51-year-old woman who came to see me after suffering for years with left-sided vulvar pain and pain with sitting. Peggy had been diagnosed with pudendal nerve entrapment (PNE).
When I evaluated Peggy, I found that she presented with a handful of myofascial trigger points in her pelvic floor and pelvic girdle muscles and also with extensive connective tissue restrictions in the bony pelvis region. In my opinion, these were the causes of the pudendal nerve irritation she was experiencing, not an entrapped nerve. Indeed, the nerve branches were not tender to palpation.
Peggy had a history of endometriosis, which likely led to her pelvic floor issues. It is therefore plausible to think Peggy developed trigger points in her hypertonic pelvic floor. Plus, endometriosis, pelvic floor dysfunction, and trigger points are all known to contribute to connective tissue restriction, which can, in turn, cause further pain and dysfunction.
Another patient who came to me who had been given a diagnosis of PNE was Tony. Tony was a 29-year-old male who came to me with a litany of symptoms including lower abdominal pain, left pain when sitting at the sit bones, perineum, penile and groin pain, urinary frequency and pain with bowel movements. Tony was an active professional who skied, snowboarded, worked out in a gym, played basketball, skateboarded and surfed.
His symptoms began after he did a few handstands in his backyard at a barbeque. Prior to booking his appointment to visit me, he had spoken to an out-of-state physician who advised him to book an appointment for a pudendal nerve decompression surgery, after only speaking with him briefly on the phone.
When I evaluated Tony, I found pelvic floor muscle trigger points as well as trigger points within his abdominal wall and overall muscle tightness and connective tissue restriction. After regular PT and one abdominal trigger point injection, Tony is now pain-free. (To read Tony’s case study in its entirety, please click here.)
A PT needs to take a detailed history to understand how patients developed their symptoms, and then undertake an initial evaluation. In the cases of severe, chronic presentations the evaluation may take up to four hours (or four one hour appointments).
During the initial evaluation, the physical therapist needs to evaluate all of the following:
- Connective tissue of the trunk, bony pelvis, and lower extremities
- Pelvic girdle muscles
- Pelvic floor muscles
- Lumbo-pelvic and hip joints
- Peripheral nerves (sciatic, pudendal, posterior femoral cutanoues, etc.) need to be palpated for Tinel’s sign
- Sensitivity of the central nervous system
Following the evaluation, the therapist should be able to develop a reasonable assessment for the patient as to which impairments are causing which symptoms and how their pain kicked off in the first place.
For example, if we look back at Tony’s case, I found out he did about 200 sit-ups daily. Additionally, I also learned he was afraid of developing hemorrhoids and therefore constantly squeezed his pelvic floor muscles, believing this would prevent the development of hemorrhoids. This behavior certainly did not prevent a hemorrhoid, but it did set him up for pelvic floor muscle tightness that irritated his nerve.
Plus, it’s known that excessive strain to muscles (too many sit-ups) can cause trigger points in the rectus abdominus muscles. Trigger points become symptomatic when activated, which happened when Tony stretched his stomach by doing that handstand. These trigger points, in turn, can cause urinary frequency and burning at the tip of the penis.
So with a little detective work on the part of the PT after taking a complete history from the patient, it is possible to understand the origins of a patient’s pain/dysfunction.
Once the PT has identified the reason or reasons for the patient’s neuralgia, treatment involves restoring normal physiology to whatever structures are involved using a variety of methods, including manual therapy.
In addition, PTs are responsible for explaining their findings to their patients as well as describing what their treatment strategy will be. Communication with the patient is imperative during the course of treatment. All too often, my patients have told me that they weren’t sure what procedure they had done or why they were undergoing certain treatments. It is absolutely crucial that both the provider and the patient are aware of what is being done and why. Treatment for these difficult issues is not a passive process and everyone needs to work together (more on this point in upcoming blog posts).
In addition to all parties being aware of what is being treating and why, it’s important for PTs and patients to have clear conversations about reasonable expectations, not just for PT, but also for the overall treatment plan. All too often, patients are led to believe that certain treatment procedures are going to be a “magic bullet” cure. This is due to misinformation and poor communication with their providers.
For instance, I see a very common pattern when talking to my patients about their previous treatments. A patient will often tell me “I had trigger point injections and they did not work because I still have pain.”
The fact that there is still pain does not necessarily mean the treatment was a failure and should be entirely discounted for future use.
For instance, I once had a female patient with vulvar burning who had injections into her obturator internus muscles prior to coming to see me for PT. Following the injection, she had temporary relief of her pain. However, she was upset when her pain returned the following day, so she put trigger point injections on the “failed treatment” list, deciding never to try them again in the future.
So why did her pain return? Either the injections did not eradicate the trigger point or the trigger point was not as heavily involved in her pain as had been thought.
Fast forward to my evaluation with the patient. I found another trigger point when examining her pelvic floor, this one in her bulbospongiosis muscle. I worked to release the trigger point, but while her burning would decrease with our sessions, it never totally went away. However, neither did the trigger point. For some reason, manual therapy was not enough to eradicate this stubborn trigger point.
At that point, I suggested that she again try trigger point injections—this time targeting the trigger point in her bulbospongiosis muscle. She was very skeptical, however, she did have the trigger point injection. The end result was that the injection (with a bit more PT) eliminated the trigger point, and her burning resolved.
My point here is that when patients don’t understand what outcomes they should reasonably expect from a particular treatment method, there is a risk that they will chalk up that treatment procedure as a failure if it does not completely cure their symptoms. So it’s important for patients and providers to have open discussions about reasonable expectations throughout treatment. That way all treatment avenues are left open, and patients don’t get overly discouraged and give up.
There is no definitive timeline for how long a patient should receive physical therapy for PN. For some patients it takes a few months, for others it could take a few years to achieve optimal results.
Realistic goals should be set on the first day of therapy and each appointment should be directed at achieving those goals. Of course, every patient’s ultimate goal is to get better and be pain-free; however, during treatment it’s important to set and to track short-term, attainable goals. At PHRC, we set short-term (six to eight weeks) and long-term goals (twelve to fourteen weeks). Short-term goals are impairment based. Examples are:
1. Eradicate obturator internus MTrP to improve sitting tolerance.
2. Decrease puborectalis hypertonus to improve ability to defecate.
3. Decrease pelvic floor hypertonus to decrease urinary frequency.
4. Normalize connective tissue in the bony pelvis to improve clothing tolerance.
The short-term goals will help achieve the longer term, functional goals. Examples of realistic long-term goals might include:
1. The patient will be able to tolerate sitting for 45 minutes to be able to drive to work.
2. The patient will void no more than six to eight times in a 24-hour period and will do so without urethral burning.
3. The patient will be able to stand for 30 minutes to cook dinner without an increase in perineal burning.
When it comes to treating patients who come to us with a diagnosis of PN from a physician or other PT, at PHRC we treat these patients the same way we treat all patients with pelvic pain. Our treatment approach is focused on restoring normal physiology to whatever structures are involved in the patient’s pain. So first step is to figure out who the culprits are and then the next step is to go after them with guns blazing! Our treatment approach includes:
- Myofascial trigger point release all along the involved pelvic girdle and pelvic floor muscles.
- Manual techniques that normalize the length, tone, and help patients regain control of the pelvic floor muscles.
- Connective tissue manipulation to normalize dysfunctional tissue.
- Restoration of normal neural mechanics through direct glides and mobilizations and indirectly by treating other impairments.
- Mobilization and stabilization of the sacroiliac and hip joints.
- Individualized Home Exercise Program
- Temporary Lifestyle Modifications
And as with all of our patients, we embrace a multidisciplinary approach when treating PN. Appropriate adjunct treatment options might include: pharmaceuticals, including vaginal and rectal suppositories; pain management, interventional medicine strategies, such as trigger point injections and botox for muscles that are compressing the nerve; peripheral nerve blocks in certain situations (but not as a first-line or mandatory component of treatment), pain education, and cognitive reprogramming. (Cognitive reprogramming is a good fit when a patient’s symptoms are associated with central sensitization. Here we’re talking about strategies aimed at rewiring the nervous system. Stay tuned for an entire post on this topic!)
Going back to Peggy’s case, after about a year and a half of regular, weekly PT, coupled with trigger point injections and medication including Neurontin and Valium suppositories, Peggy is now 95% pain-free. (I report that she is 95% pain-free because there are occasions, such as when she has to sit for long periods on a plane ride, that she will have the occasional flare up. She says that her flares are about a 3 or 4 on her personal pain scale. She manages her flares with a Valium suppository, by internally stretching her pelvic floor with a dilator and by icing.)
If you’d like to read more about our general pelvic pain treat methods, the same ones we apply to PN patients, please click here.
In this post, I hope I’ve succeeded in shedding some light on what has for so long been perceived as an intimidating diagnosis. In the coming months, please look out for the next installment in my “Demystifying Pudendal Neuralgia” Series when I’ll tackle the PNE decompression surgery, among other topics.
Click to read the previous post in the series, “How do I know if I have PN or PNE?”
In the meantime, if you have any comments about any of the points I’ve covered in this post; please leave them in the comment box below. I hope to hear from you!
All my best,