Prostatitis-like pain: Surgical decompression of the pudendal nerves can improve or cure symptoms Stanley J. Antolak, Jr., MD Christopher M. Antolak, MD AUA. Orlando, FL, USA , May 17, 2008 OBJECTIVES • Define CPPS • Acknowledge Pudendal Neuralgia as an etiology of CPPS • Review symptoms and diagnosis of pudendal neuralgia • Identify effective conservative and surgical treatments Male pelvic pain • Chronic pelvic pain syndrome – NIH Category IIIB (non-inflammatory prostatitis) • Prostate Pain Syndrome (EAU) • Prostatitis-like pains (Nickel) • Prostatodynia • Prostatosis • Prostatitis is a waste basket diagnosis. • NIH new focus is on neuropathic etiologies. Pudendal Neuropathy • Recognized by the European Association of Urology (EUA) – as a mononeuropathy that causes pelvic pain. Neuropathic Pain: a Tunnel Syndrome • Treat in a similar fashion as CTS • Fall; European Urology 2004; 46:681 Robert, et al. Surg-Radiol Anat. 1998; 20:93 Pecina MM. Tunnel Syndromes: peripheral nerve compression syndromes. 3rd edition Pages 191-4 Chronic Pelvic Pain Syndrome NIH IIIB (CPPS) “lower genitourinary symptoms, – particularly pain in the perineum or genitalia, – voiding symptoms, such as dysuria or frequency, – and sexual dysfunction…” – absence of bacteria in urine or prostate secretions Krieger; JAMA 1999; 282:236 Study Population: Prospective case series 70 men ages 18-73 (avg 47), seen in 2005 with pain in the . following areas: • • • • • • • • Perineal Scrotal/“testicular” Penile/urethral Perianal Suprapubic Ejaculatory pain Inner thigh / inguinal Absence of prostatic infection Diagnosis of pudendal neuropathy HISTORY: typical pain (sitting, driving, relieved on toilet seat) May have bladder, sexual, bowel dysfunction SENSORY EXAMINATION: changes to pinprick; Examine for other pelvic neuropathies WDT; Warm Detection Threshold test (a Quantitative Sensory Test). PNTMLT; Pudendal Nerve Terminal Motor Latency Test Smith ARB Br J Obstet Gynaecol 1989;96:29. Bleustein CB J Urol 2003; 169: 2266 Pudendal Neuralgia (Robert) Pain in perineum ...aggravated by sitting ...reduced by standing … not present when recumbent, and... Relieved sitting on a lavatory Bladder, rectal and sexual dysfunction may occur as non-pain components of pudendal neuropathy (Shafik) Robert R Surg-Radiol Anat 1998;20:93 Pudendal Neuropathy: -A “tunnel syndrome” causing pain due to nerve compression • Compression commonly occurs at two locations: •The “CLAMP” or lobster claw, between the sacrotuberous and sacrospinous ligaments. (>90%). •The Alcock canal (pudendal canal. (<10%). Three sequential treatments may relieve pelvic pain due to pudendal neuropathy • I. “Self-care”, a Nerve protection program. (All patients) Avoid exercise, cycling. Use “suspension pad”. Amitriptyline 10 mg and increase at 5 day intervals • 2. Three Pudendal Nerve Perineural Injections (PNPI) needed in (80 to 90% of patients). Monthly x 3. Steroids and bupivacaine. • Decompression Surgery (in 30 to 40% of patients). We monitor responses with Symptom Scores NIH-CPSI = the National Institutes of Health-Chronic Prostatitis Symptom Index AUASI = American Urological Association Symptom Index (International Prostate Symptom Score) SHIM = Sexual Health Inventory in Males (IIEF-5). SF – 12 Decision for surgery ( ) after failure of self care and 3 Pudendal nerve perineural injections (PNPI) PNPI Transient response to PNPI; surgery recommended NIHCPSI AUASI C on PN s PI 2 3m os pr e O p 35 30 25 20 15 10 5 0 KmbrWd Anatomic landmarks for a transgluteal decompression. • On left – Incision site marked • On right – Ischial tuberosity – Sacrum with prominent inferior lateral angle TPApr12008 Case 1 Nerve exposure left pudendal nerve. * • Rectum retracted. * • Inferior rectal nerve • Scissors at ischial spine ( ) • Anterior to (underneath) scissors is fascia of the Alcock canal TerePoiAPR12008 Case 1 Alcock canal is opened. Portion of obturator fascia is removed. Fibers of S-Sp ligament IRN Rectal vessels Main trunk Case 1 Pudendal Nerve Pathology • Pudendal nerve is in the vessel loops • Nerve flattened superiorly • Nerve is significantly compressed between S-T and SSp ligaments.( ) TerePoiAPR12008 Case 6 PN anterior to obturator fascia (Alcock canal). Nerve is flattened, splayed over obturator internus muscle Individual fascicles are apparent (significant compression). Pallor of compressed nerve suggests ischemia. WS10208 Results of Pudendal Nerve Decompression Surgery • N=70 • Follow-up available at 12 months in 47 • 23 patients lost to follow-up or with inadequate patient data • 25 patients showed improved symptoms scores with self care and/or PNPI • 22 patients with advanced disease required operation Results of Pudendal Nerve Decompression Surgery at 12 and 24 months Postoperatively n=22 at 12 months; n=14 at 24 months Cumulative NIH-CPSI averages 30 25 20 15 10 5 26.1 19.7 19.3 16.1 18 mos 24 mos 0 PreOP 12 mos Results of Pudendal Nerve Decompression Surgery at 12 and 24 months Postoperatively n=22 at 12 months; n=14 at 24 months Cumulative NIH-CPSI averages _ 30 25 20 15 10 5 26.1 19.7 19.3 16.1 18 mos 24 mos 0 PreOP 12 mos Results of Pudendal Nerve Decompression Surgery at 12 and 24 months Postoperatively n=22 at 12 months; n=14 at 24 months _averages Cumulative NIH-CPSI _ _ _ 30 25 20 15 _ _ 10 5 11 of 22 improved 26.1 19.7 _ _ 9 of 14 improved 19.3 16.1 18 mos 24 mos 0 PreOP 12 mos Results of Pudendal Nerve Decompression Surgery at 12 and 24 months Postoperatively n=22 at 12 months; n=14 at 24 months Cumulative NIH-CPSI averages 30 25 20 15 10 5 26.1 19.7 19.3 16.1 18 mos 24 mos 0 PreOP 12 mos Results of Pudendal Nerve Decompression Surgery at 12 and 24 months Postoperatively n=22 at 12 months; n=14 at 24 months Cumulative NIH-CPSI averages 30 25 20 15 10 5 26.1 19.7 19.3 16.1 18 mos 24 mos 0 PreOP 12 mos Pudendal Neuralgia: Treatment results. Males; n = 47 @ 12 months, 39 @ 24 months Cumulative NIH-CPSI Responses 30 25 20 Self-care PNPI Surgery 15 10 5 0 Prior 12 mos 18 mos 24 mos Summary •Chronic pelvic pain: a disease with multiple causes. •Prostatitis comprises only 5% of male CPPS. •Neuropathic causes include: • Pudendal neuralgia • Several other peripheral neuropathies • PN is a clinical diagnosis with simple confirmatory tests. • A sequential treatment program can successfully improve neuropathic symptoms due to pudendal neuropathy. •Pudendal nerve decompression surgery is an effective treatment for refractory neuropathic disease.