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Posted by: SirMon - 11-13-2017, 09:53 PM - Forum: Treatments - No Replies

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  Pudendal Nerve Self-Care
Posted by: Mark - 04-04-2017, 04:20 PM - Forum: Treatments - No Replies

Self-Care for Pudendal Neuralgia by Stanley Antolak, MD

Chronic pelvic pain is a boundary "disease" affecting urology, colorectal, gynecology, physical medicine, neurology and other specialties. When sitting aggravates or causes the pelvic pain (perineum, genitals, coccyx, rectum, and pubic hair) we suspect pudendal neuralgia, often called pudendal nerve entrapment. Pudendal neuralgia is considered in all men and women with pelvic/urogenital pain with or without bladder symptoms or sexual dysfunction. A simple definition is perineal pain aggravated by sitting, reduced by standing, not present when recumbent and generally relieved when seated on a toilet seat.

The striking common feature in pudendal neuralgia patients is that flections activities of the hip (sitting, climbing, squatting, cycling, and exercising) induces or aggravates urogenital pain, chronic pelvic pain, or prostatitis-like pain. Many male patients played American Football, lifted weights and wrestled as teenagers and young adults. Often, the females were active in high school athletics, gymnastics, dance line, or cheerleading.

Our primary hypothesis is that hypertrophy of the muscles of the pelvic floor during the years of youthful athleticism causes elongation and posterior remodeling of the ischial spine. A posterior and medical shift of the ischial spine leads to juxtaposition of the sacrotuberous and sacrospinous ligaments that are normally quite separated at their insertions into the ischium. This change results in the "lobster claw" of two ligaments that can compress the pudendal nerve.

Self-Care - Perineal Hyperprotection

The goal is to stop irritating the nerve. Decreasing the neurotransmitters to the spinal cord lets your pain decrease. The other secondary problems will gradually improve.
This novel but remarkably effective treatment of self-care was based on the observations by the French (Robert and colleagues) that sitting on a toilet seat relieved pain and by our continuing observations of exercise-induced pain. Therefore, treatment is to sit with the weight of the body supported on the ischial tuberosities with the perineum suspended to relieve the pressure of the ischioanal fat against the nerve. Cessation of flexion activities is extremely important.

An office testing procedure, i.e., sitting on two parallel paperback books with the perineum suspended was added to our evaluation treatment of a large cohort of over 600 patients. Reduction of pain, in only a few minutes, can be dramatically effective in over 50% of the patients. Over a period of time this technique can cure pain, bladder irritability, and sexual dysfunction.

WHAT TO DO:

DO NOT SIT!

Go to our website and download and complete the pain, voiding and sexual function scores. These provide important reference information or benchmarks for future comparisons.
Continue your medications. Wear loose clothing that keeps pressure off of your bottom. Stop ALL exercises except on a flat surface or pushups.

DO NOT SIT!

If sitting is necessary, make a "perineal suspension pad". The concept is to sit on a pad that supports your body weight by the "sit bones" or ischial tuberosities to "suspend" the perineum, thus relieving pressure from the pudendal nerve.
Use the sitting pad at work, in your car, at church, at home, and in restaurants. (An alternative is to tuck a small book under one "sit bone" to lift your perineum slightly. One businessman used a leather folder with two tablets. He left it on his chair prior to sitting and tucked it under one sit bone. The second folder contained information for his meeting).
Stand to use your computer, read the paper, or does office work.

DO NOT SIT!

Buy a simple fold-down metal wall shelf to support your computer keyboard.
Lie down as much as possible to watch TV, read, etc.
At work, lie down on your lunch hour or breaks.
Use an extension handle to pick up clothes and objects from the floor.

DO NOT DO THESE ACTIVITIES!!!

  1. Squatting
  2. Lifting
  3. Yoga
  4. Cycling
  5. Bowling
  6. Skiing
  7. Piriformis stretches
  8. Ab crunches
  9. Sit-ups
  10. Gym workouts
  11. Leg presses
  12. Jogging
  13. Stair master
  14. Pilate
  15. Spinning
  16. Ellipse
  17. Step aerobics
  18. Exercise cycle
  19. Avoid climbing stairs.  Use an elevator or escalator whenever possible.
 
Results of self-care treatment

We have demonstrated statistically significant improvements in pain and bladder symptoms. As noted in "Abstracts" and "Importance of Questionnaires" on our website.

From the Prostatitis Foundation website – 2003:

“I suffered from chronic prostatitis for many years and went through all the usual treatments with no effect at all. Then I happened to run across an article by Dr. Stanley J. Antolak, Department of Urology, at the Mayo Clinic.  I am now convinced that my disease was biomechanical in nature and not organic.  I have been pain free for a while now and I suggest that others may benefit from the simple, free, treatment advocated by Dr. Antolak. The highlights of the article are:

  1. Ninety percent of men with prostatitis are considered to have Category III, non-bacterial prostatitis.
  2. Pudendal nerve entrapment (PNE) is frequently identified as the basis for the symptoms of “prostatitis.”
  3. Treatment consists, foremost of perineal hyper-protection. Punctilious avoidance of sitting and cycling and use of special seating pads, which spare the perineum from pressure, is often curative.  I hope this information will prove useful to other sufferers.”

From past patients:

Today is my third week back to work.  As of May 8th or 9th I have NO PAIN. I can’t believe it. I wake in the morning and expect to feel that old feeling and it’s not there. I am really delighted.
  • Rosemary
After 10 years of pain and 5 years of irritable bladder the self-care program has relieved my problems almost completely.  I have no pain. I can sit in a car or plane for over 3 hours.  I can eat at restaurants and drink any type of juice without irritating my bladder.  I do not have pain during or after intercourse.  I want to reduce the amitriptyline to 5 mg at bed time.
  • Teresa
“I drove from Michigan to Daytona Beach in December and returned in February.  I had episodes of tailbone pain during the trip both ways.  It lasted for 1-2 days both ways. I did not have bladder/prostate pain or rectal pain with the travel. I did use the special seat consistently during the driving.  I still take a ½ of a 25mg amitriptyline pill every night.
I feel that I have more penile sensitivity and ejaculate without pain.
Life is good. This treatment has changed my life.
  • Don M.
On June 27th of this year I visited you regarding chronic prostatitis. Since our visit I have followed your three suggestions: 1. Stopped riding my Air Dyne cycle. 2. Stopped lifting weights.  3. Purchased and used a gardener’s pad with the center section removed.  I’ve had zero pain in the prostate area. It’s wonderful not to be taking Bactrim and to be pain free.
  • Mike

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  Pudendal Nerve Block Injections
Posted by: mark - 08-14-2016, 05:01 PM - Forum: Treatments - No Replies

Nerve Injections for Pudendal Neuralgia - By Stanley Antolak, MD

Introduction

The purpose of these injections is to relieve the pain caused by the irritation of your pudendal nerve. The nerve is deep in your buttocks and sometimes may rub against a ligament or be squeezed between two ligaments. Sometimes inflammation around the nerve will compress the nerve and cause pain. There can be other nerve problems in addition to the pain. There could be bladder problems (irritability, difficulty starting or emptying). There can be sexual problems in both sexes (pain, dryness, erection problems, reduced sensation and so forth). Sometimes there are rectal problems including difficulty with passage, painful and/or frequent bowel movements.

A series of three injections of medication into the area around the nerve may provide long-term relief of pain. The goal is to interrupt the pain mechanisms and to stop the process of nerve irritation. One medication acts as a local anesthetic, like you would receive for dental work. This medication "settles" the nerve signals to the spinal cord. The anesthetic response is almost immediate and may last for a few to several hours. The pain relief occasionally lasts for one to two days and rarely for one to two weeks.

The second medication is a steroid that helps reduce swelling and inflammation. It may, in some cases, provide more space around the nerve by decreasing the amount of fat. It is the same medication used in painful joints. Doctors use these two medicines to treat carpal tunnel syndrome. The degree and duration of pain relief you experience after these injections will help guide decisions regarding future treatment.

Injections can reduce or totally eliminate the pain. Sometimes a fourth injection will be recommended when the patient is having good but not complete relief.

Measuring your pain

Pain scores and urologic scores (if necessary) will be completed and monitored throughout your treatment.

About your procedure

The injections are usually given in both buttocks. Only one side will be injected if pain exists only on that side. A series of three injections are given at four week intervals to allow time for the steroid medication to work before the next injection is given.

Dr. Antolak will perform the first two injections using a fluoroscope for guidance. No special preparation is needed prior to the procedure. You should be able to drive after your procedure. It would be wise to have a companion along in case one or both legs are "rubbery" after the injections. A follow-up appointment is scheduled for two hours after your injection.

The third injection in the series is deeper into the pelvis and requires special imaging to guide the placement of the medicine into the Alcock canal. A radiologist will perform this injection and use a CT scanning unit for guidance. Again, a follow-up appointment is scheduled for two hours after your injection.

During your injection procedure

Please arrive early for check in. You will then change into a gown and be escorted into a room containing the fluoroscope unit. This allows Dr. Antolak to see the physical landmarks to assist in identification of the nerve pathway. The skin will be cleansed with Betasept (a surgical soap), and you will receive an injection of a local anesthetic to numb the area and the muscle through which the needle will pass.

The medication will be injected into the pathway of the nerve between two ligaments where the most benefit will occur. You will be asked to tell us when the needle is causing complaints similar to the ones you usually have. This helps us position the needle near the nerve for the best placement of the medicines. You may have tingling or other sensations in the same place you have been having your long term pain. You may experience pain if a nerve is "touched" during the injection, however, this is rare. We always check for bleeding. We cannot inject the medicines if the needle causes any bleeding.

We will check to see how you are feeling after the injection. Tell the staff if you experience any sweating or weakness caused by the stress of the procedure. Most people are surprised at the ease of the injection procedure.
You must be examined after the injection to determine the immediate response to the local anesthesia. We like to do this about two hours after the injection.

After your procedure

The following side-effects may last from one to six hours and are normal:

  • Discomfort at the injection site.
  • Numbness in your anal and genital area.
  • A bowel movement may feel different since a branch of the nerve goes to the rectum.
  • Rarely, passing of gas without awareness.
  • Rarely, dribbling of urine at the end of the stream.
Short-term muscle weakness in your legs or numbness in the back of the thigh may be caused by the local anesthesia. Most people are able to drive after the procedure. However, if there is "drifting" of the anesthesia to the sciatic nerve, you should wait until there is no longer any muscle weakness. A person occasionally requires a wheel chair for one to two hours. It would be best if a family member or friend accompany you in case you need driving assistance.

The initial anesthetic will wear off after a few hours. It sometimes lasts a day, or up to three or four days, which is a wonderful response when it occurs. The second medication will begin to provide long-term relief after seven to ten days. About 65% of people experience improvement after three injections. Often, no further treatment is necessary. Occasionally a fourth injection is offered. Surgical treatment may be needed if the injections do not provide lasting relief. The ongoing pain scores allow comparison to your original pain levels.

Complications

Complications with pudendal nerve injections are rare. However, they may include the following:
  • Rarely is there an allergic response of hives, etc., or similar problems from the local anesthetic.
  • Some people have noticed a flushing problem from the steroid medications. Bruising may occur at the injection sites. You may choose to stop aspirin for one week prior to the injections.
  • Only one or two injections out of many hundreds caused some bleeding around the nerve. That is like any other bruise and will eventually heal.
  • There may be an increase in pain in the area you usually have pain. It can be bothersome. This may last a few days until the second medication begins to work.
  • The anesthetic medicine occasionally "drifts" to the sciatic nerve. Some people have numbness in the leg. Others not a "rubber-leg" with muscles that do not work well for one to four hours. Rarely, a wheel chair is necessary for transport. You should be able to drive after three to four hours.
  • Steroid medication can cause emotional stress for a few days in some people.
  • Bone changes are seen with different doses and long term steroid treatment. We have not seen one in more than 3,000 injections.
  • Ulcers have never been reported after these injections but have occurred from other steroid use.
  • Mild acne eruption has been noted by some patients.
  • Menstrual changes are rare but may occur.
Please call MAPS Pain Clinics (763) 537-6000 if you have any questions about your injections or the information in this handout. We will try to guide you to some comfort in understanding the issues involved.
 

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  Pudendal Nerve Decompression Surgery
Posted by: mark - 08-14-2016, 04:57 PM - Forum: Treatments - No Replies

Pudendal Nerve Decompression - By Stanley Antolak, MD

A Brief Explanation

Over the past 10+ years about 30% of patients with pudendal neuropathy required surgical decompression when the nerve protection program (self-care) and the series of pudendal nerve blocks do not relieve pelvic pain due to pudendal nerve irritation and compression. Surgery can be very effective. Some patients have no pudendal pain after surgery. More often, the pain resolves over many months. The French neurosurgeon who developed the procedure noted that 9-24 months are needed for pain relief. Pain may require additional treatments after surgery. The surgeon can only decompress the nerve whereas time and Mother Nature heal it. I have decompressed the nerves in patients aged 22 to 81 years with good success that is measured using pain scores over as long as 5 years.

DESCRIPTION OF PROCEDURE

You will receive general anesthesia and then a catheter will be placed into the bladder. You will be turned over to lie on your stomach. An incision will be made at an angle approximately where a back trouser pocket would be. One incision is made on each side. We spread the muscles and open a ligament along its center (much like unzipping a zipper). We identify the nerve in front of that ligament. We follow the nerve up to where it is compressed along its pathway. We divide an inner ligament that is compressing the nerve. We follow the nerve deep into the pelvis opening the structure called the Alcock canal (pudendal canal).

After freeing the nerve from all constricting tissues, it is positioned into a new pathway without tension on the nerve. We protect the nerve with a chemical film that hopefully will prevent adhesions so that the nerve will slide smoothly through the tissues as you walk, etc. At the end of the procedure, a mixture of local anesthetics and steroids medications are placed around each nerve to assist healing and pain control. We leave a drain tube inside that would drain any tissue fluid for the first 24 to 36 hours. After that is removed, you can have a shower. Stitches are placed under the skin and Steristrips keep the edges together.

SUCCESS RATES OF SURGERY

Around the world, about 60-70% of patients having this surgery are cured or improved; i.e. take minimal or no medications. That means that about 30% fail. Often those failures are predictable ahead of time because they do poorly with injections, have long-standing, serious pain issues, and often had multiple previous pelvic operations.

HOSPITAL STAY

Hospital stays is usually two nights. We ask out-of-town patients to stay locally for 2 additional days. You may walk and stand as much as possible before or during plane flights. French surgical pioneers noted that HEALING to a pain-free state is usually between 9 and 24 months. Two of my Mayo Clinic patients, operated in France in 2000, required 4 and 5 years to be completely pain free. My personal surgical data from 2004 and 2005 indicate that the averages of patient pain scores become normal between 18 to 24 months.

FOLLOW UP

You may walk as much as you choose without causing pain (some people overdo it). You will do gliding exercises for 2 years. We try to see local patients after one month. Out-of-state patients can contact Dr. Antolak at one month intervals for the first three months.

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Paul is preparing to leave Tajikistan, while thinking back on his adolescent years. His childhood, his mother's madness, the parties, the trip to the USSR where he lost his virginity, the friend who betrayed him and the love of his life.

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From time to time you really want a cool motion picture to download. :) You begin to seek it in google and get tons no good web sites that can not give you what you want. But today you gonna get it. [b]My Golden Days[/b] motion picture was made in 2015 and it belongs to Drama genres. Dynamic sence of My Golden Days film gonna make you feel good while watching it with your best friends. Actors like Kheifets Gregory, Lou Roy-Lecollinet, Irina Vavilova, Françoise Lebrun, Elyot Milshtein, Quentin Dolmaire, Lily Taieb, Mathieu Amalric, Raphaël Cohen, Dinara Drukarova, Théo Fernandez, Pierre Andrau, Clémence Le Gall, Olivier Rabourdin, Cécile Garcia-Fogel make this Drama film exclusive. 100%, My Golden Days is one of the best film to download in Drama genre in 2015. Movie time is 123 min. Film rating is good: 5.0. Watch and download [b]My Golden Days[/b] film online.

Paul is preparing to leave Tajikistan, while thinking back on his adolescent years. His childhood, his mother's madness, the parties, the trip to the USSR where he lost his virginity, the friend who betrayed him and the love of his life.



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