930 - A Pain in the Perineum! Chronic Pelvic Floor Pain Resolved with Bilateral Pudendal Nerve Blocks

Case Diagnosis: Bilateral Pudendal Neuralgia following Total Prostatectomy

Case Description: An 84M with history of prostate cancer s/p total prostatectomy in 2001 was evaluated for severe pelvic floor and penile pain present immediately following prostatectomy persistenting ever since. Nerve conduction study completed 8 years prior demonstrated evidence of bilateral pudendal neuralgia. On the day of the initial PM&R evaluation, he reported his pain was constant, sharp increasing while lying down as well as when first waking. Pain is further described as a sensation of "sitting on a baseball" and hypersensitivity negatively affecting his quality of life. His pain improves with short walks and reducing abdominal pressure such as with bowel movements. He has undergone several rounds of pelvic floor therapy as recently as 12/2021. Additionally, he takes Cymbalta with slight improvement of symptoms. He underwent fluoroscopically guided bilateral pudendal nerve blocks at Alcock's canal with >90% relief persisting for >9 months.

Discussions: In this 84M with a 20+ year history of pelvic floor pain following prostatectomy, fluoroscopically guided injections of bilateral pudendal nerves, after failing to meaningfully improve with conservative treatment, has provided the difference of meaningful relief restoring quality of life lost for far too long. Though women experience pudendal neuralgia at more than twice the rate of males,the total estimated incidence of up to 1 in 100 in the general population means physiatrists should be familiar with this common etiology of chronic pelvic floor pain. Due to infamiliarity, this diagnosis frequently goes undiagnosed or improperly treated for years leading to patient frustration and loss of quality of life given in the important function of this nerve including motor, sensory, and autonomic functions.

Conclusions: Physiatrists can benefit their patients by understanding how to properly diagnose pudendal neuralgia, progress patients through various conservative treatments, and be aware of effective interventions such as pudendal nerve blocks.