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Just had Bi-Lateral Pulsed RF Ablation of the Pudendal Nerves


#1

I appreciate some of the offline counsel i received on going through with this procedure. Time will tell, but clearly there’s a greater risk to doing a procedure to a motor and sensory nerve like the pudendal than a purely sensory nerve like the GF. I went ahead nonetheless. My read, however, and consult with Dr. Attaman in Seattle, is that pulsed RF isn’t truly ablation as in the conventional sense of RF or cryo-ablation. That could be splitting hairs by its proponents, of course, but my doc and Dr. Attaman (a pudendal guru) both state that they would never use conventional RF or cryo on the pudendal, only pulsed.

All in all, the procedure is no big deal. It took longer than past injections because (a) it was bilateral and (b) it’s a slower process as the machine pulses at fixed intervals. It’s delivered into a fatty area of the butt check so, as you can imagine, I was on my stomach. If you’ve ever gotten a shot in your ass, that’s how it feels, and that achy feeling in both ass cheeks lingered for about 8 hours. We’ve all experienced WAY worse.

They gave me only half the sedation as with anesthetic and steroidal pain injections. Not sure why, but my gage is that the anesthetic and steroidal injections hurt more due to the injection of fluid. I think I was in recovery for 15 minutes.

The doc did this under some imaging guidance though I’m not sure if it was CT, fluoroscopy, etc.

My perineal and pudendal canal pain is down today I think from the anesthetic injected or just the general sedation. Plus, I laid low today. They say it takes 2-4 weeks for the lesions to form that block the pain sensations, so time will tell.

Once again, i have to give props to the Cleveland Clinic. My hometown Browns may suck more than any NFL team in history, but I was able to get a procedure done 4 miles from my house at the CC that many on the Pudendal Hope forum travel hundreds or thousands of miles to get.


#2

Hello!
Can you give me a layman’s description of the procedure you had done? :slight_smile: How are you feeling now? What symptoms did you have as part of the post-vasectomy pain condition? Do you feel like the procedure was a success?

I’m always researching for my husband. We’re almost 4 years out from the original vasectomy, 3 years out from the unsuccessful reversal, and we’ve exhausted the traditional treatment methods (anti-depressants, opioids, nerve blockers, cord block, experimental nerve treatment, cannabis in multiple forms, good old Advil…no luck with anything).

I’ve never heard of the procedure you described and a curious about it!

Thanks so much!
Jenn/Imthemissus


#3

No problem. My story is a bit complicated and I’m not sure how much or if it applies to the average guy (victim) on the forum. In retrospect, I sometimes wonder if the vasectomy played a part at all. I’m guessing it did, but it didn’t manifest itself like the majority here.

March, 2005 - Vasectomy, closed-end w/scalpel. Normal recovery. Back to regular activity in 3 weeks.

October, 2005 - Developed massive groin pain following last bike ride of the year. Radiated into scrotum but was regional. Remember distinctly three statements: (1) felt like a steel brush was being pushed into my inguinal canals, esp. left, and around the scrotum; (2) felt like I was sitting on a tennis ball; and, (3) felt like a hand was reach up through my anus and grabbing/squeezing my scrotum from behind. Note that scrotal pain itself was overshadowed by other pains.

Visited original urologist who was useless and dismissive. Saw another who admitted PVP existed. Sent me to Pain Mgt. who prescribed gabapentin. Same pattern as everyone here.

Feb, 2006 - Found that another uro in Cleveland had published a lot on PVPS and saw him. Great man. Suggested injections and, if they failed, reversal. Did notice I had granulomas on both vas tips. Found elevated PSA, too.

June, 2006 - Reversal.

Nov, 2006 - Pain-free for about 2 years. Continued normal activity included more than simple recreational but not competitive bicycling Spring thru Fall.

Nov, 2008 - Relapse of pain. Biggest problem was sitting. Six months of gabapentin and Celebrex.

May, 2009 - Pain-free for about 7 years.

April, 2016 - Pain started again after first bike ride of the year (see pattern here). Most notable symptom was sharp, stinging pain top of testicle but soon became regional.

Aug, 2016 - Ilioinguinal block - no result

Notably moved to perineum. Learned about pudendal pain from Pain Mgt. Never heard of pudendal nerve until now.

Nov, 2016 - Jan 2017 - Two pudendal blocks plus pelvic PT. Really helped with perineal pain, but started feeling scrotal pain AGAIN.

Apr 2017 - Spermatic cord block with Dr. P. in Orlando.

Pudendal and cord blocks knocked pain down 50-75% thru mid-July 2016. Even got back into bicycling (big mistake but, hey, it was summer). All pain (scrotal and perineal) came back

Aug 2017 - GF nerve block with pain mgt. Scrotal pain disappeared.

Oct 2017 - Pulsed RF ablation of GF nerve. Procedure is essentially the same as a nerve block other than the needle is solid and delivers pulsed of heat designed to “scramble” the pain signal on the nerve. Scrotal pain still gone.

Yesterday - Pulsed RF ablation of left and right pudendal nerves. Again, very similar to pudendal nerve blocks. Lay on stomach, insert needles in your buttocks, and wait for the machine to run its course. Other than occasional pinch, didn’t feel anything during the procedure.

Results from ablation take 2-4 weeks to develop, so I won’t know for a few weeks whether this worked.

Hope that helps. As you can see, my situation is a bit different than a lot of guys here. It’s been intermittent but long-term, and it didn’t start immediately following the vasectomy itself.

Some docs are sure the vasectomy caused this, some believe it’s from bicycling, some say both, some believe it could be referred from my lower back. As background, I had lumbar spinal fusion in December, 2012 during one of my remissions from groin pain. Looking at the nerves in the pelvis, I don’t think I’ll ever know for sure, and I’m not sure it matters at this point.


#4

@raising4girls I just want to say how much I appreciate your research, your attention to detail, and your patience documenting your history for all of us. This will be invaluable to many others down the road as long as this forum exists.


#5

Glad to help. It’s therapeutic for me, as well, but I do hope it helps others.


#6

I think the last few days I would rather be a Browns than Ravens fan. We are creating our own factory of sadness in Baltimore. Better to have no hope or incredibly low expectations…don’t get your heart ripped out that way.

Glad you are posting about this! It will be interesting to see if it works for you. I am sitting at work with a GF block and it feels pretty good. Better. I have some numbness but it’s really not that bad. I plan on trying botox with Parekattil and am going to stay with this doctor. He chastised me a bit for not trying Lyrica like he prescribed. He is big into medication in addition to procedures. I’ll be honest, I am not crazy about taking Lyrica, but I will give it a try if he wants me to.

Let us know how things progress. The Browns were competitive this year with the Steelers and Ravens and they are about to get a crapload of first round draft picks. I don’t see how they can not get better next year.


#7

I was told gabapentin (Neurontin) is 98% the same chemistry as Lyrica and that’s why docs will usually prescribe gaba since it’s generic and cheaper. Always wondered if there was something new-and-improved about Lyrica worth trying.

My uro told me his scrotal pain focused patients do better with gaba and amitryptyline and his pelvic pain / pudendal patients do better with amitryptyline. Go figure. He’s pretty well respected (on a lot of panels with Parekatill) so who am I to argue.

Good luck with the GF block. Hopefully we can get some relief, get these nerves turned off. From a purely “does it hurt” perspective, I can attest that the pulsed RF ablation done under light sedation is fairly routine. Yeah, I know, risk of death, etc. disclaimer for all procedures, but our group is past that and looking for answers and, speaking for myself, I’m willing to take a little risk. Reversal, cord denervation, resectioning of nerves, etc.? Those are another story. Major surgeries and need some comfort that there’s a good likelihood of success.

I know there are mixed views on the forum about cryo-ablation. I don’t know enough to comment other than my Pain Mgt. doc said “it used to be in vogue for nerve pain” implying that it’s a bit old school. At the same time, Dr. P. seems to believe in it, and I trust him, so what the hell do I know. For now, partly due to proximity, I’m going to let the Cleveland Clinic fire their bullets. I’ve really grown to respect the guy I’m working with.


#8

I don’t really know what’s going on but I have had such acute painful burning up high on the left that I actually started taking doxycycline. For the first time since my reversal I’ve had some issues with frequency/urgency. Makes me wonder about my patency on the left. Pain has been baaaad. I feel like I am being stabbed. Makes me wonder what the fuck is going on. Is it something like a hernia under the cord? No clue but my pain is not just in one location. As I’ve told my wife, I never should have let anyone fuck with that part of my body. I always knew it was a bad idea and said so the first time it came up “I’m not comfortable letting someone cut me down there.”. How many guys have that honest feeling but cave due to pressure and incomplete information that omits the worst case scenarios about vasectomy?


#9

Shit. Thought you might be on the mend.
I had a rough patch a few days after my GF block. Might be the nerve fighting back. Happens often after anesthetic wears off before steroid kicks in.


#10

I actually think this may be in infection because of the issues with having to pee a lot too. it’s only the second time in 5 years I’ve had to deal with it. After reversal that sort of issue pretty much disappeared completely like magic. I am going to take the doxy til it’s gone, it was an old script that was laying around, and see if the urgency thing goes away. My big fear is that this is related to patency on the left and will never resolve if that side has closed off.


#11

Fingers crossed and knocking on wood, but I’ve strung together 3 very good days Sunday, yesterday, and today. Very low pain levels, maybe down 75-80%. Could be the pudendal ablation, could be that I added 25mg of amitriptyline, could be the wine I had Friday night, but I noticed the drop in pain during dinner out with my wife Friday. Either way, it’s amazing how my outlook on life changed with just this 3-day respite.


#12

Good to hear. What can you tell me about your procedure and what part of that nerve branch it targeted. Same with gf ablation.

This is good news. While I would miss you I hope you soon get to the point where this place is a bad memory.

Thanks.


#13

One week since I started feeling relief, and it’s been sustained. Best week in a long time, I’m pleased to report. Got a little sore following a couple of walks on a treadmill and elliptical, but it went away after some rest. I’ve been able to sustain a tolerable, low-level of pain that’s better described as discomfort, not pain, and not 24/7. Very intermittent.

The procedure appears to be pretty far back where the pudendal exits the Alcock’s canal. No where near the perineum. My best guess (with limited anatomical knowledge) is that he zapped the pudendal nerves before they branch to the perineum or scrotum.


#14

Keep the good news coming! Do you know if anyone does the Pulsed RF Ablation at Johns Hopkins?


#15

Dr. Jason Attaman here. I’d like to confirm that pulsed radiofrequency treatment is non-destructive; the nerve is not harmed. There is a another use of radiofrequency energy called continuous radiofrequency ablation/neurotomy, and that is destructive to the nerve. The difference is in the temperature the needle tip is allowed to rise to. Temp is kept to 42 deg C or lower at all times for pulsed radiofrequency treatment. This is a safe temperature for the nerve. Above 45 deg C the nerve is damaged aka ablated due to heat. Typically we use 80-90 deg C for full-bore continuous radiofrequency ablation/neurotomy. It is true that there can be a motor (muscle control) component to the pudendal nerve to the anal sphincter. It appears to be inconsistent but present in a good number of people. Obviously weakening the anal sphincter permanently would be bad; hence we rarely use continuous radiofrequency ablation/neurotomy on the pudendal nerve for fear of causing incontinence. It can be rarely used in malignant pain syndromes such as pelvic cancer pain in which the patient has a short life-expectancy and comfort care trumps function. Hope this is helpful. I do not check this forum often and cannot offer specific medical advice anonymously. All the best, Dr. Attaman


#16

Thank you for your contribution and explanation here.


#17

Thanks Dr Attaman.

We appreciate you taking time to visit and share with us.

It means a lot.


#18

Does pulsed radio cause any tissue damage around the nerve? I am wondering if this is a good option to try before reversal if you have nerve pain. If this causes tissue damage it may impact reversal if you do it later.


#19

Funny about cycling raising girls, as my issues started with cycling too. Have you had semen checked to see if reversal worked?


#20

I didn’t have any SA’s right after the reversal in 2006 because I attained pain-free status about 5 months post-reversal. Then, we unexpectedly welcomed a 4th daughter, hence my user name, a year later, so, again, why bother? In late 2008, however, I suffered a pain relapse that lasted about 6 months. During that period, I had 3 SAs. One was low like 7MM, but others were 47MM and 60MM, so doc assumed reversal was still good by early/mid 2009.

Had an SA when this bout started back in 2016. Registered 10MM. Doc’s concluded that I was still OK, but I recognize one side could be kicking out all 10MM. I definitely fear that my pain side (left side) is closed up. The problem is that no one wants to test one side’s patency. It apparently requires injecting dye into the vas and the needle itself creates a risk of scar tissue forming and closing up a potentially open vas.

Seems like the uro’s and insurance want to force us to try denervation as a first surgical option. I’m going to see if another spermatic cord block gets rid of the pain like last year’s block. Also going to look into neurectomy and the diagnostic nerve blocks they do beforehand.

I think a re-do reversal on the left/painful side is something I could only do if neurectomy or denervation don’t work. Will talk it over with Dr. P. after my injection. Hard to figure out if it’d help.