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Pudendal Nerve Pain - ultrasonic guided injection & surgery


#1

Hello,
quick recap: vasectomy 3.25 months ago; pain during surgery and ever since. 3 weeks with large hematoma, maybe damaging the pudendal nerve (as pointed out as a possibility in a post by Aschiro (Pelvic Floor/Bulbospongiosus Pain). Now the pain is spreading to the lower abdomen (hot burning sensation 24/7), where the bladder or prostate are, my best guess. Pain is aggravated by ejaculations or lifting only the slightest items.
Now, the interesting piece: it is dependent on position.
As said here https://en.wikipedia.org/wiki/Pudendal_nerve_entrapment:
“Anesthesiologist John S. McDonald of UCLA reports that sitting pain relieved by standing or sitting on a toilet seat is the most reliable diagnostic parameter”.
Well that exactly describes me.
So I wonder now if my pain is mostly pain nerve, maybe there is also some damage from cutting the vas in the first place - don’t know - but for sure my pelvic is cramped up and I really believe this could be the source of the problem.
Now, I wonder what the treatment options are.
I am trying pelvic floor stretching exercise already, but the pain has flared up since I do that, so I am not sure whether I am doing something wrong or if it’s caused by something else.
Then, I stumbled across high resolution ultrasonic imaging to be able to locate the nerve. Apparently, also the transmission time of the signal can be measured along a nerve, indicating if it is damaged, but not where or why, followed by a block under ultrasonic guidance and possibly surgery.
I wonder if anyone has had similar problems and tried anything remotely related.


#2

Juno - I had some similar problems during this bout that started for me 2-1/2 years ago. In fact, from Sept '16 - Feb '17 and from Oct '17 - Dec '17, my perineal pain was worse than my scrotal pain.

I went through 2 rounds of pelvic PT which included stretches and external and internal massage of the pelvic floor muscles. I also had 2 blocks of the pudendal nerve and 1 pulsed RF ablation of the pudendal nerve. These treatments have kept the perineal pain successfully at bay since last December.

I believe I was suffering from classic pelvic floor tension, not true pudendal neuralgia. Your case may be different, not sure, but certainly worth exploring these non-surgical treatments.


#3

Did any type of stretching exercises ever made it worse for you?
Can it be that at the beginning it actually increases pain before the pain gest less?
I really thought I had something to hang on to, but now I am a little hesitant with the stretching exercise because the pain has increased.
I am supposed to stretch some muscles, which I general brings a relief while I am doing at and for a short period afterwards; I am also supposed to tense my rectum for 3-4 seconds and then let loose. When I do that, I definitely feel that it hurts, so I stopped doing that and only do the stretching.


#4

How are you doing lately @raising4girls?


#5

@juno I would not do the Kegal excercises of rectum if your pain is a result of muscle tightness but concentrate on the other stretches internal and external to relax the muscles. Kegal could make things worse


#6

Yes, I did a bunch of stretches, no clenching of my butt muscles though. I had to do fake “voiding” where I’d sit on the toilet and relax my muscles as if I was pooping and peeing (sorry, I just finished 2 glasses of wine and couldn’t think of the medically correct terms).


#7

I’m going to post an update. Ups and downs.


#8

No worries, I got you. Hope it was a good wine :slight_smile:


#9

I found a doctor claiming he can “see” nerves when doing high resolution ultrasonic scans, and use then diagnostic blocks to determine the suspected nerve before any more serious treatment.
Did you do something like that?


#10

Do people get ultrasound guided injections when talking about nerve blocks (no matter where the location)?
I got my bupovacaine injection without any imagining guidance. Just took out the needle and went for it. I really regret having done it because it was so terribly painful. And it did not help.
What are the “typical” nerves involved in nerve pain?
So far, my - limited - understanding is there is nerves running along the spermatic chord that was cut during the vas, and then there is the branches of the pudendal nerve at the back of the testicles that might have been damaged due to the large hematoma that I had for 3 weeks after surgery.


#11

I think some do, some don’t when it comes to US guided injections. I’ve had some with, some without. On one with Pain Mgt, they inserted a probe that beeped more and more frequently as the needle approached the nerve. I don’t quite understand it as I was under twilight sedation. And, with Dr. P., I’ve been under general anesthesia, so I’m not sure if he uses US or not.

From a neuropathic pain perspective, it seems that the pudendal, II/IH, and GF innervate the scrotum coming from different segments of the spine. I’ve seen mentioned of sympathatic or parasympathetic scrotal nerves, as well, but I’m not sure if they are branches of the others I mentioned or totally different.


#12

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#13

Thanks, I found a radiologist who does this high resolution US and injections.
He advised to get an MRI first, followed by a high resolution US to possibly find the culprit for my pain. The radiologist who does this helped me organize it (have all in 1 day in 2 weeks) says he needs the MRI first and then will use US to guide an injection. I consulted another pain specialist meanwhile and mentioned that; he thought it’s an idea worthwhile exploring, and this pain specialist actually recommended Botox injections - any experience or thoughts on that?
I will also see a highly specialized surgeon for peripheral nerves, recommend by the radiologist, on the very same day to discuss my options should the injection bring any relief. I am not sure what to expect; of course, surgery is not what I want, but he might have some ideas what to do (RF ablation? I understood, this is not “surgery” in the sense of cutting). Looking forward to get this done, even if it turns out there is nothing obviously wrong with me based on MRI and ultrasound.


#14

Sounds reasonable. I was also looking into MRI but was unable to convince the urologists.
The downside of free healthcare is you cannot get them to do anything they think is going to be a waste of money…
I could not even pay myself since I still needed a prescription from a MD.