A 59 year-old male, traveling from out of state, presented here to SPHH with the chief complaint of  "penis pain" he's had for 14 years. 

He's already seen physicians at the top  medical centers all over the U.S. He's had pudendal nerve decompression surgery (...because he was told "MAYBE" he had pudendal nerve entrapment. This is NOT the same as pudendal neuralgia; and surgery is a last resort IF the right differentials and treatments are tried), numerous other procedures such as pudenda nerve blocks, pulsed radio frequency ablation and cryoablation to the pudendal nerves. He's had many different types of imaging tests - pelvic MRI and spine MRI. He's tried all sorts of medications. Nothing helped with his discomfort, or if it has, it was fleeting for a few days. Every place he went, they tried their best treat for what was considered a "pudendal issue." Based on his symptoms, I was glad to know he found professionals who even knew about the pudendal nerve and types of treatments. This is not always the case. Often, patients go for years hearing "I deal with the back and hips, not  that  region" or "It must just be in your head, stop worrying about it so much" and so forth. The issue in his case is that it appears that not all of the differentials were properly considered or assessed. THIS is the key. 

When I completed a long, detailed patient history discussion and listened to his story, I realized this is a patient who has been possibly misdiagnosed. The pain is at the pubic region and  base of his penis. He also doesn't like to eat meals during the day because his lower abdomen feels "bloated" and his pain gets worse. He appeared to have an umbilical hernia (at the belly button).  When I pressed on it, that seemed to  reproduce some of his  penile pain.  I could decrease his pain by closing the gap at his  belly button  AND if I lifted his  abdomen  up  or  put a lot of pressure  in an upward direction on his  sit bone area  and perineum.  Typically,  patients with pudendal neuralgia  feel worse with compression  or any type of pressure with sitting. He feels better sitting on a very hard surface and worse on  soft surfaces.  He's also had previous inguinal hernia surgery.

Since our initial visit , he's had a  minor surgery to correct the umbilical hernia and already had relief of some of the symptoms. I placed him on an exercise program to facilitate  improved movement,  better breathing, and  activating  the  "core" muscles in  a way that was supportive vs. too much lower abdominal pressure.  He's also started  a pelvic floor strengthening and coordination program  (usually this is not recommend  with pudendal issues). 

Any guesses what the  likely  correct diagnosis is for this patient?  I helped the patient find the right healthcare professionals for a "virtual team" and we are continuing  treatment  and care  for what appears to be some form of an   ilioinguinal, iliohypogastric and /or genitofemoral  neuralgia or entrapment (and ruling out an enterocele and/or vascular components).  Stay tuned for updates! 

All of the usual treatments  for pudendal nerve, even the  conservative pelvic physical therapy treatments  are not optimal. In fact,  he  does better  with a program for  strengthening and coordinating  better control of  "core" muscles and engaging the pelvic floor and glutes.  

**  This is merely one case. Just remember that each and every case is so different and the  assessment and plan must be individualized. I find that so often  people go online and see similar symptoms  and run out and have  unnecessary procedures. Find someone who  understands  this. Most  physicians, nurses, and physical therapists do not get specialized training in pelvic neuralgias and pelvic pain .  ~ Tracy Sher, MPT, CSCS

Tracy Sher, MPT, CSCS and Loretta J. Robertson , MS , PT  teach  a  pudendal neuralgia and differential pelvic pain course for MDs and Physical Therapists  internationally. The  next courses are in Salt Lake City , April 18/19, 2015 and Orlando May 30/31, 2015.

Check out  our article : The 5 Things We Wish You Knew About Pudendal Neuralgia. 

Here are a few more tips regarding the hysterectomy procedure and what we see after the surgery. Did you know that we treat patients after all types of GYN surgeries (after 6-8 weeks post-op and with surgeon clearance) to ensure the best recovery and postoperative outcomes? 

Additional Tips:
1. If you wake up from a hysterectomy (other other GYN) surgery with a NEW, severe pain that does not go away, this is a red flag. In rare cases, there can be surgical materials (sutures, staples, mesh, etc) accidentally placed through or near nerves. This is something that needs to be addressed - possibly even with another surgery to remove it. 
2. If you notice significant leg numbness or weakness after surgery, you may have had a lot of  compression or stretch on a nerve during the surgical positioning. A pelvic PT can help with this recovery (and time).
3. There are new surgical tools being invented right now to possibly decrease the "morcellation effect." One of the leading physicians for this is Dr. Hoyte. If you have concerns, you may want to read more or wait until the new safeguards are implemented (still needs FDA approval). http://www.tampabay.com/news/health/hospitals-adjust-hysterectomy-surgeries-after-fda-warning/2183404

If you have any more questions, feel free to leave a comment or contact us!