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.
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.