Pelvic Pain Treatment in Delhi - Removemypain

1. Pelvic Pain Treatment in Delhi, Pelvic Pain Treatment in Delhi, Dr.Amod Manocha is The Best pain Dr.Amod Manocha is The Best pain specialist in Delhi specialist in Delhi - - Removemypain Removemypain Pel Pelvic pain vic pain Pudendal Neuralgia/ Neuropathy (PN) Pudendal nerve is one of the main nerves of the pelvis, with one nerve on each side. It runs from the lower back, along the pelvic floor to supply the genitals, lower part of rectum, and perineum (area between the sit bones). This nerve is closely involved with urinary and bowel functions. Pudendal neuralgia is a condition related to irritation or damage of pudendal nerve, which presents as pain or altered sensation in the genital, rectal region or deep inside the pelvis. It is more common in women and is also addressed as cyclist syndrome, Alcock’s canal syndrome and pudendal nerve entrapment. Despite the significant advances in the evaluation and management of chronic pelvic pain, it often goes unrecognised. It can be associated with other conditions such as Chronic Pelvic Pain Syndrome, dysfunctional voiding, painful bladder syndrome, chronic prostatitis etc. Pudendal Neuralgia - Patient Information Leaflet Signs and symptoms of Pudendal Neuralgia Burning, shooting, electric shock like, crushing, aching, prickling or itching sensation in the areas of pelvis supplied by the pudendal nerve. Pain worse on sitting or exercising and resolves when lying flat (as during the night) or standing Better when sitting on the toilet seat

2. Intermittent initially but can change to a constant pain with time It can radiate (travel) to buttocks (around ischial spines) and legs (inner thigh), feet Other symptom which may be present include Other symptom which may be present include Urge to go to the toilet often (urinary frequency) or a feeling of a bladder infection, Pain on passing urine Increased sensitivity in pelvic area Numbness, pins and needles sensation in pelvis Pain during sex or sexual arousal or orgasm/ ejaculation. It sometimes presents as persistent sexual arousal Foreign body/fullness sensation in rectum, vagina or perineum (like a tennis ball) Rectal pain with an urgent need to open the bowels Causes of Pudendal Neuralgia (PN) Causes of Pudendal Neuralgia (PN) Compression or entrapment of pudendal nerve (cycling, prolonged sitting, pelvic floor muscle spasm, any growth pressing on the nerve) Stretching of the nerve as during childbirth or surgery Direct Injury to pudendal nerve as during pelvic trauma, falls on the buttock or even with severe constipation Compression at the level of spinal cord or nerve roots Biochemical injury from infections and diseases (diabetes, multiple sclerosis, viral infection- herpes zoster, HIV) Genitofemoral Neuralgia Genitofemoral nerve is an important nerve in the lower abdomen and pelvis. It originates from the upper part of lumbar spine (lower back) and passes through a large muscle on the side of spine called the psoas muscle. This

3. muscle stretches from the spine to the hip and helps in raising the hip towards the abdomen. Once the nerve comes out of the psoas muscle, it divided into 2 branches – one travelling towards the front and outer part of thigh (femoral branch) and the other towards the genitals and upper part of inner thigh (genital branch). manifests as pain, altered sensation in the groin, lower abdomen and genitalia. This is addressed as genitofemoral neuralgia or genitofemoral neuropathy. Symptoms Symptoms associated with this condition include A common presenting complain is groin, lower abdominal or genital pain which can be a dull, heaviness sensation or severe, burning, electric shock like, throbbing, sharp pain. In males it involves the scrotum whereas in females the labia majora and mons pubis are involved. Pain may be accompanied by altered sensations such as tingling, numbness in the affected area Pain may be intermittent or constantly present. Generally, it affects one side, rarely both sides can be involved Often there is tenderness close to the side of pubis (pubic tubercle) on the affected side Physical activity such as walking, running, jumping, sexual intercourse can cause worsening of pain. Extension of lower back as while bending backwards can also increase the pain. Often patients with this condition walk in a bent over position.

4. CAUSES Main cause of this condition is nerve damage . This rarely occurs by itself and may be secondary to Inguinal hernia surgery- Persisting pain after inguinal hernia surgery is not uncommon and genitofemoral nerve problem is one of the known causes. It can happen after both laparoscopic and open hernia surgery and multiple mechanisms may be responsible such as injury during laparoscopic port insertion, surgical hernia repair, mesh placement and securing, tying of the cremasteric artery, entrapment of the nerve in the scar tissue and in the adhesions around the mesh. There are reports of genitofemoral nerve injury after many other surgeries such as Pelvic lymph nodes dissection as in ovarian, uterine, bladder, or prostate cancer surgery or when a large pelvic mass is removed Kidney removal (Nephrectomy) Appendix removal (appendectomy) Uterus removal (Hysterectomy) Caesarean section Other surgeries involving retraction of the psoas muscle such as spinal surgery- lateral interbody fusion by retroperitoneal transpsoas approaches. Other non-surgical causes include Abdominal / pelvic trauma or pelvic fractures or retroperitoneal haematoma (blood collection in the posterior part of abdomen)

5. Psoas muscle related issues such as compression due to abscess or Potts disease (TB of spine) Spinal problems such as compression fractures, cancer spread to bones, narrowing of the spine (spinal stenosis) at upper lumbar levels Peripheral neuropathy- nerve damage due to conditions such as diabetes, alcohol abuse, vitamin deficiencies, cancer treatments etc. INVESTIGATIONS INVESTIGATIONS Diagnosis of genitofemoral neuralgia can be challenging as there is significant overlap in the distribution of nerves in this area. If the history and examination point towards genitofemoral neuralgia then investigations such as MRI, MR Neurography or ultrasound scans are requested to aid the diagnostic process and rule out other conditions with similar presentation. MRI spine may also be requested to rule out any problems in the spine and neighbouring psoas muscle from where the nerve originates. Not uncommonly, selective blocking of nerves is required to pinpoint the source of pain. TREATMENT TREATMENT A multimodal approach with combination of several modalities is used to provide relief. The modalities used include Lifestyle modifications Medications acting on the nerves (neuropathic agents), anti- inflammatory medications Nerve blocksPulsed radiofrequency treatment

6. Cryoablation Spinal injections Surgical interventions Injections play a key role from the diagnosis to the management of this condition. These are non-surgical options which have the potential to provide prolonged relief. The options are discussed in further detail below Ultrasound Guided Nerve blocks Ultrasound Guided Nerve blocks Genitofemoral nerve identification under ultrasound requires reasonable amount of skill. The nerve block injections involve injecting a mixture of numbing agent (local anaesthetics) and a small dose of steroids. The local anaesthetic provides immediate relief but is short lasting, whereas the steroid takes time to start working but can provide longer lasting relief. These injections can help reduce the inflammation, may help freeing the nerve of the pressure from surrounding structures and also reduce the sensitivity of the nerves thereby reducing the pain signals being transmitted via these nerves. The use of ultrasound increases the accuracy of injections and reduce the potential of side effects. Ultrasound Guided Pulsed Radiofrequency Treatment Ultrasound Guided Pulsed Radiofrequency Treatment This is a safe, effective treatment modality that can help in reducing the pain. The treatment involves modulating the way pain signals are transmitted and processed, with the potential of providing lasting pain relief. This treatment is performed as a day case under local anaesthesia, using special needles and a radiofrequency generator. A needle is

7. placed close to the nerve under ultrasound guidance followed by testing to guide accurate needle placement. The radiofrequency treatment is then performed on a small area of the nerve by using the radiofrequency machine. This reduces the pain signals being transmitted by the nerves to the brain resulting in pain relief. Ultrasound Guided Cryoablation Ultrasound Guided Cryoablation Cryoablation, offers advantages over radiofrequency such as immediate pain relief, no risk of neuroma formation and higher chances of successful pain relief as the probe targets a larger area. The pain relief from the procedure may last from months to a year. As the procedure leaves the outer layer of nerve intact the nerve does grow back but the original pain for which the procedure was performed may not return or be less severe if it returns. Spinal injections Spinal injections Genitofemoral nerve originates from the upper part of lumbar spine as explained previously. Any problems in the spine from where the nerve originates, such as pressure on the nerve roots, manifest with similar symptoms and may not respond to injections done distally along the path of the nerve. This area is also targeted if the nerve in the front is not accessible due to scarring etc. Sometimes a combined procedure is performed where the nerve is targeted both in the front and where it comes out of the spine, to increase the changes of pain relief. These injections are performed under x-ray guidance as a day case procedure. The options include nerve root blocks, epidurals and pulsed radiofrequency treatment.

8. Surgery Surgery This is considered for intractable pain not responding to other treatments. The aim of surgery is to either free the nerve of all external pressure/entrapment or to excise a part of the nerve (neurectomy). If cases with scarring due to previous surgery, visualisation and release of the nerve can be challenging. The cut nerve ends are tied and buried into the muscle fibres to prevent neuroma (a swelling of the nerve) formation. A neuroma if formed can lead to worse pain later. Cutting the nerve produced numbness or reduced sensation in the areas supplied by the nerve which includes the parts of the gentalia mentioned previously and upper thigh.