Brian P. Jacob, David C. Chen, Bruce Ramshaw, Shirin Towfigh (eds.) - The SAGES Manual of Groin Pain-Springer International Publishing (2016)

11. Groin Pain Etiology: Pudendal Neuralgia
145
Treatment
Noninvasive Treatment and Modalities Avoiding activities that are
causing the pudendal pain is the single most important step to treatment
[ 14 ]. Scarring around the pudendal nerve can increase with repeat
trauma from certain activities, and some of these can also cause pelvic
floor muscle spasms, leading to severe pain. High-risk patients include
those who perform specific activities such as cycling, gymnastics, ballet,
and competitive athletics. These patients can halt progression of their
symptoms and reduce the risk of developing chronic pudendal neuralgia
if they decrease or stop their activity altogether.
Physical therapy provides excellent benefits in this patient population.
Pelvic floor therapists address muscle spasms and improve upon muscle
imbalances. Their therapies can help release restrictive connective tissue
and improve other symptoms that patient may be experiencing [ 5 ]. Pelvic
floor therapy applies “hands-on” techniques, improves posture and range
of motion, strengthens surrounding muscles, and provides patient
edu cation to prevent further injury and trauma to the area. A majority of
patients with pudendal neuralgia suffer from significant pelvic floor
muscle spasms, with subsequent muscle shortening throughout the pelvic
girdle. Manual techniques help release the spasms and result in lengthening
of the muscles. Techniques focus on myofascial release, soft and
connective tissue mobilization, and trigger point release. Other modalities
therapists might include in their treatment approach include biofeedback,
ultrasonography, and electrical stimulation.
Pharmacotherapy Medical therapy can play a role in multimodal
therapy for the effective treatment of pudendal neuralgia. Table 11.3
lists options for medical therapy. However, little research has been performed
to validate the efficacy of any of these medications as a preferred
treatment for pudendal neuralgia. Since the symptoms are a result
of neuropathy with or without muscle spasm, medical therapy is
directed to these entities [ 15 , 16 ]. No single medical treatment regimen
is currently recommended; the patient may need to attempt multiple
different combination treatments for symptomatic control.
Botulinum Toxin Injections If patients with significant pelvic floor
muscle spasms do not have improvement with physical therapy, the next
line of treatment is botulinum toxin injections [ 2 , 17 ]. These have been
found to be very effective in decreasing the muscle spasms of the pelvic
floor. Doses between 50 and 400 units of botulinum toxin have been