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

146
M. Hibner and C. Coyne
Table 11.3. Medications for treatment of pudendal neuralgia.
Medication Dose Comments
Oral muscle relaxants (e.g., Variable
Marginally effective
diazepam,
cyclobenzaprine,
carisoprodol, tizanidine)
Diazepam and Baclofen
vaginal suppository
Diazepam 5 mg
Baclofen 4 mg
Appears effective
No studies available
Start qHS, increase
to BID
Belladonna and opium
rectal suppository
Belladonna 16.2 mg
Opium 30 mg
Appears effective
No studies available
Gabapentin Titrate to 2400–
3600 mg/day in
three divided doses
Pregabalin
Start at 75 mg BID
and titrate up or
down
Significant side effects
No studies available for
pudendal neuralgia
Side effects
No studies available for
pudendal neuralgia
reported to block these spasms. The timeline for effect of the toxin is
5 days postoperatively with a maximum effect occurring 2 weeks postoperatively.
Response to botulinum toxin will vary per patient. Some
will improve after a single dose and will not require further treatment.
However, the majority of patients will need repetitive injec tions every 3
months as the effects of the toxin wear off. Approximately 70–80 % of
patients have significant improvement of pain after the toxin injection.
Pudendal Nerve Block Pudendal nerve blocks can be completed
either unguided or guided. Unguided, they are performed through the
vagina, perineum, or buttock. Guidance can be completed with the assistance
of ultrasound, fluoroscopy, or computed tomography (CT) imaging
[ 18 ]. Guided blocks are used to both diagnose and treat pudendal neuralgia.
If a patient experiences temporary relief of pain after the block, this
establishes that the pain is directly related to the pudendal nerve or the
area innervated by the pudendal nerve. A positive block with temporary
relief of the pain does not confirm pudendal nerve compression. If the
block is negative, meaning the patient does not receive any pain improvement,
it rules out the pudendal nerve as the cause of pain .
Along with local anesthetic injection, patients also experience longterm
relief with injected steroids. One study found that 92 % of patients
experienced some relief after undergoing a steroid injection [ 19 ]. In our