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Abdi et al • Pudendal Nerve Block 319

Pain Physician. 2004;7:319-322, ISSN 1533-3159

A Technical Report

A Novel Technique for Pudendal Nerve Block

Salahadin Abdi, MD, PhD, Pam Shenouda, MD, Nilesh Patel, MD, Bhupinder Saini, MD, Yogendra Bharat, MD,
and Octavio Calvillo, MD

Pudendal nerve block is performed to risk and decreased patient discomfort. the pelvis. The pudendal nerve block is per-
confirm the diagnosis of pudendal neuralgia. Description of the Technique: With the formed at this level.
Many physicians and patients are hesitant patient in the prone position, the C-arm is Conclusion: We described a new and
to pursue diagnostic nerve blocks to con- projected in the anteroposterior position novel technique to block pudendal nerve un-
firm the diagnosis of pudendal neuralgia sec- until the pelvic inlet is visualized. Subse- der fluoroscopic visualization safely with in-
ondary to significant patient discomfort, the quently, the ischial spine is highlighted by creased patient comfort.
need for special equipment, and the risk in 5 to 15 degree ipsilateral oblique angulation Keywords: Pudendal neuralgia, pudendal
the traditionally described approach. of the fluoroscope. A 25-gauge 3.5 cm nee- nerve block, piriformis muscle, fluoroscopy
Objective: To describe a novel tech- dle is advanced to the tip of the ischial spine
nique for pudendal nerve block with minimal where the pudendal nerve transiently leaves

Despite advances in the understand- for special equipment, and the associated advantages of the traditional approach to
ing of pain mechanisms, chronic pel- risks with the traditionally described ap- the pudendal nerve block and described a
vic pain continues to be a diagnostic and proach (8). Traditional descriptions of computed tomography–guided approach.
therapeutic dilemma for physicians (1-5). this technique involve placing a patient Their technique allows for minimal pa-
Patients with chronic neuropathic pel- in the lithotomy position. In a female pa- tient discomfort, negates the need for
vic pain for which no etiology could be tient, the ischial spine is palpated through the lithotomy position, and probably in-
found despite comprehensive diagnostic the vaginal wall, and the physician uses a creases patient and physician safety. How-
testing were originally described as suffer- Koback needle or an Iowa trumpet and ever, the majority of pain clinics are not
ing from “psychosomatic vulvovaginitis” guides the needle along the course of the equipped with a computed tomography
by Dodson and Friedrich (6) in the late finger (Fig. 1B). Ten to fifteen milliliters of (CT) scanner and thus would have to send
1970s. Turner and Marinoff (7) later de- local anesthetic is then injected just pos- their patients to have the procedure per-
scribed this clinical presentation as con- terior to the attachment of the sacrococ- formed in a radiology suite. This increases
sistent with pudendal neuralgia. Conse- cygeal ligament to the ischial spine. In a patients’ travel time and time absent from
quently, with suspicion of pudendal neu- male patient, the ischial spine is palpated work and takes the procedure away from
ralgia, a pudendal nerve block may be per- through the rectum, and the needle is in- the patient’s primary pain physician.
formed to confirm the diagnosis. serted transperineally (8). A fluoroscope-guided approach to
Many physicians and patients are Several problems are associated with a pudendal nerve block has not been de-
hesitant to pursue diagnostic nerve blocks these traditional approaches. First, there scribed in the literature. This is important,
secondary to patient discomfort, the need is the possibility of a high level of pa- because most interventional pain clinics
tient discomfort associated with the pro- are equipped with a fluoroscopy machine.
From Department of Anesthesiology, Periopera- cedure. Second, many pain clinics are not Performing pudendal nerve block under
tive Medicine and Pain Management, UM/Jackson equipped to place patients easily in the li- fluoroscopy has the advantages of the CT-
Memorial Hospital, Miami, Florida, Department thotomy position. Third is the danger in- guided approach and yet allows the per-
of Anesthesia and Crictical Care, Massachusetts
General Hospital, Advanced Pain Management volved for the patient, as this is a blind formance of the procedure in any pain
Center, Milwaukee, Wisconsin, and Baylor College technique in a vascular region near the clinic that has fluoroscopy available.
of Medicine, Houston, Texas. ddress Correspon- bowel and bladder. Finally, danger is in- Thus, we sought to describe a nov-
dence: Salahadin Abdi, MD, PhD, Department of
Anesthesiology, Perioperative Medicine, and Pain
volved for physicians performing this el approach to the pudendal nerve block
Management, UM/Jackson Memorial Hospital, procedure, as they direct a needle, by pal- that may be both more acceptable to pa-
1611 N.W. 12th Ave, C-301, Miami, FL 33136. E-mail: pation, along the course of their fingers tients and safer. to palpate appropriate landmarks. This
Funding: There was no external funding in prepara-
places such physicians at high risk for ac- ANATOMY
tion of this manuscript.
Conflict of Interest: None cidentally puncturing their fingers with The pudendal nerve arises from the
Acknowledgement: Manuscript received on 3/31/ the needle. sacral plexus. It is formed from contribu-
04. Revision submitted on 5/25/04. Accepted for
publication on 6/4/04.
Calvillo et al (9) recognized the dis- tions from the second, third, and fourth

Pain Physician Vol. 7, No. 3, 2004

320 Abdi et al • Pudendal Nerve Block


Fig 1a. Distributions of the branches of the pudendal nerve and pelvis superimposed over the surface anatomy. 1:
pudendal nerve; 2: inferior rectal nerve; 3: perineal nerve; 4: dorsal nerve of the clitoris; 5: ischial spine; 6: ischial
tuberosity. b. Blockade of the pudendal nerve via the transvaginal approach.
(Reproduced with permission [20])

sacral nerve roots. The pudendal nerve dendal nerve run relatively superficially CLINICAL PRESENTATION
courses through the superior aspect of through the pelvis, they become increas- Patients with pudendal neuralgia
the pelvis anteriorly and inferiorly, exit- ingly vulnerable to injury. tend to describe neuropathic pain symp-
ing through the greater sciatic foramina
PATHOPHYSIOLOGY toms in the nerve’s distribution. Common
just inferior to the piriformis muscle. At
complaints include burning pain, pares-
that point, the nerve crosses posterior to Insults to the pudendal nerve tend to thesias, hyperalgesia, hypesthesia, and in-
the attachment of the ischial spine and be unilateral. The most common puden- termittent lancinating pain. This pain can
the sacrococcygeal ligament, anterior to dal nerve injury occurs during childbirth. disrupt an affected patients’ ability to car-
the sacrotuberous ligament. It then reen- This “obstetrical neuropathy” has been re- ry out normal functions of day-to-day liv-
ters the pelvis through the lesser sciatic fo- ported to be both a temporary and a per- ing, including being seated comfortably
ramina. The nerve courses posteriorly and manent cause of morbidity (11, 12). Oth- and engaging in sexual intercourse. Pa-
inferiorly through Alcock’s canal, eventu- er causes of injury to the pudendal nerve tients may also complain of associated
ally dividing into three branches: the infe- include traumatic injury leading to frac- motor deficits, including lack of control
rior rectal nerve, the perineal nerve, and ture of the ischial spine; entrapment of of their external anal sphincter and peri-
the dorsal nerve of the penis or clitoris the nerve as it courses beside the ischi- urethral and perineal musculature (19).
(Fig. 1A). al spine between the sacrotuberous and Diagnosing pudendal neuropathy
The inferior rectal nerve provides sacrococcygeal ligaments (13); compres- requires a high index of suspicion while
sensation to the distal aspect of the anal sion of the nerve as it courses through obtaining a patient’s medical history and
canal and to the perianal skin. It also pro- Alcock’s canal (14); infectious damage performing a physical examination. In the
vides motor innervation to the external to the nerve’s structure (15, 16); and iat- event of trauma, one may suspect puden-
anal sphincter. The perineal nerve pro- rogenic injury as the nerve is penetrated dal nerve injury after seeing a fracture of
vides sensation to the perineum and the with a large, dull needle during pudendal the ischial spine. On physical examina-
ipsilateral posterior surface of the scro- nerve blocks or as damage to the nerve or tion, scar tissue may be palpated along the
tum or the labia majora. It also provides its blood supply during any type of surgi- course of the nerve. Ultimately, the diag-
motor innervations to the superficial and cal interventions requiring exploration of nosis can be made by performing a pu-
deep transverse perineal muscles, the bul- the pelvis. dendal nerve block.
bospongiosus, the ischiocavernosus, the Bilateral pudendal nerve injury is
sphincter urethrae, and the levator ani relatively rare. The mechanism of bilater- DESCRIPTION OF A NEW TECHNIQUE
muscles. The final branch of the puden- al injury usually involves a patient’s fall- The patient is placed in the prone po-
dal nerve—the dorsal nerve of the pe- ing and straddling a blunt object, such as sition, and the gluteal region is prepared
nis or clitoris—supplies sensation to the a bicycle seat (17) or an equestrian sad- and draped. Then a C-arm fluoroscope
skin and deeper structures of the penis or dle (18). is projected in the anterior-posterior po-
clitoris (10). As the branches of the pu-
sition with the patient in the prone posi-

Pain Physician Vol. 7, No. 3, 2004

Abdi et al • Pudendal Nerve Block 321

Author Affiliation:
Salahadin Abdi, MD, PhD
Chief of Pain Medicine
Professor of Anesthesiology
JUM/Jackson Memorial Hospital
1611 N.W. 12th Ave. C-301
Miami FL 33136

Pam Shenouda, MD
Massachusetts General Hospital
Department of Anesthesia
32 Fruit Street
Boston, MA 02114

A. Straight AP radiograph of the B. Oblique view of the ischial Nilesh Patel, MD

pelvic bones. spine. Note that the tip of the Advanced Pain Management Center
needle is at the falciform process Milwaukee, WI
of the ischial bone. 5900 S. Lake Drive
Cudahy, WI 53110
Fig 2. Pudendal nerve block with our new approach.
tion (at the level of the two femoral heads) od, as effective pudendal blockade (with a Bhupinder Saini, MD
until the pelvic inlet is visualized. The fal-
fraction of the dose demanded by the con- Advanced Pain Management Center
ciform process (the ischial spine) is then ventional technique) is ensured when im- 5900 S. Lake Drive
highlighted by 5- to 15-degree ipsilateral age guidance is adopted. Cudahy, WI 53110
oblique angulation of the fluoroscope. A Further research has to be performed E-mail:
25-gauge 3.5 inch needle is advanced to on this novel technique. Questions to be
the tip of the ischial spine, where the pu- answered include the following: Which Yogendra Bharat, MD
dendal nerve transiently leaves the pelvis. technique is most successful in isolating Advanced Pain Management Center
At this point, 3 to 4 ml of local anesthetic and blocking the pudendal nerve? Which 5900 S. Lake Drive
provides excellent anesthesia in the distri- technique has the highest rate of compli- Cudahy, WI 53110
bution of the pudendal nerve (Fig. 2). cations? Which technique provides the
most patient and physician satisfaction? Octavio Calvillo, MD
DISCUSSION Elucidating the answers to such questions Baylor College of Medicine
Despite diagnostic and therapeutic should result in an increased ability to di- 6550 Fannin Street, Suite 2421
advances, patients with deep pelvic and agnose and treat pudendal neuralgia. Houston, TX 77030-2748
perineal pain continue to pose a signifi- E-mail:
cant challenge for the majority of pain cli- CONCLUSION
nicians. Pudendal entrapment and neu- The authors’ belief is that the fluo-
ralgias are implicated in some clinical pre- roscopic approach to the pudendal nerve 6. Dodson MG, Friedrich EG Jr. Psychosomat-
sentations. Pudendal blockade may pro- block is safe and effective. ic vulvovaginitis. Obstet Gynecol 1978;
vide some hope for these patients. Late- 51(1):23S–25S.
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