This topic contains 6 replies, has 2 voices, and was last updated by 
Anonymous December 18, 2018 at 1:46 pm.
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AnonymousI’m wondering if anyone else has come across a pudendal nerve entrapement?
Having a hard time diagnosing between pudendal nerve entrapment vs. proximal hamstring tendinosis, in a current patient.
History fits tendinosis, but patient does report of pain radiating into perineum at times.
Any thoughts on this would be greatly appreciated.
Thanks!
Keith Puri, DC
I have read a true pudendal nerve entrapment PNE is rare and is most likely a consequence of surgery or trauma in which the nerve becomes entrapped and has to be released. What is more common is pudendal neuralgia (PN) which is non-specific and follows a gradual progression of symptoms as opposed to PNE which symptoms are often denied pre-surgery/trauma and develop insidiously afterward.
Does your patient have any P+/P- factors for this perineum pain and where exactly is this pain located? Below is referral charts for the peripheral and cutaneous nerves of the perineum. Do his symptoms following any of these distribution patterns?
I once had a case which questioned a PNE vs. PHT but ended up being a posterior femoral cutaneous nerve entrapment. I do not recall the specifics but I do remember his symptoms began following a cycling accident and by the time I saw the patient he was approximately 12-month post-trauma with ongoing symptoms. He had seen multiple providers, undergone extensive imaging and diagnostic injections with little to no lasting relief. I am certainly better equipped now to triage a case similar to this given the ID 7 first-order hx questions and diagnosis worksheet.
Carl Nottoli, DC
Brian, what are your 7 1st order Hx points and response to treatment thus far?
I see you’re skipping steps again 🙂
Anonymous58 yo, Male
Sym Location: right posterior thigh in crease of posterior hip, around inside of proximal medial thigh, perineum region
Sym Qual: Burning, aching
Sym Int: 4/10 most days, 7 out of 10 at worst
Prov: prolonged sitting (>20min), bending forward, driving, walking
Pall: lying down, ice
2nd Order:
Onset: 1 and 1/2 years
Occupation: drove UPS truck for 30 years, has been retired over 2 years
Recreation: weight training (not currently), golfing
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Exam:
R-SLR: 84%, L-SLR: 86%
R-SHF: 100%, L-SHF: 100%
QLF: 10001 – 20%
R-KHE: 75%, L-KHE: 75%
SLPF: 80% – finger tips 5 inches from floor
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Currently:
QLF: MMI – 80% (11222)
KHE: Bilateral 12″
SLR – MMI 95% bilateral
Lower back and left iliac crest region feel much better, but still experiencing Proximal posterior thigh and proximal medial, perineum pain.
Carl Nottoli, DC
I still don’t see the connection of tendinosis in this case. Maybe you can point specifically to those data points.
Peripheral NE is still high on the list of suspects. Check out those charts more and see if any of those nerves fit. Put the area under tension and assess with IAR if he’s lean. If not, do the same thing with the area under tension and palpate for any increased tension spots or tender areas where the small nerves live.
William Brady, DC
I would also consider the possibility of an extruded or sequestered disc. A very large disc SOL can compress the lower lumbar and sacral nerve roots in the canal as high up as L1/L2 (remember the spinal cord stops at L1). We tend to think about the IVF and get a little tunnel vision.
With this mechanism in mind, it better explains the sitting AND walking as provocatives. Only lying down is palliative.
Do you have imaging of his lumbar spine?
AnonymousSorry for the delay. That whole getting married thing got in the way.
Patient is currently on a 4 week Maintenance schedule, as his lumbar spine is quite degenerated with multiple levels of disc degeneration and herniations at L4/5 and L5/S1. Patient reported feeling improvement in proximal posterior thigh and pudendal region symptoms over past 4 weeks.
QLF today was 80%, holding nicely.
KHE B – 12″, holding nicely.
SHF – R @ full range with proximal posterior thigh tension. “feels like the pain he is still experiencing”
Originally when I palpated the proximal posterior thigh for tension and treated what I imagined was nerve entrapment there, symptoms flared up pretty bad for 48 hours or so. Today, i re-palpated the region and it was not as sore and I could feel, more distinctly, 1 area of tension and what i expect to be Nerve Entrapment located adjacent (medial) to proximal hamstring tension overlying proximal portion adductor magnus. Worked that for 4-5 passes with much less discomfort to patient. Less symptoms on retest of supine hip flexion post treatment as well.
I will follow-up with patient in 2 days to see if we got any flared symptoms. If he experiences another flare, i believe that points me more into the direction of Dr. Brady’s suspicion of disc injury pressing on nerve roots which will lead to an updated MRI. If not, and more progress is made, i will believe it to be a very complicated case and un-layering and time between visits of healing were of much necessity to see this case to completion instead of a simple pudendal nerve entrapment.
Thanks for all the engagement and guidance. Always appreciated!
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