Medical Student UCF College of Medicine Orlando, Florida
Case Diagnosis: Two patients with pudendal neuralgia, as confirmed by diagnostic pudendal nerve block, underwent cryoablation of the pudendal nerves through a novel ischiorectal fossa approach with significant pain reduction and no anal sphincter compromise.
Case Description or Program Description: Two patients with longstanding pelvic pain and positive response to diagnostic pudendal nerve blocks underwent bilateral cryoablation of the pudendal nerves for pudendal neuralgia. This procedure was conducted with the patients in prone positioning and percutaneous insertion of a cryoablation probe medial to the ischial tuberosity and lateral to the rectum. Correct positioning on the pudendal nerve was achieved with nerve stimulation eliciting visible anal sphincter contraction and fluoroscopic imaging of the probe relative to the ischial spine. The probe was set to -88 Celsius for 108 seconds and a total of two cycles were performed.
Setting: The patients presented to a private pain practice and the procedures were conducted at an outpatient surgical center under minimal intravenous sedation without intubation.
Assessment/Results: The patients reported significant pain reduction for several weeks and no anal sphincter dysfunction. This procedure was repeated in both patients at approximately 4 months post-operation for pain recurrence and demonstrated similar reported pain reduction as the initial procedure with no evidence of incontinence.
Discussion (relevance): The ischiorectal approach to handheld cryoablation of the pudendal nerve with fluoroscopy and nerve stimulation demonstrates utility by offering physicians a reproducible and efficacious technique to address pudendal neuralgia. This report details a safe, easy to perform, alternative to CT guided pudendal nerve cryoablation.
Conclusions: This percutaneous ischiorectal approach to pudendal cryoablation seems to be a simple, reproducible procedure with promising results of reduced pelvic pain without the theoretical risk of anal sphincter dysfunction that might be associated with pudendal nerve thermal ablation. This technique, we believe minimizes the risks and simplifies cryoablation to be performed on an outpatient basis by more pain physicians.