penile pain

[onechance]

Other than meds (which have failed in my pt), what procedure/s do you guys perform? Pt is s/p radical prostatectomy several years ago and his pain started right after the surgery.
Pain gets better in supine position and worse with standing.

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[Ligament]

He probably has pudendal neuralgia. Block the pudendal nerves with US or CT. If good but short term relief, Pulsed RF of the pudendal nerves and/or S2-S4 DRGs. If no benefit, consider ganglion impar block. If no lasting benefit, do a sacral nerve root stimulator, place leads retrograde over S2-S4, and possibly anterograde over conus. You will be certain of good coverage.

 

[drf]

Despite being a fan of US, I find pudendal blocks easiest using prone fluoro. A little oblique and caudal tilt to bring the ischial spine into view then touch it with the needle. If you use a stim needle walking medial and lateral can ensure parenthesis to the painful area. Same for pRF. Sometimes the nerve has already split into branches at this point and it can be a bit tricky getting penile, perineal, or rectal stim to ensure you are treating the correct branch.

 

[NOSfan]

This technique under fluoro is very straightforward.

http://www.painphysicianjournal.com/2004/july/2004;7;319-322.pdf

 

[drf]

This technique under fluoro is very straightforward.

http://www.painphysicianjournal.com/2004/july/2004;7;319-322.pdf

That's what I do. Takes two minutes. No fingers where they don't belong...

 

[onechance]

Thank you all for your replies...very helpful.

 

[clubdeac]

Saw a penile pain patient today. Planning to do pudendal. How do you guys bill for this?

 

[lonelobo]

Saw a penile pain patient today. Planning to do pudendal. How do you guys bill for this?

Depends on how you Dicktate it

 

[epidural man]

He probably has pudendal neuralgia. Block the pudendal nerves with US or CT. If good but short term relief, Pulsed RF of the pudendal nerves and/or S2-S4 DRGs. If no benefit, consider ganglion impar block. If no lasting benefit, do a sacral nerve root stimulator, place leads retrograde over S2-S4, and possibly anterograde over conus. You will be certain of good coverage.

Agree.

Pudendal, then ganglion impar. I will even try a caudal, and GFN. Also, superior hypogastric.

Pulse if any of those give you traction.

I do pudendal under CT, but I realize most don't have the opportunity to use CT. Doing blocks with CT is like cheating.....it is so damn easy. I just had a case report for GFN block under CT accepted. I don't know when it will be published however. Again...so freakin easy....much easier than US and I love doing US.

For non-intervention, no meds - send the patient to pelvic floor PT. It may have tremendous benefit.

 

[lord_jeebus]

Saw a penile pain patient today. Planning to do pudendal. How do you guys bill for this?

64430 + 77002

 

[Ducttape]

arent you a little bit concerned about the radiation involved the CT guided injections, particularly if these are done at least 2-4 times a year?

 

[epidural man]

Ct fluoroscopy has very little radiation. Some have shown it is even less than the same procedure using fluoroscopy.

But yes, some concern.

 

[bronchospasm]

Did a ganglion of impartial block on a patient with pain in the perineal region that started after prostatectomy done 10 years ago.
Almost 80% pain relief lasting about 2 months.
Never done a pudendal nerve block.

 

[clubdeac]

Did one today, bilateral. Hit ischial spine and injected a couple cc's then walked needle off medial side and injected another couple cc's. We'll see if it does anything. Easy and cool block

 

[drf]

Agree with fluoro technique. Very easy to do. Add a stimulating needle to pick off any of the three branches.

Easy with US as well once familiar with pelvis. Scan for PSIS. Scan south until you see SIJ, or simply ilium and sacrum joining. Scan south to enter greater sciatic notch. Scan a touch medial to catch ischium deep and lateral to sacrum. Watch as ischium flattens out and peaks medially. This is the ischial spine and the two bright white lines are the sacrotuberous and sacrospinous ligaments with the pudendal artery and nerve between.

Try this on skinny patients first.

If you know US guided piriformis it is 0.5-1 cm caudad.