Pudendal nerve block

[RoloTomassi]

Can someone please give me a refresher on technique, pearls and pitfalls? It's been a while. Thanks.

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[Ferrismonk]

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In recent years, ultrasound has become an essential tool for clinicians who care for patients suffering from acute or chronic pain. Comprehensive Atlas of Ultrasound-Guided Pain Management Injection Techniques, 2nd Edition, depicts in clear, step-by-step detail how to prepare and perform...

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That being said:
Use an ultrasound (Curvilinear usually preferred), place it over the ilium and move caudally along bone until ischial spine is identified. Find the sacrospinous ligament, sacrotuberous ligament, and internal pudendal artery. Nerve is between the two ligaments medial to artery. Hyperechoic. Use in-plane approach.

 

[nvrsumr]

used to do with xray. touch needle tip on os at ischial spine then walk off medial and ventral a cm and inject. Just turned down the first case in years a couple weeks ago as those patients are a level of crazy I dont want to get sucked into anymore.

Obs will do a transvaginal block at fornix

 

[Orin]

Can someone please give me a refresher on technique, pearls and pitfalls? It's been a while. Thanks.

I do enjoy NYSORA for their US imaging and guidance here

Ultrasound-Guided Blocks for Pelvic Pain - NYSORA

Chronic pelvic pain (CPP) is defined as noncyclic pain of at least 6 months duration, severe enough to cause disability or seeking of medical attention, and occurring in locations such as the pelvis, anterior abdominal wall at or below the umbilicus, lower back, or buttocks [1]. The...

www.nysora.com

https://utee63lakop1ozmny1lmo13a-wpengine.netdna-ssl.com/wp-content/uploads/2022/03/fig8-10.jpg

 

[RoloTomassi]

Thanks all. I should've specified fluoro. Is the internal pudendal artery of concern with fluoro?

 

[Agast]

Thanks all. I should've specified fluoro. Is the internal pudendal artery of concern with fluoro?

This is the approach I use. Seems to work ok.

https://www.painphysicianjournal.com/current/pdf?article=MTQ2&journal=20

 

[deleted875186]

This is the approach I use. Seems to work ok.

https://www.painphysicianjournal.com/current/pdf?article=MTQ2&journal=20

I use this approach, it’s quite easy, but honestly never had any success with this block for pelvic pain.

 

[Agast]

I use this approach, it’s quite easy, but honestly never had any success with this block for pelvic pain.

I use it more for vaginal pain. If pelvic I do superior hypogastric plexus. Perineal I will do ganglion impar. Sometimes I will combine them depending on pain distribution.

 

[painfree23]

I use it more for vaginal pain. If pelvic I do superior hypogastric plexus. Perineal I will do ganglion impar. Sometimes I will combine them depending on pain distribution.

Superior hypogastric for “general pelvic pain” or more for cancer type pain? Is that considered a “sympathetic block” for billing? What level do u inject? Thanks in advance!

 

[pastafan]

If pain relieved with diagnostic block I have had good success with pulsed RF.

 

[deleted875186]

Superior hypogastric for “general pelvic pain” or more for cancer type pain? Is that considered a “sympathetic block” for billing? What level do u inject? Thanks in advance!

I do sympathetic block at L5 for chronic pelvic pain, endometriosis, etc.

 

[buddababa]

I do sympathetic block at L5 for chronic pelvic pain, endometriosis, etc.

steroid? how long does relief usually last for?

 

[deleted875186]

steroid? how long does relief usually last for?

Steroid, not more than a few months, so I don’t typically offer them all that often.

 

[powermd]

I've had a few referrals for vaginal pain lately and did two blocks on one elderly patient. Her complaint was a bit strange (they all are). Burning pain in the vagina with prolonged sitting. But she sits a lot... hours and hours. So says her husband. She was about 50% better with one block, zero pain two weeks after block #2. Amazing.

I'll have to keep pulsed RF in my back pocket for these. Pasta Man, any particular settings you use?

 

[pastafan]

I've had a few referrals for vaginal pain lately and did two blocks on one elderly patient. Her complaint was a bit strange (they all are). Burning pain in the vagina with prolonged sitting. But she sits a lot... hours and hours. So says her husband. She was about 50% better with one block, zero pain two weeks after block #2. Amazing.

I'll have to keep pulsed RF in my back pocket for these. Pasta Man, any particular settings you use?

Pulsed RFA was performed at a maximum temperature of 42 degrees C for 6 minutes utilizing pulse duration of 20 ms and pulse rate of 2 HZ. Voltage remained between 41-45V.

 

[painfree23]

Pulsed RFA was performed at a maximum temperature of 42 degrees C for 6 minutes utilizing pulse duration of 20 ms and pulse rate of 2 HZ. Voltage remained between 41-45V.

How much do you charge do u do for this?

 

[pastafan]

How much do you charge do u do for this?

Too little.

 

[Ducttape]

how did you decide on 6 minutes?

when i have pulsed nerves (not the pudendal), usually i do it timewise like RFA - 2 minutes. please post a study if you have one.

 

[pastafan]

Most studies used 3 minutes but some used a total of 6 minutes. My thought is longer can't hurt and may be beneficial. Results have been good.

Pulsed Radiofrequency for Chronic Pain - PMC

www.ncbi.nlm.nih.gov