What would you do?

[ateria radicularis magna]

Elderly man with pelvic pain

Pain started after catheterization for urinary retention, he states.
Pain includes perineum and anus. Especially bad with defecation. It is constant and severe.
He has history of rad for prostate cancer several years ago.

I've talked with a urology friend...said to make sure someone checked PSA recently, said to find out if he's had his bladder scoped recently. He sees a urologist, so I'm pretty sure these have been done.

I tried superior hypogastric but his L5/S1 fusion made this procedure too difficult for me to do, and I aborted. I've tried a few meds without much success.

What would you do? I can't stop thinking about this patient.

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[Dr. Ice]

Stim trial?

 

[lobelsteve]

Norco

 

[DOctorJay]

there are multiple cases like this discussed with good results on the DRG stim list serve

(the list serve being a forum where practicing physicians are discussing their cases, not something pushed by the manufacturer)

 

[Timeoutofmind]

Elderly man with pelvic pain

Pain started after catheterization for urinary retention, he states.
Pain includes perineum and anus. Especially bad with defecation. It is constant and severe.
He has history of rad for prostate cancer several years ago.

I've talked with a urology friend...said to make sure someone checked PSA recently, said to find out if he's had his bladder scoped recently. He sees a urologist, so I'm pretty sure these have been done.

I tried superior hypogastric but his L5/S1 fusion made this procedure too difficult for me to do, and I aborted. I've tried a few meds without much success.

What would you do? I can't stop thinking about this patient.

Pudendal block to pulsed RF if successful...seems less invasive than an implant

 

[Ducttape]

norco could make urinary retention worse, if he still has. maybe nucynta?

you can also do a superior hypogastric block from an anterior approach.
https://www.ncbi.nlm.nih.gov/pubmed/10499763
https://www.ncbi.nlm.nih.gov/pubmed/23577819

but with perineal and anal pain, id consider ganglion impars block next.

 

[willabeast]

what is your diagnosis? if not known, what would be a list of most likely diagnosis?
from what you have mentioned, without a physical exam, it is a little tough for me to come up with a DDX, but
for a start, anyone with a history of cancer with pain on defecation s/p XRT needs to have a GI work up to exclude malignancy. a simple cheap test that makes metastatic malignancy much less likely if negative is an ESR. if + it tells you very little (unless it is over 100 then you have something serious).
once cancer is excluded i think most likely diagnosis is still GI (radiation proctitis, anal fissure).
hate to see you doing nerve blocks for an anal fissure but i suppose there are worse things...

 

[hyperalgesia]

Elderly man with pelvic pain

Pain started after catheterization for urinary retention, he states.
Pain includes perineum and anus. Especially bad with defecation. It is constant and severe.
He has history of rad for prostate cancer several years ago.

I've talked with a urology friend...said to make sure someone checked PSA recently, said to find out if he's had his bladder scoped recently. He sees a urologist, so I'm pretty sure these have been done.

I tried superior hypogastric but his L5/S1 fusion made this procedure too difficult for me to do, and I aborted. I've tried a few meds without much success.

What would you do? I can't stop thinking about this patient.

PT, biofeedback

 

[lobelsteve]

norco could make urinary retention worse, if he still has. maybe nucynta?

you can also do a superior hypogastric block from an anterior approach.
https://www.ncbi.nlm.nih.gov/pubmed/10499763
https://www.ncbi.nlm.nih.gov/pubmed/23577819

but with perineal and anal pain, id consider ganglion impars block next.

And Tylenol could give him Stevens-Johnson syndrome. I've never seen anyone get urinary retention with low dose hydrocodone. It's a much more cost-effective alternative to procedures and surgeries.

 

[ateria radicularis magna]

Norco

Thank you. He is on some opioids, and they are helping to a certain extent. They were giving him a lot of constipation, but other meds have more or less solved that.

There is something about that patient who really does not want to be on opioids that really makes me want to come up with a way for them not to be on opioids.

 

[gdub25]

Sounds like he's a reasonable guy and in that case I would stim or DRG trial him. Risks from this are minimal and could potentially treat long term, opioids have marginal benefit and lot of risks. If trial isn't clearly helpful then fall back on meds.

 

[bronchospasm]

Ganglion of Impar block. Have helped a few patients with perineal pain.

 

[bedrock]

agree with ganglion impar block. Could consider pudendal if that fails. pRF to either if they get brief relief.

Stim if blocks fail

 

[Orin]

I'd second the ganglion of impar, higher volume than usual.

Sacral stim is technically on label for him if he has nonobstructive urinary retention and it would be a relatively easy chip shot into the S2 or 3.

 

[DrCommonSense]

Elderly man with pelvic pain

Pain started after catheterization for urinary retention, he states.
Pain includes perineum and anus. Especially bad with defecation. It is constant and severe.
He has history of rad for prostate cancer several years ago.

I've talked with a urology friend...said to make sure someone checked PSA recently, said to find out if he's had his bladder scoped recently. He sees a urologist, so I'm pretty sure these have been done.

I tried superior hypogastric but his L5/S1 fusion made this procedure too difficult for me to do, and I aborted. I've tried a few meds without much success.

What would you do? I can't stop thinking about this patient.

Thai Chi, Yoga, Cognitive Behavioral Therapy, a Shaman/Witch Doctor from Africa, Oriental Herbs and possibly Chiropractic/Acupuncture if you want to be really high yield in treatment options.

Use the DRX 9000 machine at 5K/month, it should do the trick!

(Source: Rodger Chou at OHSU, these treatments are very high yield and evidence based)

 

[Ducttape]

And Tylenol could give him Stevens-Johnson syndrome. I've never seen anyone get urinary retention with low dose hydrocodone. It's a much more cost-effective alternative to procedures and surgeries.

i have... from as low as 20 mg hydrocodone a day.

the hydrocodone might make defecation more painful, too, if it causes concominant constipation.

 

[DrCommonSense]

Elderly man with pelvic pain

Pain started after catheterization for urinary retention, he states.
Pain includes perineum and anus. Especially bad with defecation. It is constant and severe.
He has history of rad for prostate cancer several years ago.

I've talked with a urology friend...said to make sure someone checked PSA recently, said to find out if he's had his bladder scoped recently. He sees a urologist, so I'm pretty sure these have been done.

I tried superior hypogastric but his L5/S1 fusion made this procedure too difficult for me to do, and I aborted. I've tried a few meds without much success.

What would you do? I can't stop thinking about this patient.

Also if you have any issues with acid reflux/hiatal hernias/etc I suggest using this guy for a "high yield" solution for this problem using EBM:



I suggest you send this patient PERSONALLY to this guy. Don't worry about the price of the flight or hotel room, its worth it if he has to travel for this level of high yield care.

 

[thecentral09]

there are multiple cases like this discussed with good results on the DRG stim list serve

(the list serve being a forum where practicing physicians are discussing their cases, not something pushed by the manufacturer)

Question for you as I have not used DRG for this area but what is your likely neural target for trial/perm

 

[Hoya11]

Elderly man with pelvic pain

Pain started after catheterization for urinary retention, he states.
Pain includes perineum and anus. Especially bad with defecation. It is constant and severe.
He has history of rad for prostate cancer several years ago.

I've talked with a urology friend...said to make sure someone checked PSA recently, said to find out if he's had his bladder scoped recently. He sees a urologist, so I'm pretty sure these have been done.

I tried superior hypogastric but his L5/S1 fusion made this procedure too difficult for me to do, and I aborted. I've tried a few meds without much success.

What would you do? I can't stop thinking about this patient.

Caudal with bupi and depo? If not great success then Ganglion impar, opiates and lyrica or neurontin

 

[DOctorJay]

Question for you as I have not used DRG for this area but what is your likely neural target for trial/perm

some physicians are targeting DRGs T12 & L1, others S2 & S3 - Tim Deer recommends starting at T12 & L1 if there's a specific known nerve injury here and considering S2 & S3 if T12, L1 doesn't work or it's more of a generalized pelvic pain issue.

 

[neutro]

1) Caudal ESI with high volume which will target lower sacral nerve roots and its easy to do.
2) Ganglion impar block (you may get that with caudal ESI also, the injectate may spread through Sacrococcygeal ligament).
3) Low dose opioid, esp. if he is low risk, tramadol/ vicodin + neuropathic agent
4) Neuromodulation if refractory

Does he have any leg pain? Whats the nature of his pain? Any positional component? Whats the DDx? FBSS or urological?

I bet you can do an SCS trial, just for diagnostic reasons to see if this is a manifestation of post lami pain vs. urological. It would be an atypical presentation if this is due to FBSS, but I have had had patients with predominant pelvic pain. Caudal ESI with high volume may also help symptomatically.

 

[lobelsteve]

Are we shooting for the most expensive way the best way to make money off his insurance, or the best care for this patient?

 

[Ligament]

This sounds like pudendal neuralgia. Rule it out and treat it before moving onto stim trial and implant.