[Pudendal neuralgias]

PUDENDAL NEURALGIAS. Diagnosis of pudendal neuralgia (NP) is clinical, based on the neuropathic type of pain and its topography, in the territory of the terminal branches of the pudendal nerve. It does not require specific paraclinical exploration and perineal electromyography should no longer be systematically proposed. However, a pelvic exploration such as magnetic resonance imaging (MRI) should be requested to rule out any tumoral pathology or anatomical anomaly. The most well-known cause is pudendal nerve entrapment (PNE). This syndrome must meet the five Nantes criteria and include a clear response to local anesthetics injection. Among other causes, known as "non-entrapped" neuropathies, we can mention: stretching neuropathies from dystocic deliveries, direct traumatic neuropathies, metabolic neuropathies of diabetes, herpes infections, chemotherapy-induced neuropathies, toxic neuropathies, and encountered in myofascial syndromes of the buttock or perineal muscles. It is also important to recognize the neuropathic pudendal pain, often poorly systematized and associated with other pelvic pains, from central pelvic hypersensitization. The treatment of PNE benefits from management recommendations (Convergences PP), including a first-line multimodal treatment. In case of failure and after a positive response to the block test, decompression-neurolysis surgery should be considered due to its low aggressiveness, its effectiveness in pain improvement (70 to 80%), and its healing rate (50 to 60%) in properly selected patients. Radiofrequency and cryotherapy, as well as botulinum toxin injections, do not have sufficient evidence and can only be proposed as third-line treatments, within therapeutic protocols, in specialized centers. Neuromodulation and the peri-nerve catheter, connected to a continuous diffusion pump of local anesthetics, are considered in case of failure or recurrence after surgery.