Herman & Wallace is excited to announce a collaboration with Dr. Michael Hibner, an international expert on pudendal neuralgia and chronic pelvic pain. Dr. Hibner is presenting a new remote course on January 9, 2022, titled Pudendal Dysfunction: The Physician's Perspective. Pudendal neuralgia is a painful, neuropathic condition involving the dermatome of the pudendal nerve. This condition is not widely known and often goes unrecognized by many practitioners. Dr. Hibner runs the Arizona Center for Chronic Pelvic Pain (AZCCPP), a comprehensive center for treating chronic pelvic pain, and places a heavy emphasis on working as part of a care team with physical therapists and other pelvic rehab providers.
In a recent publication by Dr. Hibner, he shares that “the International Pudendal Neuropathy Association estimates the incidence of this condition to be 1/100,000; however, most practitioners treating patients with this condition feel the actual rate of incidence may be significantly higher.” Many patients go an average of 10-15 years attempting to get a diagnosis for their pain. Diagnosis of this condition is heavily based on the utilization of Nantes Criteria in conjunction with clinical history and physical findings.
Dr. Hibner began his career as a urogynecologist. In the early 2000s, some of his patients presented with a vulvar burning pain that didn’t fit any known criteria. When he reviewed the histories of these patients, he found that the only thing in common between these patients was kickboxing. Further research then led him to pudendal neuralgia.
What are some of the typical patient characteristics/presentations and the time of diagnosis and referral?
If you think of chronic pelvic pain, it really spans multiple specialties. It spans urology, colorectal, gastrointestinal, and physiatry. A lot of it is musculoskeletal pain, so a lot of it is physical therapy, orthopedics, and neurosurgical. However, for pudendal neuralgia patients, there are three distinct groups of patients. The younger group, 20-year-olds, are mostly injured in some type of athletic activity (skiers, gymnasts, cyclists, workout, etc.). The second group is slightly older, approximately mid-30s. Their most common cause of PN is traumatic vaginal childbirth. The older group often has had a mesh procedure (such as for prolapse) with the older kind of meshes.
What is your standard approach to PN patient complaints?
My protocol is that every patient that comes in gets a pelvic MRI before being seen (while doing Kegels and Valsalva). Even if seeing a physical therapist, I would have them see one associated with my practice so that the PT could take part in the patient meeting. I have my fellow take the patient history. Then we meet in my office, myself, the physical therapist, and my fellow, with MRI results, before seeing the patient. Then I meet the patient and can offer options.
How do I diagnose and treat PN?
I used to believe that the Nantes Criteria is what you had to use when diagnosing pudendal neuralgia. I recently retranslated the criteria for a textbook that is coming out soon. Patients should meet some of these criteria but don’t need to meet all of them. It just means that your pain is in the area of the pudendal nerve, but it doesn’t tell you that the nerve is entrapped. More pain with sitting is an important criterion. Having no pain at night is not true all the time, as it depends on the origin. However, this is not true with mesh origination PN.
The second part of it is the MRI. I have had very high hopes for the MRI in relation to diagnosing PN. This is not the answer for all of it. It is important, but the resolution of the PN is smaller than the MRI so that you can see the vascularization. A lot of times, you find other things than the compression of the nerve. It is a very good test to make sure that there is nothing else you are missing.
When talking about the MRI, what other diagnostic tests are helpful?
The warm threshold test, PN modern terminal latency test (you need to know the length of the nerve so it is not effective as that cannot be determined). The Pinprick test - not useful or accurate. What works best by far is the patient history, just talking to the patient. The [patient's] history is the key. What happened? The nerve can’t become entrapped on its own. If you see enough patients over the years, you can learn through experience. The MRI is valuable to make sure there is nothing else.
A pelvic exam by a qualified pelvic rehab therapist is important because it helps to rule out pelvic muscle spasms. The pain from the PN and the Obturator Levator muscle may be very similar and difficult to differentiate. Does the amount of spasms correlate with the number of symptoms/pain that they have?
You can’t treat the PN without addressing the pelvic floor. What I tell patients is this. The number one thing for repetitive injury is to stop what you’re doing. The number two thing is to choose physical therapy over anything else. By far the majority of patients are helped by appropriate pelvic floor physical therapy.
Pudendal Dysfunction: The Physician's Perspective is scheduled for January 9, 2022. Course topics include pathoanatomy and clinical presentations, basics of surgical techniques, and terminology. The latter half of the course focuses on the physician and the rehab therapist working together and features case studies and clinical pearls from Dr. Hibner, a pioneer, and leader in the field.
The interview excerpts are taken from Dr. Hibner's interview with Holly Tanner and Jessica Reale for the H&W Pelvic Floor Level 2A course pre-recorded lectures.