Conquering misdiagnosed pudendal neuralgia for years: case study

The aim of the study: to present the diagnostic and clinical features of pudendal nerve neuralgia and create awareness among clinicians of this rare and painful condition. Case: A generally healthy 40-year old female with constant, disabling and for a long-time misdiagnosed pain in perineum. Perineal pain appeared gradually in 2004, without obvious reason, at first interpreted as urethritis, but after urological investigations and treatment there was no pain relief. Besides gynecologist, proctologist, psychiatrist and spine surgeon consulted patient and no reason for pain was found. Patient has chronic constipation history due to inner rectal prolapse. Patient complained of stabbing, burning, intolerable pain (maximal NRS 10) in vulva, vagina, rectum and urethra, urination hesitancy, needed to void several times per hour, sexual dysfunction. Pain aggravated with sitting and often worsened throughout the day, but did not wake her at night. After 10 years of suffering untreated perineal pain patient had to quit her job. At last pudendal neuralgia was diagnosed in 2019, pain specialist examination revealed thermal hyperalgesia and mechanical allodynia in perineum. Pudendal neuralgia was confirmed by diagnostic pudendal nerve block on both sides, afterwards bilateral cryodistruction was performed. Patient became 100% painless for 1 month, but after 3rd month pain started to return. At that time ganglion impar diagnostic block was performed (Lidocaine 40 mg with Dexamethasone 8 mg) with consequent pain reduction for 50%, one week later ganglion impar neurolysis (Phenol 6% 3ml) was done. Unfortunately, perineal pain still persisted, so pudendal nerve cryodistruction was repeated on the 4thmonth after first cryoablation procedure, afterwards pain 80% reduction was achieved. Patient continue prescribed medicine therapy and started CBT with psychotherapist, she reported daily pain in perineum NRS 2, but her quality of life crucially improved.