"Dr. Amod Manocha is a Pain Management Specialist in Saket, Delhi & gurgaon take care of Neuropathic Pain, Chronic Post Surgical Pain, Pelvic pain, Thoracic spine, knee pain, back pain, Joint Pain etc. with advanced technology."

1. Pelvic Pain Treatment in Delhi,
Dr.Amod Manocha is The Best pain
specialist in Delhi - Removemypain
Pelvic pain
Pudendal Neuralgia/ Neuropathy (PN)
Pudendal nerve is one of the main nerves of the pelvis, with one nerve on
each side. It runs from the lower back, along the pelvic floor to supply the
genitals, lower part of rectum, and perineum (area between the sit bones).
This nerve is closely involved with urinary and bowel functions.
Pudendal neuralgia is a condition related to irritation or damage of pudendal
nerve, which presents as pain or altered sensation in the genital, rectal region
or deep inside the pelvis. It is more common in women and is also addressed
as cyclist syndrome, Alcock’s canal syndrome and pudendal nerve
entrapment. Despite the significant advances in the evaluation and
management of chronic pelvic pain, it often goes unrecognised. It can be
associated with other conditions such as Chronic Pelvic Pain Syndrome,
dysfunctional voiding, painful bladder syndrome, chronic prostatitis etc.
Pudendal Neuralgia - Patient Information Leaflet
Signs and symptoms of Pudendal Neuralgia
Burning, shooting, electric shock like, crushing, aching, prickling or itching
sensation in the areas of pelvis supplied by the pudendal nerve.
Pain worse on sitting or exercising and resolves when lying flat (as during the
night) or standing Better when sitting on the toilet seat

2. Intermittent initially but can change to a constant pain with time It can radiate
(travel) to buttocks (around ischial spines) and legs (inner thigh), feet
Other symptom which may be present include
Urge to go to the toilet often (urinary frequency) or a feeling of a bladder
infection,
Pain on passing urine
Increased sensitivity in pelvic area
Numbness, pins and needles sensation in pelvis
Pain during sex or sexual arousal or orgasm/ ejaculation. It sometimes
presents as persistent sexual arousal
Foreign body/fullness sensation in rectum, vagina or perineum (like a tennis
ball)
Rectal pain with an urgent need to open the bowels
Causes of Pudendal Neuralgia (PN)
Compression or entrapment of pudendal nerve (cycling, prolonged
sitting, pelvic floor muscle spasm, any growth pressing on the nerve)
Stretching of the nerve as during childbirth or surgery
Direct Injury to pudendal nerve as during pelvic trauma, falls on
the buttock or even with severe constipation
Compression at the level of spinal cord or nerve roots
Biochemical injury from infections and diseases (diabetes, multiple
sclerosis, viral infection- herpes zoster, HIV)
Genitofemoral Neuralgia
Genitofemoral nerve is an important nerve in the lower abdomen and pelvis. It
originates from the upper part of lumbar spine (lower back) and passes
through a large muscle on the side of spine called the psoas muscle. This

3. muscle stretches from the spine to the hip and helps in raising the hip towards
the abdomen. Once the nerve comes out of the psoas muscle, it divided into 2
branches – one travelling towards the front and outer part of thigh (femoral
branch) and the other towards the genitals and upper part of inner thigh
(genital branch).
manifests as pain, altered sensation in the groin, lower abdomen and genitalia.
This is addressed as genitofemoral neuralgia or genitofemoral
neuropathy.
Symptoms
Symptoms associated with this condition include
A common presenting complain is groin, lower abdominal or
genital pain which can be a dull, heaviness sensation or severe,
burning, electric shock like, throbbing, sharp pain. In males it
involves the scrotum whereas in females the labia majora and
mons pubis are involved.
Pain may be accompanied by altered sensations such as tingling,
numbness in the affected area
Pain may be intermittent or constantly present. Generally, it
affects one side, rarely both sides can be involved
Often there is tenderness close to the side of pubis (pubic tubercle)
on the affected side
Physical activity such as walking, running, jumping, sexual
intercourse can cause worsening of pain. Extension of lower back as
while bending backwards can also increase the pain. Often patients
with this condition walk in a bent over position.

4. CAUSES
Main cause of this condition is nerve damage . This rarely occurs by
itself and may be secondary to
Inguinal hernia surgery- Persisting pain after inguinal hernia
surgery is not uncommon and genitofemoral nerve problem is one
of the known causes. It can happen after both laparoscopic and
open hernia surgery and multiple mechanisms may be responsible
such as injury during laparoscopic port insertion, surgical hernia
repair, mesh placement and securing, tying of the cremasteric
artery, entrapment of the nerve in the scar tissue and in the
adhesions around the mesh.
There are reports of genitofemoral nerve injury after many other
surgeries such as
Pelvic lymph nodes dissection as in ovarian, uterine, bladder, or
prostate cancer surgery or when a large pelvic mass is removed
Kidney removal (Nephrectomy)
Appendix removal (appendectomy)
Uterus removal (Hysterectomy)
Caesarean section
Other surgeries involving retraction of the psoas muscle such
as spinal surgery- lateral interbody fusion by
retroperitoneal transpsoas approaches.
Other non-surgical causes include
Abdominal / pelvic trauma or pelvic fractures or retroperitoneal
haematoma (blood collection in the posterior part of abdomen)

5. Psoas muscle related issues such as compression due to abscess or
Potts disease (TB of spine)
Spinal problems such as compression fractures, cancer spread to
bones, narrowing of the spine (spinal stenosis) at upper lumbar
levels
Peripheral neuropathy- nerve damage due to conditions such as
diabetes, alcohol abuse, vitamin deficiencies, cancer treatments etc.
INVESTIGATIONS
Diagnosis of genitofemoral neuralgia can be challenging as there is
significant overlap in the distribution of nerves in this area. If the
history and examination point towards genitofemoral neuralgia
then investigations such as MRI, MR Neurography or ultrasound
scans are requested to aid the diagnostic process and rule out other
conditions with similar presentation. MRI spine may also be
requested to rule out any problems in the spine and neighbouring
psoas muscle from where the nerve originates.
Not uncommonly, selective blocking of nerves is required to
pinpoint the source of pain.
TREATMENT
A multimodal approach with combination of several modalities is
used to provide relief. The modalities used include
Lifestyle modifications
Medications acting on the nerves (neuropathic agents), anti-
inflammatory medications
Nerve blocksPulsed radiofrequency treatment

6. Cryoablation
Spinal injections
Surgical interventions
Injections play a key role from the diagnosis to the management of this
condition. These are non-surgical options which have the potential to
provide prolonged relief. The options are discussed in further detail below
Ultrasound Guided Nerve blocks
Genitofemoral nerve identification under ultrasound requires
reasonable amount of skill. The nerve block injections involve
injecting a mixture of numbing agent (local anaesthetics) and a
small dose of steroids. The local anaesthetic provides immediate
relief but is short lasting, whereas the steroid takes time to start
working but can provide longer lasting relief. These injections can
help reduce the inflammation, may help freeing the nerve of the
pressure from surrounding structures and also reduce the
sensitivity of the nerves thereby reducing the pain signals being
transmitted via these nerves. The use of ultrasound increases the
accuracy of injections and reduce the potential of side effects.
Ultrasound Guided Pulsed Radiofrequency Treatment
This is a safe, effective treatment modality that can help in
reducing the pain. The treatment involves modulating the way pain
signals are transmitted and processed, with the potential of
providing lasting pain relief.
This treatment is performed as a day case under local anaesthesia,
using special needles and a radiofrequency generator. A needle is

7. placed close to the nerve under ultrasound guidance followed by
testing to guide accurate needle placement. The radiofrequency
treatment is then performed on a small area of the nerve by using
the radiofrequency machine. This reduces the pain signals being
transmitted by the nerves to the brain resulting in pain relief.
Ultrasound Guided Cryoablation
Cryoablation, offers advantages over radiofrequency such as
immediate pain relief, no risk of neuroma formation and higher
chances of successful pain relief as the probe targets a larger area.
The pain relief from the procedure may last from months to a year.
As the procedure leaves the outer layer of nerve intact the nerve
does grow back but the original pain for which the procedure was
performed may not return or be less severe if it returns.
Spinal injections
Genitofemoral nerve originates from the upper part of lumbar
spine as explained previously. Any problems in the spine from
where the nerve originates, such as pressure on the nerve roots,
manifest with similar symptoms and may not respond to injections
done distally along the path of the nerve. This area is also targeted
if the nerve in the front is not accessible due to scarring etc.
Sometimes a combined procedure is performed where the nerve is
targeted both in the front and where it comes out of the spine, to
increase the changes of pain relief.
These injections are performed under x-ray guidance as a day case
procedure. The options include nerve root blocks, epidurals and
pulsed radiofrequency treatment.

8. Surgery
This is considered for intractable pain not responding to other
treatments. The aim of surgery is to either free the nerve of all
external pressure/entrapment or to excise a part of the nerve
(neurectomy). If cases with scarring due to previous surgery,
visualisation and release of the nerve can be challenging. The cut
nerve ends are tied and buried into the muscle fibres to prevent
neuroma (a swelling of the nerve) formation. A neuroma if formed
can lead to worse pain later. Cutting the nerve produced numbness
or reduced sensation in the areas supplied by the nerve which
includes the parts of the gentalia mentioned previously and upper
thigh.