This case report summarizes the effectiveness of ultrasound-guided pulsed radiofrequency treatment of the pudendal nerve in three patients with chronic pelvic pain. The three patients, two males with interstitial cystitis and one female with pudendal neuralgia, underwent ultrasound-guided pudendal nerve blocks followed by pulsed radiofrequency treatment of the pudendal nerve. All three patients experienced reduced pain scores and decreased analgesic use following the treatment. No complications occurred. The report concludes pulsed radiofrequency treatment of the pudendal nerve under ultrasound guidance provided effective analgesia for chronic pelvic pain in these cases without adverse effects.

1. Chronic pelvic pain is a condition that
arises in cases of pudendal neuralgia, in-
terstitial cystitis, piriformis syndrome as
well as neuropathy of the ilioinguinal, ilio-
hypogastric and genitofemoral nerves [1].
Although their etiologies are different, the
common clinical finding of this syndrome
urinary urgency, accompanies sharp pain
usually in the perineal and suprapubic ar-
eas, resulting in hesitancy and a burning
sensation [2]. Treatment can be carried
out by medicinal therapy, pudendal nerve
block, decompressive surgery and neuro-
modulation methods. This article reports
on the clinical effectiveness of pulsed ra-
diofrequency (PRF) treatment, which was
applied to the pudendal nerve under ul-
trasonography (USG) guidance in three
patients who were admitted to our pain
clinic due to chronic perineal pain.
Case report
Three patients, a 65-year-old man, a
72-year-old man and a 40-year-old wom-
an, were being followed up with diagno-
ses of interstitial cystitis (the first two pa-
tients) and pudendal neuralgia (the third
patient). The complaints of the two male
patients diagnosed with interstitial cystitis
were perineal pain, urinary urgency and
hesitancy which had started 1 and 2 years
ago, respectively. Both male patients had
undergone transurethral prostatectomy
and multiple cystoscopic examinations.
The female patient had complaints of
burning perineal pain for approximately
1 year, which increased while sitting and
was spreading to the gluteal area. The pa-
tient had been treated with epidural ste-
roid injections and piriformis muscle in-
jections because of a misdiagnosis. All
three patients had been receiving peroral
gabapentin (1800, 2400 and 1800 mg/day,
respectively), tramadol (peroral 300 mg/
day) treatment and physiotherapy. The
pain scores were 8/10, 8/10 and 7/10, re-
spectively, according to the numerical rat-
ing scale (NRS) score (. Table 1).
A diagnostic pudendal nerve block was
administered to the patients who were
planned to undergo pudendal nerve PRF.
The patients were placed in the lithoto-
my position. The perineal skin was steril-
ized with povidone iodine. A Sonosite M-
Turbo ultrasound instrument (Bothell,
WA) with a curved array transducer (HFL
38x/13-6 MHz transducer) was used to
perform the pudendal block. The curved
transducer probe was covered with a ster-
ile transparent sheath. When the ischial
tuberosity was palpated the USG trans-
ducer was placed on the oblique ischial
tuberosity (. Figs. 1, 2). After observing
the hyperechogenicity of the ischial tu-
berosity the transducer was moved in a
medial direction to observe the sacrotu-
berous ligament, which is less echogenic
than bone. At the junction of the sacrotu-
berous ligament and the ischial tuberosi-
ty the pudendal artery was viewed via col-
or flow Doppler imaging. A 22G 100 mm
Echoplex peripheral block needle (Vygon,
Paris, France) was subsequently advanced
to the junction of the sacrotuberous liga-
ment and the ischial tuberosity just medi-
al to the artery by using an in-plane tech-
nique. If the pudendal artery could not be
viewed, the needle was advanced to the
junction of the sacrospinous ligament and
the ischial tuberosity [3]. The localization
of the pudendal nerve was confirmed by
ipsilateral anal sphincter contraction in-
duced using a 0.5–0.6 mA Plexygon nerve
stimulator at 1 Hz (Vygon, Padova Italy).
After ensuring that blood was not aspirat-
ed 8 ml of 0.25% bupivacaine was inject-
ed. The same procedure was applied to
the contralateral side (. Fig. 2).
When the RF needle (100 mm insulat-
ed with 10 mm straight tip, NeuroTherm,
St Paul, MN) reached the target pudendal
nerve area, 0.25 mV of sensory stimula-
tion was applied twice at 42°C for 120s us-
ing pulsed RF (NT1100, NeuroTherm) at
D. Ozkan1 ·T. Akkaya1 · S. Yildiz2 · A. Comert3
1 Anesthesiology and Pain Department, Ministry of Health DiskapiYildirim
BeyazitTraining and Research Hospital, Cayyolu Ankara,Turkey
2 Anatomy Department, Gulhane Military Medical Academy, Ankara,Turkey
3 Anatomy Department, Ankara University Faculty of Medicine, Ankara,Turkey
Ultrasound-guided pulsed
radiofrequency treatment
of the pudendal nerve in
chronic pelvic pain
Anaesthesist 2016 · 65:134–136
DOI 10.1007/s00101-015-0133-4
Received: 12 September 2015
Revised: 16 December 2015
Accepted: 16 December 2015
Published online: 26 January 2016
© Springer-Verlag Berlin Heidelberg 2016
Table 1 Numerical rating scale scores of the patients at baseline and during the follow-up
period
Baseline 1 h 1 month 3 months 6 months
Case 1 8/10 2/10 1/10 2/10 2/10
Case 2 8/10 2/10 2/10 3/10 3/10
Case 3 7/10 0/10 0/10 2/10 4/10
134 | Der Anaesthesist 2 · 2016
Kasuistiken

2. the point where the impedance was 400 Ω
15 days after the administration of the di-
agnostic block. A total of 5 ml of 2% li-
docaine was administered following the
pulsed RF application. The interventions
were well tolerated by the patients and no
complications occurred.
The postprocedural NRS values af-
ter 1 h were 2/10, 2/10 and 0/10, respec-
tively and the NRS values were evaluated
as 1/10, 2/10 and 0/10 after 1 week, 2/10,
3/10 and 1/10 after 1 month, 2/10, 3/10
and 2/10 after 3 months and 2/10, 3/10
and 4/10 after 6 months, respectively. The
average tramadol dose used via the per-
oral route was reduced from 300 mg to
50 mg daily. While urgency symptoms re-
gressed, perineal sensitivity was observed
to disappear.
Discussion
Pudendal neuralgia commonly presents
as chronic pain in the penis, scrotum, la-
bia, or the anorectal region. It is mainly
caused by pudendal nerve entrapment be-
tween the sacrotuberous and the sacrospi-
nous ligaments or through the pudendal
canal (Alcock’s canal) [4]. Interstitial cys-
titis characterized by suprapubic pain re-
lated to bladder filling increased daytime
and nighttime micturition frequency,
without a proven urinary infection. The
etiology of interstitial cystitis is unknown
but explain afferent hyperexcitability as a
result of neurogenic bladder inflamma-
tion and urothelial dysfunction [5].
The pudendal nerve block is known
to be effective in chronic perineal pain
caused by interstitial cystitis and puden-
dal neuralgia. The pudendal nerve is a
sensory motor nerve originating from S2,
S3 and S4 branches of the sacral plexus. It
provides the sensory and somatic inner-
vation of the vagina, vulva, scrotum, pe-
nis and the anal area. The pudendal nerve
block hinders the pain signaling arising
from the pelvic area [6]. A block of the
pudendal nerve can be performed under
the guidance of various imaging meth-
ods, such as fluoroscopy and computed
tomography (CT) for treatment of peri-
neal pain [1]. Transgluteal and transvag-
inal approaches may be used in the pu-
dendal nerve block. Recently, USG-guid-
ed pudendal nerve blocks performed with
the patient in the lithotomy position were
reported [3]. Applying a pudendal nerve
block guided by fluoroscopy requires dif-
ficult additional equipment. Transgluteal
USG-guided trials have been done; how-
ever, the pudendal nerve is small and vi-
sualization of the pudendal artery, which
may be taken as the landmark required
for Doppler imaging, is not easy [7];
therefore, visualization of the sacrotuber-
ous ligament via USG in the lithotomy
position more easily facilitates pudendal
block application in lithotomy position.
Although the mechanism of PRF is
not fully known it is a treatment meth-
od which is considered to cause neuro-
modulation and is safer than conven-
tional continuous radiofrequency abla-
tion (CRF) [8]. There are several cases
of chronic neuralgia in the literature that
were successfully treated with PRF (e.g.
lateral cutaneous neuralgia, ilioinguinal
neuralgia and intercostal neuralgia) [9].
There are only a limited number of stud-
ies about RF administration for chronic
pelvic pain. A period of 1.5 years of good
pain relief was reported in a patient af-
ter PRF administration using a transvagi-
nal blind technique in a case of pudendal
neuralgia [4]. A good analgesia over a pe-
riod of 5–6 months and patient satisfac-
tion were achieved in the three cases de-
scribed in this article and the amount of
analgesics administered could be substan-
tially reduced.
Conclusion
The administration of PRF with patients
in the lithotomy position and under USG
guidance provided an adequate analgesia.
Good patient satisfaction was achieved
and no complications were encountered
in these three patients with chronic pelvic
pain. Randomized controlled trials are re-
quired to show the effectiveness and reli-
ability of this treatment.
Corresponding address
D. Ozkan
Anesthesiology and Pain Department,
Ministry of Health DiskapiYildirim Beyazit
Training and Research Hospital
Koru M Kavakli S No: 4/44
06810 Cayyolu Ankara
derya_z@yahoo.com
Fig. 2 8 Ultrasonography scan of the pudendal nerve block (curved trans-
ducer C60x/5-2 MHz). A ischial tuberosity, B needle, C spread of local anes-
thetic solution and D sacrotuberous ligament
Fig. 1 8 Sketch of the pudendal block in the lithotomy position
135Der Anaesthesist 2 · 2016 |

3. Compliance with
ethical guidelines
Conflict of interest. D. Ozkan, T. Akkaya, S. Yildiz,
and A. Comert declare that there are no conflicts of
interest.
All studies on humans described in this manuscript
were carried out with the approval of the responsible
ethics committee and in accordance with national
law and the Helsinki Declaration of 1976 (revised
form). Informed consent was obtained from all pa-
tients included in the studies. Consent was obtained
from all patients identifiable from images or other
information within the manuscript.
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Abstract · Zusammenfassung
Anaesthesist 2016 · 65:134–136
DOI 10.1007/s00101-015-0133-4
© Springer-Verlag Berlin Heidelberg 2016
D. Ozkan ·T. Akkaya · S. Yildiz · A. Comert
Ultrasound-guided pulsed
radiofrequency treatment
of the pudendal nerve
in chronic pelvic pain
Abstract
Chronic pelvic pain is a condition that can
be caused by pudendal neuralgia, intersti-
tial cystitis, piriformis syndrome and neurop-
athy of the ilioinguinal, iliohypogastric and
genitofemoral nerves. Based on three case re-
ports this article discusses the clinical effec-
tiveness of pulsed high-frequency radiofre-
quency (PRF) treatment applied to the pu-
dendal nerve under ultrasound guidance in
medicinally treated patients with chronic pel-
vic pain.
Keywords
Case study · Ultrasonography, interventional ·
Neuralgia · Analgesia · Cystitis, interstitial
Ultraschallgeführte gepulste
Radiofrequenzbehandlung
des N. pudendus bei
chronischem Beckenschmerz
Zusammenfassung
Chronische Schmerzen im Beckenbereich
können durch eine Pudendusneuralgie, eine
interstitielle Zystitis, ein Piriformissyndrom
und durch Neuropathien des N. ilioinguinalis,
iliohypogastricus und genitofemoralis be-
dingt sein. Anhand dreier Fallberichte
wird dieWirksamkeit der gepulsten hoch-
frequenten Radiofrequenzbehandlung des
N. pudendus unter Ultraschallkontrolle bei
medikamentös ausbehandelten Patienten
mit chronischen Beckenschmerzen erörtet.
Schlüsselwörter
Fallstudie · Interventioneller Ultraschall ·
Neuralgie · Analgesie · Interstitielle Zystitis
Fachnachrichten
Prof. Dr. med B.W. Böttiger
berät oberste amerikanische
Gesundheitsbehörde
Das„Institute of Medicine“ (IOM) hat Prof.
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einzigen nicht-amerikanischen Experten
eingeladen bei der Erstellung einer nationa-
len Agenda zumThema„Wiederbelebung“
mitzuwirken. Dabei konnte er wichtige
Aspekte wie die Ausbildung von Schülern
inWiederbelebung, dieTelefonreanimation
und die Laienausbildung einbringen.
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National Academy of Sciences der USA und
wurde bei uns unter anderem mit der Kam-
pagne und dem Focus auf„To err is human“
(„Irren ist menschlich“) bekannt.
Professor Böttiger, Schriftleiter der
“Notfall+Rettungsmedizin”, wurde als
international anerkannter Experte in das
IOM eingeladen, um über die europäische
Perspektive in derWiederbelebung nach
Herzkreislaufstillstand zu sprechen.
Gemeinsam mit anderen hatte er bereits,
mit dem Fokus auf Laienausbildung in
Wiederbelebung undTelefonreanimation,
eine nationale Initiative begründet, die in
Deutschland dazu geführt hat, dass deu-
tlich mehr Laien als noch vor zwei Jahren
mitWiederbelebungsmaßnahmen begin-
nen.Wenn ein Laie mitWiederbelebungs-
maßnahmen beginnt – das ist bis heute
nur in 30% der Fälle so -, dann verdoppelt
bis verdreifacht dies die Überlebensrate
der betroffenen Patienten. Und das ist
kinderleicht: beim Erwachsenen genügt die
Herzdruckmassage.
Der gesamte IOM Bericht und der Kurz-
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