PELVIC NEUROPATHIC PAIN SYNDROME,
LAPAROSCOPIC PELVIC NEUROSURGERY & LION PROCEDURE
Neuropathic Pelvic Pain Disorders: Vulvar Pain, Vulvodynia, Coccygodynia (Coccyx Pain), Pudendal Nerve Pain, Sciatica, Chronic Prostatitis, Prostate Pain, etc.
Chronic neuropathic pelvic pain disorders are pain syndromes originating from pathologies of the pelvic nerves. They include disorders such as vulvodynia (vulvar pain), coccygodynia (tailbone pain), pudendal nerve pain, sciatica and prostatodynia (prostate pain). Pelvic neuropathic pain may occur due to damage or irritation of pelvic nerves, both resulting in neuropathic pain (well-located burning pain also called “allodynies” with irradiation down to the buttock, the genitoanal areas or the legs) and pelvic organ dysfunction (bladder, bowel and sexual dysfunctions). The multidisciplinary approach of neuropelveology allows the physician to make an individualized diagnosis and determine the appropriate medical or neurosurgical treatment.
Pelvic Nerve Irritation
Pelvic nerve irritation is by far the most frequent cause of neuropathic pelvic pain. The nerves are not injured, but just compressed or tied by external causes. The nerve functions are then not decreased but increased. Pain symptoms combine to increase in superficial skin sensitivity or paraesthesia (sensations of tingling, tickling, or burning) in the areas of pain. Functions of pelvic organs are also increased: the urinary voiding function is normal, but patients suffer from increased urinary frequency, urgency, and even overactive bladder.
The most frequent cause is the compression of the pelvic nerves is enlarged veins (varicose veins) – a condition called “pelvic vascular entrapment.” The pain then increases in all situations that increase pressure in the pelvic veins (excessive sitting or standing, etc.) or cause pulsation of the pelvic veins (tricuspid regurgitation, anatomic proximity to arteries, etc.).
Endometriosis and scare tissue (fibrotic entrapment) are also possible causes for irritative pelvic neuropathic pain. Fibrotic entrapment mostly develops after surgery in proximity to the nerves, or after postoperative hematoma. Procedures with mesh or sling implantation for pelvic organs prolapse are procedures that particularly expose patients to such fibrotic entrapment of the pelvic nerves. Nerve lesions by fibrotic tissue or vascular compression / entrapment usually require several months or even years to develop.
Laparoscopic nerve decompression is the most common form of treatment of such pelvic nerves irritation. In decompression surgery, all structures causing nerve compression are removed laparoscopically while the nerve itself is left intact. Endometriosis, old sutures or mesh material surrounding the affected nerve can, for example, be removed in this manner. If enlarged blood vessels are causing nerve impairment, the vessels should be coagulated and then removed to prevent their redevelopment. Tumors causing nerve compression must also be removed – preferably by laparoscopy.
Pelvic Nerve Damage
Damage happening during interventions are due to coagulation, suturing, ischemia or cutting and induce troubles of sensation, pain and dysfunctions starting immediately after the procedure or after a short interval of several days. Neuropathic pain is accompanied by numbness in the buttocks, genital region or legs and, in some cases, partial or complete loss of muscle or organ function (urinary retention, constipation, motor dysfunction, erectile dysfunction, etc.). Phantom pain may ultimately develop. Also endometriosis, rare pelvic tumors but also primary pathologies of the nerves themselves (multiple sclerosis…) are causes of nerve damages.
Laparoscopic nerve release will not suffice in such cases. Neuromodulation therapy – the implantation of electrodes that continuously stimulate the damaged nerves – is required. The technique of laparoscopically implanting electrodes (neuroprotheses) on damaged pelvic nerves, known as the “LION procedure” developed by Professor Possover is the therapy of choice: microelectrodes are placed in close proximity to the damaged nerves by laparoscopy in order to stimulate the nerves for the elimination of pain and pelvic organ dysfunction.