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Post-Operative Rehabilitation Protocol Following Pudendal
Nerve Decompression
Stephanie A. Prendergast, MPT and Elizabeth H. Rummer, MSPT
Pelvic Health and Rehabilitation CenterSan Francisco, California
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2001 - 2007Evaluated over 500 patients with PN
Evaluated and treated 51 post-operative patients:
36 patients: Transgluteal Decompression and Transposition
15 patients: Trans-Ischial-Rectal Decompression
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Persistent post-operative pain and dysfunction
51/51 patients: unable to sit without pain51/51 patients: urinary and/or bowel and/or sexual dysfunction
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Physical Therapy EvaluationConnective Tissue RestrictionsMyofascial Trigger PointsAdverse Neural TensionPelvic Floor DysfunctionStructure and Biomechanics
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Connective Tissue Restrictions
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Mechanisms for formation of Subcutaneous Panniculosis (SQP)
Result of visceral referred painIn dermatomes associated with the nerve roots of an inflamed peripheral nerveSuperficial to muscles with Myofascial Trigger Points (MTrPs)Superficial to areas of joint dysfunction
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Sites of SQP in patients with persistent post-operative pain
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Sites of SQP in patients with persistent post-operative pain
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Myofascial Trigger Points (MTrPS)
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Adverse Neural Tension
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Pelvic Floor Dysfunction:Source or Symptom of Pudendal Neuralgia?
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Structure and BiomechanicsSacro-iliac joint dysfunctionLumbar spine, hip, lower extremitiesFootNeuromuscular controlStrength, stability, flexibility
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Physical Therapy Treatment PlanMobilize restricted connective tissues
Lower extremities, abdomen, gluteal region, low backDistribution of the Pudendal Nerve: medial to the ischial tuberosities and inferior pubic ramus, labia, scrotum, suprapubic region,posterior thigh, lateral to rectum
Connective Tissue Manipulation, Dry needling
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Physical Therapy Treatment PlanEradicate myofascial trigger points
Obturator internus, piriformis, adductors, multifidi, gluteal group, quadratus lumborum, rectus abdominus, obliques, bulbospongiosis and ischiocavernosis, levator ani
Manual therapy, dry needling, trigger point injections
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Physical Therapy Treatment PlanReduce adverse neural tension
Dorsal pudendal nerve branches, perineal branch, inferior rectal branch, Alcock’s Canal, ischial spine
Connective tissue manipulation, nerve glides, PNB if patient cannot toleratephysical therapy
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Physical Therapy Treatment PlanEliminate Pelvic Floor Dysfunction
Lengthen short pelvic floor, eliminate MTrPs, normalize motor control (concentric contraction, , eccentric lenghtening, volitional ‘drop’), strengthen if weak*
Vaginal/rectal MFR, PNF, TPIs, PNB if patient cannot tolerate RX, pelvic floor ‘aerobics’
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Physical Therapy Treatment PlanNormalize structure and mechanics
SIJD (hypermobility), pelvic obliquity, LLD, foot alterations, core strength and neuromuscular control, LB and hip mechanics
Manual therapy techniques, prolotherapy, stabilization belts and exercises, orthotic devices
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Home Exercise Program and Lifestyle Modifications
Unique per patientGenerally: ice massage and contrast baths to PN distribution, spouse-trained in CTM and MFR, paradoxical relaxationCushion use, sit until pain increasesCardiovascular exercise dailyStretching and strengthening ONLY after MTrPs eradicated
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Home Exercise Program and Lifestyle Modifications
Unique per patient!
PNF D2 for pelvic floor relaxation
Nerve glides, self-mobilization
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Physical Therapy Treatment Plan:Frequency and Duration
1 - 4 hours/week12 weeks - 24 monthsShort-term hyperprotection vs long-term quality of lifeMulti-disciplinary management
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Questions?Thank-you!