Pamela A. Downey, PT, DPT, WCS, BCB-PMD, PRPC is Senior Faculty with Herman & Wallace and is instructing the upcoming Pudendal Neuralgia and Nerve Entrapment scheduled for January 27, 2024. She is the owner of Partnership in Therapy, a private practice in Coral Gables, Florida where she treats women and men with pelvic floor dysfunction, related urogynecological and colorectal issues, spine dysfunction, osteoporosis, and complaints associated with pregnancy and the postpartum period. Her mission is to educate and integrate healthy lifestyles for patients on the road to wellness. Pam sat down with the Pelvic Rehab to discuss her upcoming course.

What makes pudendal neuralgia such a difficult diagnosis to treat?

I think people often see the content in Pelvic Function Level 1 - Introduction to Pelvic Health and it's like a tidy little box. Then you get the patient and as the practitioner you're like I don't know what to do with this person. We need to show that pudendal skills are needed in differential diagnosis. Even though this course is called Pudendal Neuralgia and Nerve Entrapment, it is about differential diagnosis for a lot of pelvic pain. When you feel more secure in knowing what you're treating and have a systematic way of looking at it, then you can be more productive in your patient care.

I think some ortho therapists treat in a linear fashion, and they go from week one to week eight through a protocol and things generally go well because it's a predictable course when you're rehabbing a total knee replacement, or you have an elbow tendonitis, and you expect these structures to follow a path. But then when you come into the nerve side of things, nerves can be unpredictable. They're influenced by lots of factors. It could be your mood. It could be the range of motion around a joint. It could be a previous history of another neurologic problem feeding it, such as disc pathology. It can be something around a postural habit, and it could be a straight up other dysfunction that then affects the pudendal distribution. And if you don't treat the cause of the initial, you will never improve the latter, which is the neurological presentation in pudendal.

I love that it's more about figuring out the differential diagnosis for pelvic pain and going from that angle into pudendal dysfunction, entrapment, neuralgia, and everything that goes with that. For example, you're going to get a patient with an order for pudendal neuralgia, or even worse entrapment. When they get an order for pudendal neuralgia, then they'll kind of forget that the person may not have pudendal neuralgia. They have problems in the pudendal distribution, but that's basically everything we treat. So as a pelvic rehab practitioner they have to tease it out.

When I look at a script I always say, “that's nice.” The referring doctor may have written it as pudendal neuralgia so that the patient could get reimbursement for the therapy with the diagnosis code. But then we get to add our diagnosis codes on top of that and drive a treatment plan.

So, I think that is a big hangup. Practitioners run when they usually see this diagnosis. You don't want a pudendal patient. Especially if you do not have a lot of skills, because you are going to be like, well, what can I do for this patient? If they sit, they have pain. If they exercise, they have pain. They don't have like a whole repertoire. In the pudendal neuralgia course, we talk about how to figure out if the driver is the spine, the hip, the nerve itself, if it's the pelvic floor musculature, or if it's biomechanical. There are so many facets.

How often do these scripts come in for patients that have pudendal neuralgia?

In pelvic pain they're probably coming in a high percentage, like I would say three-quarters. In practice, depending on who's referring into the person's practice, it's going to be a significant amount of walk-in traffic and referred traffic. Because every levator syndrome patient could have a pudendal issue driving the levators, and long-standing levator pain can end up being pudendal.

It's kind of like are you treating the chicken or the egg? I think giving the person skills to do test and retest and having a way to keep falling back on to this  and then to also be able to transmit the idea that this isn't a fix -it problem. You know, we just don't put a band aid on it and you're done. Other folks who are more newish, who expect this linear event, they're going to struggle because there's going to be setbacks and sometimes doing more is the exact opposite of what needs to be done. Less is more.

When you look at the H&W course catalog, where would you recommend that practitioners take the Pudendal Neuralgia course?

The sweet spot for taking the pudendal neuralgia course would be practitioners who have taken PF1 and Pelvic Function Level 2A - Colorectal Pelvic Health, Pudendal Neuralgia, and Coccyx Pain, because they learn the rectal canal and PF2A. Practitioners who focus specifically on treating  the male pelvic patient would benefit from this course because it is a good thinking course for how to treat men. It could pair well with Pelvic Function Level 2C - Men’s Pelvic Health and Rehabilitation (formerly Male Pelvic Floor). In my practice I get a lot of men coming in because they look on the internet and decide that they got pudenda neuralgia.

If you understand differential diagnosis you can touch on is this a sciatic nerve problem? Is this a genitofemoral problem? We look at the lumbo-sacral plexus in a decision tree, and then we then focus on pudendal and then how people manage them from a medical standpoint and from a therapy standpoint. I talk about using a rule-out method - this could be genital femoral, this could be pudendal nerve. And then you prove what the problem is by doing test and retest.

There's also a lot of pain neuroscience, so practitioners who have taken Pain Science for the Chronic Pelvic Pain Population would benefit from this course. The pudendal neuralgia course goes really well with this course because the practitioners who have taken the pain science course already know that there's going to be ups and downs. Also Nari Clemon’s nerve courses, Lumbar Nerve Manual Assessment and Treatment and Sacral Nerve Manual Assessment and Treatment, are definitely lab -oriented courses and this could be a backgrounder even going into her series, because she's going to talk about a lot of nerve techniques that can be then applied to the pudendal. Nari's courses give solid hands-on skills to deal with nerves, palpation, and finding them. Then this course shows you how to treat them. Not necessarily Pudendal, but all the nerve things. These courses enhance each other. It's like a decision tree where pudendal is on there and you can pass through it and go into Nari’s stuff where you can get a good idea and then use your myofascial, your orthopedic, your neuro skills.

Dr. Michael Hibner is an international expert on pudendal neuralgia and chronic pelvic pain. Dr. Hibner joins Holly Tanner to discuss his new exclusive course with H&W titled Pudendal Dysfunction: The Physician's Perspective.

Pudendal neuralgia is a painful, neuropathic condition involving the dermatome of the pudendal nerve. This condition is not widely known and often goes unrecognized by many practitioners. Dr. Hibner runs The Arizona Center for Chronic Pelvic Pain (AZCCPP), a comprehensive center for treating chronic pelvic pain, and places a heavy emphasis on working as part of a care team with physical therapists and other pelvic rehab providers.

In this interview Dr. Hibner discusses how he treats pudendal neuralgia, “I treat patients with all reasons for pelvic pain but mostly pudendal neuralgia or patients with mesh injury or had an injury caused by pelvic mesh… I work very closely with physical therapists and I am a great, great believer in physical therapy. I am very happy that you are allowing me to share my perspective on Pudendal Neuralgia, and my perspective on physicians working with physical therapists.”

If I had pudendal neuralgia and I had a choice between surgery, injections, physical therapy, or medication. I would for sure have chosen physical therapy every time…there is no doubt in my mind. You can’t treat the PN without addressing the pelvic floor. What I tell patients is this. The number one thing for repetitive injury is to stop what you’re doing. The number two thing is to choose physical therapy over anything else. By far the majority of patients are helped by appropriate pelvic floor physical therapy.

Pudendal Dysfunction: The Physician's Perspective is scheduled for January 9, 2022. Course topics include pathoanatomy and clinical presentations, basics of surgical techniques, and terminology. The latter half of the course focuses on the physician and the rehab therapist working together and features case studies and clinical pearls from Dr. Hibner, a pioneer, and leader in the field.