Episode 32: Pudendal Neuralgia | Hernia Talk Live Q&A

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Speaker 1 (00:00:02):

Good evening everyone. My name is Dr. Shirin Towfigh. As you know, you are joining me for Hernia Talk Live. This is our weekly event, which we call Hernia Talk Tuesdays. We are currently simulcast on Zoom and Facebook Live. You couldn’t also catch this recording later on YouTube. You can follow me on Twitter as well at hernia doc. Today’s esteemed guest panelist to answer all of your questions is Dr. Michael Hibner. Dr. Hibner is a urogynecologist by training. You can follow him on Facebook at Michael dot Hibner. He is a fantastic surgeon, great human being. But really interestingly, and the reason why I have him on this week is he is one of the very few specialists in treatment and evaluation of pubalgia, which we will learn about and discuss for the rest of the hour. So welcome everyone to Dr. Hibner. Hi Michael, how are you?

Speaker 2 (00:01:03):

Hey, how are you Shirin? Thank you for inviting. I’m really honored. I’m really

Speaker 1 (00:01:08):

Honored. So for the audience, this is actually the first time I’m seeing what Dr. Hibner, I have known about him and read his work for many, many years. He actually has a chapter on ental neurology in my book, the Sage’s Book of Hernia, chronic Pain and Hernias, which is very unique. It’s a great, great chapter. I highly recommend that you guys take a look at. So that was my first kind of interaction. We have a mutual friend, Dr. Jonathan Solnick, who is head of gynecologic, like minimally invasive surgery in Toronto now. He’s excellent surgeon. We used to share a lot of patients and then I learned about Dr. Hibner. But you’re a different state. You’re in Arizona, which looking back there, it looks like it’s not that hot. Usually I’m used to seeing

Speaker 2 (00:02:04):

The tallest day in the last two weeks it was pretty cold already and today is back to nineties.

Speaker 1 (00:02:12):


Speaker 2 (00:02:13):

Just for a day.

Speaker 1 (00:02:16):

So we have tons of people on both Zoom and Facebook and we’ll kind of go through those questions. But before we do that, I want to just get a little introduction of what you do. What does it mean when you’re a urogynecologist, how are you different from a urologist or what we call female urology specialist? And just give us a little bit more information about what you do.

Speaker 2 (00:02:47):

Yes. So thank you. So I am by training, by my residency training and board certification. I am an ob gyn doctor. I do not practice any obstetrics nor I have ever practiced obstetrics. And right after my OBGYN residency I did a fellowship in at Mayo Clinic in female pelvic medicine and reconstructive surgery, which is a urogynecology, it is a specialty for that is designed to treat patients with prolapse and incontinence, female patients with prolapse and incontinence. And I actually have, after my fellowship, I have actually never practiced prolapse or incontinence because right after my fellowship I got interested in treating patients with pelvic pain. So I actually really see patients for a different specialty that I trained for. And it is the specialty that at the time, 17 years ago, I graduated from my fellowship in 2003 at that time didn’t really exist. When I decided to see patients with pelvic pain, everybody was surprised that that’s what I want to do because honestly no one really wants, no gynecologist wants to see patients with pelvic pain.

Speaker 2 (00:04:14):

Very difficult. But I was very persistent and initially I was seeing patients with endometriosis because that’s what we are taught in gynecology. And very quickly I noticed that there are patients who have conditions that are just not endometriosis, they just don’t meet that endometriosis picture. And I was very determined to figure out what is wrong with them. Luckily in 2004, the Google was already very operational, so I started Googling their symptoms. So I actually did what patients do now that’s what I did as a physician. So I googled their symptoms and the name pudendal neuralgia came up. And when the name pudendal neuralgia came up, I already had a name of the disease, which was very useful because then I could take the name, the name and I could go on Medline, which I dunno if all the patients know, but Medline is the online library with medical articles.

Speaker 2 (00:05:19):

And when I typed in neuralgia, very few articles came up. But what I noticed is that most of them had one common name and that name was Roger Robert. Roger Robert is a French neurosurgeon in Mount France. So I realized that he wasn’t always the first author, but his name was in on most of the articles. So I realized that this is the person I need to get to and this is the person that I need to somehow work with. And I have a friend here. I do speak some French, but not enough to write a letter. But I have a friend here in Phoenix who is half French. I understand that when you write a letter to France, it has to be in French. Yes. And so what I did, I had a letter written to him, which I didn’t have his email, I had his regular address. So I send the letter to Roger Robert asking him, asking him if I could come and learn from him. And for two weeks I haven’t heard anything. And two weeks later I got an email from him in perfect English that absolutely yes. And how about in two weeks I can come and visit him.

Speaker 2 (00:06:33):

That was not easy because in two weeks I already had plans and also we had little children, but I was able to go and I spent almost three weeks with Roger Robert who we became. We quickly became friends and I learned everything at that time that I could learn about.

Speaker 1 (00:06:56):

Fantastic. We should encourage that more often. Really. There are people out there that it’s like for us it’s like we’re in Disneyland. It’s like a life experience. You go there and you can learn so much. I do that for many of my colleagues, some of them in Europe that come for a specific need. And I learned from other specialists kind of when I do hernia talk, that’s it’s my way of learning from you all. But that’s a great story. That’s a great story.

Speaker 2 (00:07:27):

So I really like what you just mentioned because I actually trained at Mayo Clinic from a very great, one of the best gynecological surgeons, Dr. Javier Rina. And those are his words. If we were done with surgery early, which wasn’t too often, but if we were, he would tell me, he’s like, don’t go home, go to another room, just pick up any OR and go wherever there’s surgery and just go there and watch. Because I do

Speaker 1 (00:07:54):

That, I do that all the time. When there’s downtime in between my operations, I go, some people think I’m sneaking or poking in there, they get all nervous. Yes. I just go there to learn, see what they’re doing. We don’t necessarily get exposure.

Speaker 2 (00:08:10):

And actually when I do pudendal nerve decompression surgery, most of the instruments that I use are actually E N T instruments. So I actually use a neurosurgical microscope because the way that I do pudental nerve decompression surgery, the transgluteal approach, I don’t use that. I don’t use laparoscopy, it’s, it’s really an open surgery through the incision in the buttock. But one of the modifications, so I actually had significantly modified the surgery from what Roger Robert in France does. And one of the modification was that I use neurosurgical microscope, but most of the instruments are actually the ENT instruments, which took time because I had to go through the trays, I had to go through what they use, what instruments they use, and none of the instruments are like gynecological instruments. And actually in fact, one of the suggestions for the instruments came from the patient because one of the things when you operate on the Pudental nerve, the Pudental nerve actually enters what’s called an Alcock’s canal.

Speaker 2 (00:09:21):

Alcock’s canal is the canal in the muscle in the obtuator internist muscle. So it’s a narrow canal. And the patient many years ago asked me, how do you actually see in the canal? And I was thinking, it’s like actually we don’t really see that well. And he actually is a gentleman. He actually made me think about it. And the next day I went to work and I spoke with my favorite scrap tech and scrap techs are so knowledgeable, her name is Cindy. And I’m like, Cindy, what do I do to actually see in there? And she suggested the longest possible nasal speculum. And that works so perfectly. And ever since I’ve been using the longest possible nasal speculum. And that’s actually what works.

Speaker 1 (00:10:08):

So I mean nasal speculum is like your speculum, right? The gynecologic speculum, it’s

Speaker 2 (00:10:12):

Just is just a little bit

Speaker 1 (00:10:13):

Different, much smaller and

Speaker 2 (00:10:15):

Longer, much smaller and longer. But the point is that I have modified the surgery that I actually listened to. Suggestions of the suggestion came from the patient that I need something and the idea to use actually came from one of my scrubs. And that happens when you are almost reinventing the server that doesn’t exist. You have to be very open-minded and you have to listen to people that actually may know something that you don’t.

Speaker 1 (00:10:46):

Yes, agreed. So many of your fans are already on live, they understand that you have recently switched to private practice. Can you just give a quick blurb? Where is your practice? How could they find you? Are you seeing patients full-time now? Give us an update on your practice.

Speaker 2 (00:11:05):

Yes. So for 17 years I worked at Dignity Health St. Joseph’s Hospital in Phoenix. And I left in May of this year. This was my academic practice where I was involved with teaching in medical schools. And in May I left. And it took me few months to get organized, but in September I opened my private practice here in Scottsdale, which is a suburb of Phoenix. I’m actually still in Phoenix. Yes, my practice, hold on, I’m going to come. My practice is called Arizona Center for Chronic Pelvic Pain. Yes. And so the, it’s AZ C C P P. So my website is https://azccpp.com/ And on the website I’ll all our and emails are on the website. I am, I opened the practice end of September, but I’m still getting organized. So of course I’m seeing patients and I’m doing surgeries, but I’m still getting organized as far as the staff. So if you are calling, please don’t get discouraged. I am more of an academic type. I’m not a business person. So it’s taking time for me to learn all the ins and outs of the practice or running the practice.

Speaker 1 (00:12:26):

And even though you’re a gynecology train for pudendal neuralgia, you do treat males and females, correct?

Speaker 2 (00:12:34):

Yes, correct. So actually, and this, thank you so much for bringing this up because I initially saw male patients until 2012, from 2005 until 2012. And then American Board of OBGYN said we stopped seeing patients, they reversed their ruling, but my institution did not allow me to do that. And now when I’m remember practice, I do see male patients. And actually as it is right now, I would say since I started, I would say about half of my patients are after male patients because male patients can get pal neuralgia just like women can get pudendal neuralgia. And is

Speaker 1 (00:13:12):

The economy different?

Speaker 2 (00:13:14):

No, the anatomy mean once you get to the nerve, it looks pretty much the same. The surgery and male patients is a little bit difficult. And the reason why it is a little bit more difficult than in women because when you cut through the buttock you have to cut through, well actually I don’t cut the fibers of the gluteus muscle. And males tend to have a thicker gluteus muscle. Even the guys that are not very muscular tend to have a, so the nerve is just deeper. So once you get to the nerve, it looks the same, but you are basically working in the deeper area to get to the nerve. And that makes it a bit more difficult. And someone asked me that question I think a few days ago. Of course, I’m a gynecologist really by training and I feel very, very sorry for women that are in pain. And that’s really my first goal is to take care of women. But I really feel really bad about male patients because I feel that that guys have really nowhere to go because for women, there are gynecologists that take care of pelvic pain. There’s not that many, but at least there’s somebody to talk to. For guys, there’s often nobody to talk to.

Speaker 1 (00:14:36):

Yeah, I agree. And it’s such a terrible, it usually most diseases have a name that describes a reason for the problem. pudendal neuralgia, nerve pain from the pudendal nerve. But this term, chronic pelvic pain has always bothered me because it’s like a miscellaneous, it could be anything. It’d be a hernia. I see tons of people with that have been labeled as chronic pelvic pain and they have a hernia, I fixed a hernia, pain goes away. Or they could have something super complicated, pudendal neuralgia. So on that note, can you give us just a brief discussion of what is dental neuralgia and then how do people know if they have it?

Speaker 2 (00:15:18):

Sure, of course. That’s a really good question. And for our listeners, when you talk to different providers, they actually may have a different term of what pubalgia is. And my term may be different or what I call pubalgia may be different from other providers. So what I do is I actually strictly separate the term pubalgia and pudendal nerve entrapment, just to keep it separate and to keep it clear. So for me, at least in my practice, pudendal neuralgia is pain in the area of the prandial nerve without necessarily saying what the cause of the pain is. So if someone has pain in the area of the innovation of the nerve, and I would call that pudendal neuralgia, but I am not necessarily saying that their pudendal nerve is injured. And the reason I do it that way, because it is very difficult to actually know if the nerve is injured or not because there’s really no good test to, that I can do to find out if the nerve is injured. Now, pudendal nerve entrapment is if the nerve is injured, either by scar tissue, suture material, Mesh tumor compression, external compression or anything else. So pudendal nerve entrapment is going to cause pudendal neuralgia. But there are other causes of pudendal neuralgia. And for example, if someone has severe pelvic floor muscle spasm, yes they are going to have symptoms of pudendal neuralgia because if someone has severe pelvic floor muscle spasm, those spasming pelvic floor muscles are going to put pressure on the pudendal nerve and they’re going to have the symptoms of pubalgia.

Speaker 1 (00:17:27):

So cause the nerve starts in the back as all nerves do from the spine and then it runs through the pelvic floor muscles. So any pelvic floor spasm can potentially poke or irritate the pudendal nerve that’s running through it. Right?

Speaker 2 (00:17:45):

Yes. So there’s that. Yes. So there’s that area of the pudendal nerve that’s, that runs through what is called the alcock’s canal. The alcock’s canal, like I mentioned, that’s a part of the obtuator internist muscle, which is one of the pelvic muscles. And when pudendal nerve runs through the obtuator internist muscle, the, there’s a very fairly tight canal and when the muscle is spasming, it is going to put the pressure on the nerve. And so that patient has a PAL neuralgia, but that patient doesn’t really have a PAL nerve entrapment. Got it. Cause the treatment for that patient would not necessarily be to operate on the nerve. The treatment on for that patient would be to somehow relax the muscles. And there’s many treatments that can be done for that.

Speaker 1 (00:18:30):

And what are the symptoms of pudendal nueralgia, there’s so many branches from it, what are the different symptoms?

Speaker 2 (00:18:37):

So it is the pain and the area of the pal in of pudendal nerve, which, and women, it’s labia, clitoris, vagina, perineum, and rectum. And in men it’s perineum and rectum, penis and scrotum. So not testicles, but scrotum. And the pain is generally much worse with sitting than with standing or laying down. And generally the pain is better when sitting on the toilet versus sitting on the chair because that center of the pelvis is elevated in the air.

Speaker 1 (00:19:20):

Like a donut.

Speaker 2 (00:19:21):

Like a donut, yes. So this is the biggest symptom and there’s something that is called non criteria. So N is the city in France where Roger Robert works that that’s the guide that I learned from. And so they came up with an inclusion criteria, exclusion criteria, and complimentary criteria. So the list is very long of those criteria. I don’t necessarily agree with everything that Roger Robert published. So even though he’s my mentor, I still don’t agree with everything because for example, he’s, he states that in pudendal nerve, nerve entrapment, there’s never pain at night when the patients are sleeping. Well, that’s not necessarily a true, because if someone has an untrapped nerve by pelvic Mesh or the suture, yes they’re going to hurt regardless whether they’re laying down or sitting down. So I think that the criteria really need to be modified.

Speaker 1 (00:20:25):

They’re talking about probably primary P dental neuralgia where the nerve itself like a cyclist, is that the most common, it’s like a cyclist. They’re on that small little horrible, painful.

Speaker 2 (00:20:39):


Speaker 1 (00:20:39):

Cycling seat, this is the little areas are always being pushed on.

Speaker 2 (00:20:45):

So this is the question, especially the race seats, which are really narrow. So this is actually the question that I ask get asked quite often because patients are like, well, I don’t ride the bikes. So this is where the misconception came from. So pudendal neuralgia for the very first time was described by a French psychiatrist and neurologist Girard Merenko from Paris in 1980s. And he noticed that there is this pain that he didn’t know what it was that happens in cyclists and bikers and there’s a lot of them in France. So he called that the cyclist syndrome. Yeah. Because at that point he didn’t really know if it’s a pudendal nerve, if it’s any other nerve, if it’s a muscle or whatever it is. So he called it the cyclist syndrome because he noticed that it happened, happens in cyclists later on, he figured out that it’s an injury to the pudendal nerve because what happens when you sit on the narrow bike seat? Yes, the bike seat presses against the sit bones. I mean medically we call it the ischial tuberosities, but most of the people call it sit bones and the nerve travels on the inside part of those sit bones. And so there’s this misconception that pudendal neuralgia mostly happens in cyclists, but that’s not true. I mean it happens in cyclists, but it is, there’s many, many, many other ways to get it that I believe are actually more common than writing about.

Speaker 1 (00:22:26):

So I read back in, I think World War I, did they have Jeeps in World War I?

Speaker 2 (00:22:31):

No, Jeeps start in World War ii, but they had world

Speaker 1 (00:22:35):

War. Yeah, the soldiers were sitting on their seats, but there were no cushions on the seats, yes. Would jump up and down and they would get pudendal neuralgia.

Speaker 2 (00:22:47):

I read something like that. And at that point, of course they didn’t know that. But of course sitting on the hard surfaces, yes, I had many patients that have developed it from sitting on the hard surfaces actually people that have prolonged sitting, just sitting for many, many, many hours because it puts pressure on the nerve itself. So cases where I, I’ve, I’ve had patients that took a long flight to Japan or for many, many hours where they were stuck in the seat and never got up. And there may be some ischemia to the nerve just from sitting in an uncomfortable position. And I definitely have patients that took a long hard trip across the country or were sitting on the hard seat. So yes, absolutely.

Speaker 1 (00:23:39):

Maybe all these zoom meetings we’re doing, are you going to see an increase in pal neuralgia?

Speaker 2 (00:23:44):

Well, I guess we’ll know. That’s a very good point also. And that is before COVID times, I had a group of patients that were attorneys or engineers. I mean those are the people that tend to sit, luckily for us, the surgeons, I mean even if we do the robotic surgery, still get up and walk. But some attorneys, they sit for hours and hours and hours in depositions and stuff. And so yes, I think they’re more

Speaker 1 (00:24:13):

Good for your back anyway. You should get up and stretch every hour. So let me ask you this. So when you get it, because of prolonged sitting, do you see it mostly really thin patients or cachectic patients? I’ve seen them in super thin patients and I’ve also seen it in patients that are wheelchair bound.

Speaker 2 (00:24:34):

Yes, that’s a great observation because I totally agree. I think people that are super thin, they have less of the padding of the fat and I think they’re more likely to get it. So that’s one thing. But there is another observation that actually one my previous physical therapist that Loretta, who was in my office, and Loretta was this super brilliant observant physical therapist, she retired, but she made, and we actually, Loretta and I used to go to the cadaver lab and we made some observations in the cadaver lab. And one of the observations is, so it’s different when someone had surgery and they had Mesh because a big part of my practice right now are patients that, for example, had prolapse or incontinence and they had some kind of a Mesh and that injures the nerve. So that’s a separate category, but I think there are people that are anatomically predisposed to pudendal neuralgia. And the area where the nerve most commonly gets entrapped is the area where two ligaments in the pelvis cross or they actually come close to each other. That’s the sacrospinous and sacrotuberous ligament. And different people have different space or that width between the ligaments.

Speaker 2 (00:25:56):

And I think people that tend to be thin and tall that, so for example, for women that would be more of a boyish type of the build of pelvis, like slim, like small pelvis, tall narrow

Speaker 1 (00:26:15):


Speaker 2 (00:26:16):

Yeah. Yes. Narrow pelvis. They tend to have that space narrower. So those are the patients that space is narrower. So the nervous probably more likely to them and track. The good thing about it is that those are also the patients that are easier to do the surgery because they have less path and the nerve is more superficial. So it’s easier for me to get to, but they have less padding. Definitely.

Speaker 1 (00:26:41):

So when you’re treating these patients, do you trying to figure out, do they present with every single part of the neurologist? So in a female they get clitoral, vaginal, labial, perineal and perianal pain, all of it?

Speaker 2 (00:27:03):

No, they can have all of it or they can have more of a selective one branch pain. Generally patients that have all of it, at least we think, I don’t know if it’s really, we have good research to prove it, but I think those patients tend to do better because it’s easier to surgically decompress the whole trunk of the pudendal nerve rather than the branches. But there are definitely people that have selective branches of the nerve that are compressed. Got it. And so just the anal pain or just the clitoral pain. And actually for that reason that you just mentioned, a few years after I went to France, I actually went to Austria to work with another surgeon in Austria, Dr. Oscar Ashman, who is doing dorsal clitoral or dorsal penile nerve decompression. So those are patients that have selective pain either in the clitoris or the penis where you can actually selectively decompress just that one branch of the nerve. Interesting. And in those patients, the incision is in the different area and it’s a different surgery. So

Speaker 1 (00:28:20):

The nerve starts the back and comes forward. So can you have anal pain without the penile pain or penile pain without the anal pain? Both.

Speaker 2 (00:28:27):

Yes. Yes. Correct. You because the nerve can be compressed in different areas. So what I do for those patients, and that’s something that actually I came up with because when I went to France, the Roger Robert, only the one kind of surgery when I went to Austria, Dr. Ashman only did the other kind of surgery. Now I had a dilemma, how do I decide which type do I do? So I came up with an idea and me and my coworkers, we came up with an idea of doing a selective nerve block. So we came up with a techniques where using the ultrasound I can selectively block one of the branches of the nerve. Wow. Perineal branch or clitoral branch. It is a little bit more difficult to block the rectile branch, but radiologists can generally do that with a ct. And this way it allows me to distinguish which of the surgeries do patients need depending on which branch do I block.

Speaker 1 (00:29:29):

Okay. One of the questions is, is there a connection between pudendal neuralgia and proctalgia fugax? Can you explain that?

Speaker 2 (00:29:38):

Well, so I think proctalgia fugax is one of those conditions that, so I think proctalgia fugax is what it really is… It’s the spasm of the pelvic floor muscles and it’s a condition that has multiple names. So that’s something that I used to call spastic pelvic floor syndrome. Actually I used to call it pelvic floor tension myalgia. Now I call it spastic pelvic floor syndrome. Some people call it vaginismos. They call it obtuator syndrome. So yes, there is a connection because patients with injured pudendal nerve, they will have the spasm of the pelvic floor muscles. Almost always when you have the injured pudendal nerve, you almost always have spasm of the pelvic floor muscles. Got it. So whenever you have a bowel movement and the pelvic floor muscles are stretched it, it’s extremely painful. Now most of the patients,

Speaker 1 (00:30:44):

Sorry, proctalgia means anal pain, right?

Speaker 2 (00:30:47):


Speaker 1 (00:30:47):

Yes. So proctalgia kind of like any anal pain?

Speaker 2 (00:30:51):


Speaker 1 (00:30:52):

So no one can figure out,

Speaker 2 (00:30:54):

Yeah, no one can figure out. But I think if you actually examine those patients, you would find that a lot of them actually have the spasm of the pelvic floor muscles. And I know fugax means because proctalgia is anal, but fugax means that it just comes and goes without any good reason. But I think if you figured it out, if you talk to a patient that a lot of times it is somehow related to stretching those muscles or putting some kind of a pressure on those muscles. So I think my first thought in those patients would be to actually look into spasm of the muscles and make sure that this has been rolled out before doing anything else. Got it. So

Speaker 1 (00:31:43):

Non nerve pain, but a muscle spasm issue.

Speaker 2 (00:31:47):

So generally with all the patients that have pudendal neuralgia type of pain, and again I’m trying to separate pudendal neuralgia from pudendal nerve entrapment. So if they have pain in that area, whether it’s proctalgia fugax most like whatever you call it, the first thing that I do in patients is to make sure that pelvic floor muscle spasm is not what is contributing to the pain. Got it. The way I do that is I do send patients for physical therapy. I am a huge, huge proponent of Botox. So I inject Botox vaginally, I inject Botox into the anus, I inject Botox into abductor muscles in the legs, piroformis muscles because once I eliminate muscles spam and patients are still hurting. I think that’s the time when I can comment on the nerve injury. I think as longest patients have significant muscle spasm, I think it’s very difficult to assess their nerves because Got it. You just don’t know.

Speaker 1 (00:32:52):

Yeah, primary versus secondary issues.

Speaker 2 (00:32:54):

Exactly. Exactly.

Speaker 1 (00:32:55):

Okay. You talked about pelvic floor Mesh and how that can potentially injure the pudendal nerve. So two questions on that. How is it that pelvic floor Mesh can injure the pudendal nerve because the pudendal nerve is not exposed, where is placed? And then secondly, we have a live question, which is what do you recommend if a patient’s pal nerve is caught within the scar tissue, the pelvic floor or somehow pelvic floor fascia? What do you do for

Speaker 2 (00:33:23):

That? Okay, so the first question, it depends on the type of the Mesh. So, and I actually just last week gave a, we had this big conference and I gave a big webinar to the physicians on how Mesh can entrap the nerve. And it really depends. There are different meshes that attach to different parts of the pelvis because when you place the pelvic Mesh, it actually has to have an attachment point. And so there are meshes, there are meshes that attach to what is called a sacrospinous ligament. That’s one of those ligaments that I mentioned where the pudendal nerve is traveling nearby. And I have multiple patients where the Mesh went into deep into that ligament or it went a little bit too lateral, too much to the side in the ligament and it actually directly injured the Mesh. And I have videos of that where the Mesh is actually piercing right through the nerve.

Speaker 2 (00:34:24):

If this is the nerve, the Mesh actually pierces right through the nerve. So there can be absolutely a direct injury to the nerve. So that depends on the type of the Mesh. The second way that in my mind that the Mesh can do it is if for example, Mesh is placed into the obtuator muscle, obtuator internist muscle, that muscle will start spasming. Yes. And just like I mentioned, because the Mesh nerve actually travels through that muscle, when the muscle spasms around the nerve, it will, it’ll give the symptoms of pubalgia. Yes. So it very, very,

Speaker 1 (00:35:02):

What do you do? So you just have to remove the Mesh?

Speaker 2 (00:35:07):


Speaker 1 (00:35:08):

And then can, can’t the scar tissue from that operation then also cause pal neuralgia?

Speaker 2 (00:35:14):

Yes. So what I do is when I have a patient that had a Mesh and now develop pubalgia, like I really studied the operative reports and tried to figure out what Mesh the patient had, and then most of the cases I would recommend removal of the Mesh. Once I get to the nerve and I actually decompress the nerve, I wrap the area, the decompression with something that would prevent the scarring of the nerve.

Speaker 1 (00:35:42):

Like intercede?

Speaker 2 (00:35:43):

No, some people use intercede. I actually used to use something that’s called neurogen, which is a Nerve conduit. It is a collagen tube that is actually made specifically for nerve repairs. But a few years ago I switched to something that’s called AmnioFix. So AmnioFix is an amniotic membrane. And the amniotic membrane is actually very beneficial because it has nerve growth factors and it also has chemicals that attract your own body stem cells. So you repair the nerve, you wrap it with AmnioFix, and then your own body stem cells are attracted to that area of the nerve to promote the repair of the nerve. Yeah. Got it. So the second question is, I partially answered it. If the nerve is entrapped in the scar tissue, in majority of patients I can surgically decompress the nerve. So that’s the procedure, that’s the neurolysis. So I go in with a surgical microscope at the high magnification. And like I mentioned earlier, I use E N T instruments. So they’re small, tiny instruments and sometimes it, depending if there’s a lot of scar tissue may take hours and one fiber at the time I basically cut out the nerve out of the scar tissue. And once the nerve is free and now are sometimes those are very time consuming surgeries depending on the amount of scar tissue, that actually is not the most, it’s

Speaker 1 (00:37:09):

Difficult area.

Speaker 2 (00:37:11):

It is. And that actually, once you find the nerve cutting it out of the scar tissue is not the most difficult. What is the most difficult is actually to find the nerve in the first place because you’re cutting into the bottle and you’re looking for a needle in the haystack to actually find the nerve. If once you find it, it just becomes easy. But I do have devices that allow me to find the nerve. So I have this, something’s called the NIMS monitor nerve integrity monitoring system. So it’s an electrical device that when I touch the nerve, it sends the electrical signal and it beeps. So I have a wand and I basically start touching in the area. And once I touch the nerve, it’s kind of like the guy on the beach in San Diego looking for a matter I’m walking with. And once I find it, I’m okay. The nerve is somewhere here.

Speaker 1 (00:38:07):

That’s pretty funny. Yeah. Have you seen that this PD neurologist also associated with other chronic pain problems such as interstitial cystitis?

Speaker 2 (00:38:20):

Absolutely. So I think those conditions absolutely tend to go together. So interstitial cystitis is actually one of the other conditions that I commonly see patients for. But, and I’m sure a lot of people are aware that interstitial cystitis is like no one really knows what it is. No one really knows what causes it, right. And no one, we don’t really know how to diagnose it. So if you talk to a lot of urologists or urogynecologists, we all have our ideas about interstitial cystitis. Yeah. So I believe that interstitial cystitis is a condition that is actually primarily caused by spasm of the pelvic floor muscles and patients in ability to empty the bladder. The bladder becomes irritated because constantly pushed to urinate. So if you have pudendal nerve injury, you develop pelvic floor muscle spasm, and then you have what we call medically obstructive voiding, meaning yes, you sit on the toilet and you can’t go. So patients are pushing to empty the bladder and when they do that, the bladder becomes irritated. So that’s how interstitial cystitis goes together with pudendal nerve injury.

Speaker 1 (00:39:36):

So the issue I have, which Tracy shares on this, she says, hi,

Speaker 2 (00:39:40):

Hi Tracy.

Speaker 1 (00:39:42):

She brought this up too on Facebook is I see patients with, they already have five diagnoses. They’ve been told they have pudendal neuralgia, interstitial cystitis, they have endometriosis, none of these proven by the way, these are always kind of these diagnoses thrown at them. Nerve entrapment, can’t tell you what nerve, but you have nerve entrapment. They get spinal nerve stimulators, all of these things, in my case, they end up having a hernia because hernias can give pelvic floor spasm that can cause urinary frequency because of it as well as some tenesmus, which is like rectal anal pain and feeling like you have to avoid but you don’t. But it’s all secondary to pelvic floor spasm, which is due to the hernia fix. A hernia goes away. They’ve been told they have obtuator neuralgia, they obtuator nerve problems. And so I have a little bit if issue with it because I feel these patients are just, every diagnosis is thrown at them. Chronic fatigue syndrome, Lyme disease, that’s a big one in California, we don’t even have ticks that cause Lyme disease, but okay, everyone’s got Lyme disease. So what do you feel about that? Do you see that too? You must see a lot of that.

Speaker 2 (00:41:02):

So just to give you an example, I mean it’s a perfect timing. I saw a young patient today, I actually had seen her before at St. Joe’s and in my previous practice and she came back. So she actually has proven endometriosis. Known endometriosis, yes. She has heart tissue from years of endometriosis. She has IBS or she was told she has IBS.

Speaker 1 (00:41:27):


Speaker 2 (00:41:28):

Yes. She was told she has IC and interstitial cystitis and she probably probably does because her bladder hurts as it fills up. So that’s by definition when the bladder hurts, when it fills up, she has really bad muscles spasm because I can feel it. And so I told her she has all these things, so she’s like, oh. And I said, listen, I don’t want you to get upset because all of the things that I have mentioned to you can be explained by one thing. So it’s not that you are so unlucky and everything in your life is just super unlucky, but you got endometriosis because 10% of women have endometriosis that your endometriosis was worse, but it’s a common condition. You got endometriosis that led to your pelvic floor muscle spasm and that pelvic floor muscle spasm gave you an ability to empty the bladder and the bowel so your bladder became painful and your bowel became irritated.

Speaker 2 (00:42:30):

And so I said to her, you have a common condition and you probably have all these things, but it doesn’t mean that it’s like the end of the world. You probably need to fix your endometriosis and we need to fix your pelvic floor. I need to remove your endometriosis scar tissue, I need to give you Botox and send you to physical therapy and give you some suppositories that I am a great believer that Valium [inaudible] ketamine suppositories help relax the muscles and your IBS, your interstitial cystitis is probably going to get better. So it is not that, I mean Lyme disease and chronic fatigue. So what happens, and she was such a perfect example that your question was you asked it at the perfect time because that’s someone that I saw few hours ago. So young woman, she’s 29, she gets up to urinate to the bathroom six times every night. Guess what? She’s really tired because she doesn’t sleep.

Speaker 1 (00:43:32):

That’s right.

Speaker 2 (00:43:35):

So I can fix her chronic fatigue, not even by giving her sleeping pill. I can fix her chronic fatigue if I not I, me and physical therapist, if we relax her pelvic floor and she can empty her bladder before she goes to bed, then she’s going to sleep the entire night. But she goes to bed with a full bladder because she never empties it.

Speaker 1 (00:44:00):

Very good point. I just feel that a lot of diagnoses are thrown at patients that they get so lost, they don’t know who to see what to do. And then many get unnecessary procedures like these nerve stimulators that are implanted that never addressed the main problem. Quick question, if you could just quickly talk about the difference between pudendal neuralgia and obtuator nerve

Speaker 2 (00:44:26):

Problems. Yes. So I actually, I do see patients for both. I do take of both. There are different nerves. pudendal nerve innervates, like I mentioned innervates, the perineal area, the labia vagina clatter is penis rectum. The obtuator nerve is innervates the inner part of the thigh. Yes. Mostly that part about the knee. And there are different ways that those nerves get injured. So the obtuator nerve, well obtuator nerve is in your territory. I mean the obtuator hernia. Hernia, yeah, that’s something you could probably talk a lot about. But in gynecological patients, the obtuator nerve may get injured in several ways. So it may get injured with some types of the meshes. So it’s the trans or meshes. So there’s a certain type of the meshes that they attach to the very near the obtuator nerve and the nerve may get injured. The obtuator nerve may also get injured and patients that have lymph nodes removed during gynecological cancer surgery because those lymph node are around the obtuator nerve.

Speaker 2 (00:45:34):

So those patients generally have pain on the medial part of the tie in that area above the knee. They may also have some moderate deficits, meaning they may have difficulty bringing their legs together, but it’s generally more of a pain than moderate deficit. And depending on the nerve can be blocked also just like the pudendal nerve, the nerve block is more difficult than the pudendal nerve. But it can be blocked because you want to block the nerve and you want to make sure it’s the obtuator nerve, not the genital femoral nerve because there’s many other nerves in that area. And it’s also important to know that there’s an overlapping innovation. So

Speaker 1 (00:46:16):


Speaker 2 (00:46:17):

In that groin area there’s many nerves that may go to the same spot. So before you start operating on the nerve, you want to know which nerve to operate on. So the genital camera nerve goes to that area, operate on nerve, goes to that area, and that’s kind of what you want to do. And both nerves can be addressed either surgically or with injections, but they’re completely different nerves. They get injured in different ways.

Speaker 1 (00:46:41):

When you do your injections, I know there’s two different ways to do it. There’s a posterior approach to doing it. Like my pain management people, they’re comfortable doing the posterior approach to the buttock area. But the female urology surgeons, they do an anterior approach for the pudendal nerve. Does it matter? Does the injection response kind of give you the diagnosis? Give me a little bit more information about.

Speaker 2 (00:47:09):

So what I do, so what I do is I actually do two types of the pudendal blocks. Not depending on the approach, but depending on the intent of the block. If I do the block to diagnose the pudendal neuralgia. Yeah, historically, historically I send to radiology to do it with a CT through the buttock. And the reason for that is that I believe that if I’m going to use that information to decide on someone’s surgery, I want to make sure that it really went right next to the nerve in. And those are the ones that are done with the steroids and are again done in the radiology. If I do pudendal nerve, like with an intent of providing pain relief for the procedure. So for example, I do some kind of a procedure in that area and I want patient not to have pain for hours after surgery, then I do it through the vagina.

Speaker 2 (00:48:10):

So for example, when I do Botox injection, I do pudendal nerve block because I want the patient to be numb for a few hours. Now having said that, having said that, I had a patient, several patients that actually wanted me to do that where I did a transvaginal pudendal nerve block where I added a little contrast to this and after doing the transvaginal pudendal nerve block, we actually put a patient in the CT scanner and the location of the block was exactly in the same spot if it was done with a ct. So I honestly don’t think it makes much difference.

Speaker 1 (00:48:41):

So if you do a pudendal

nerve block and the pain a hundred percent goes away, you have your diagnosis. Is that correct?

Speaker 2 (00:48:47):

Well, so this is one of the non criteria, but I think it is very misleading. And I think actually part of it is that the way that it was translated from French initially was kind of very misleading. So I actually wrote a couple book chapters on [inaudible] and I did my own translation from French where I tried to correct the misleading thing. If you have pain in the pudendal area and you do the pudendal nerve block and the pain goes away, it doesn’t mean that the nerve is injured, it just means that the nerve is involved in pain. So Got it. So this is what I tell patients, and I know this may sound brutal, but sometimes that’s the way to explain it to patient. If someone kicked you in the perineal area and you were hurting and someone gave you pudendal nerve block, you wouldn’t be feeling that pain.

Speaker 2 (00:49:37):

It doesn’t mean that your pudendal nerve is injured, it means that the pudendal nerve involved in the pain transmission. But it is very important to do the block because there are patients where you have pain in that area, you do the pudendal nerve block and the pain doesn’t go away right after the block. So that means that the pain has is somewhere from a different nerve than the pudendal nerve. So that patient is actually not a candidate for surgery and that patient you need to look further and try to figure out what else may be hurting.

Speaker 1 (00:50:13):

And in those patients you would do it for the buttock because it gets the most proximal, the largest branch of the PD nurse will get all the branches down downstream as well.

Speaker 2 (00:50:22):

Is that right? So that’s one. That’s one. But the other thing, when you do it through the buttock with a ct, you also have proof that because you see it on the picture that it was done correctly. Because if you do the block and the patient doesn’t have any relief, then you’re wondering, well maybe I just didn’t do it right.

Speaker 1 (00:50:38):

Okay. We have two kind of technical questions. So when you do your E N T scope kind of method to open up alcock’s canal, which is the canal, the bony canal through which the PAL nerve runs through, you unroof that canal and does your operation in any way provide any risk of pelvic instability?

Speaker 2 (00:51:03):

Yes. So those actually, I’ll answer those questions separately because they’re

Speaker 1 (00:51:08):

The smart people I have on online answer all these

Speaker 2 (00:51:11):

Questions. I love it. The problem with me, I like to talk a lot and because really

Speaker 1 (00:51:17):

You have nine minutes, you have nine minutes to discuss, actually have one case. So give me like two minutes or three minutes at the end to,

Speaker 2 (00:51:25):

So I’ll be very quick. So I used to unroof the canal, but honestly after doing hundreds of those surgeries, I realized that majority of the compression is at where the ligaments cross. So I cannot take a look, but I very rarely see that there is any compression there. So I generally leave it alone because I don’t want to be adding to the scar tissue. Got it. Because it’s not that easy to wrap the nerve in the alcock’s canal, but I can very easily wrap it where the, it’s crossed. I look, if it looks fine, I leave it. But I used to unroof it, I don’t do it anymore. The second thing, the instability of the pelvis comes from cutting the sacrotuberous ligament. And majority of people that were doing that surgery were cutting it and leaving it cut and not putting it back together. So I am the first person after I returned from France, from learning from Roger Robert that I decided to actually bring and fix the ligament together. And luckily my uncle is an orthopedic surgeon, so I actually called him before my first surgery and I said, Hey, how do you fix the ligaments? Tell me, because Roger Robert doesn’t do that or didn’t used to do that. And my uncle explained to me how to bring the ligaments together. So I started fixing the ligament from my very first patient and my patients never developed, at least her physical therapist who examines them have never developed pelvic instability because I do repair the ligament.

Speaker 1 (00:52:48):

So there is a risk, but only if they do that. That’s fascinating.

Speaker 2 (00:52:51):

Yes. If you do not repair the sacrotuberous ligament

Speaker 1 (00:52:54):

Yes. We had a story that came in, I’m going to read it to you, it’s a bit long, but I’m sure people can relate. So this is a patient female, she was diagnosed with pelvic floor dysfunction a year ago. She was told that her sphincter was in constant spasm and she had pelvic muscle tightness too. She had Botox, trigger point injections, pudendal nerve block, ganglion impar, none of this helped. Okay. So pelvic four dysfunction, sphincter and spasm, pelvic muscles and spasm. She did PT and was given muscle relaxers four months ago. Things changed. She noticed the pain become more severe, she could barely sit down. And now she has constant shooting, stabbing, burning pain under her coccyx, which shoots into her pelvis and down her left leg. Could this pp dental neuralgia, she’s been referred to pain management for pulse radio frequency, coccyx pain is a difficult one. What can you tell us about this patient? And also,

Speaker 2 (00:53:58):

Yeah, so let’s get the coccyx pain out of the way. So this is how I probably are, there are many other reasons for coccyx pain. But a patient like that, generally what happens, this is how I explain it to the patient with pelvic floor muscles, there are many, many different muscles, but one of the biggest muscle is the pubic coccyxiduous muscles. Muscle runs between the pubic and the

Speaker 1 (00:54:25):

The front of your pelvis or the back of your pelvis basically. Correct. To your tailbone. Yeah.

Speaker 2 (00:54:30):

Correct. So when that muscle goes into spasm, what it does, it pulls on the coccyx. So often the cock six pain is actually from the pubic muscle pulling on the coccyx and I, it’s still hurts, still hurts my coccyx to see that some patients get their coccyx removed for that pain. Cause what those patients generally need is really good physical therapy and Botox into the pubic muscle and that generally helps.

Speaker 1 (00:55:00):

Yeah. This does not sound like a nerve problem, it sounds like it’s very muscular.

Speaker 2 (00:55:05):

Correct. So in this patient where the who ask the question, well one thing that is missing from here, what is really important is number one, how did the pain start? To me, this is the single most important question because the pudendal nerve entrapment does not just happen. You don’t just wake up one day and have pudendal nerve entrapment. Yes.

Speaker 1 (00:55:29):

And this is such an important point. You don’t just entrap a nerve, you don’t wake up one day. I see that all the time. Oh, I have entrap nerve. How no surgery, no trauma. Yeah.

Speaker 2 (00:55:40):

Yeah. So what I call it is you have to have a trauma to the pelvis and by trauma, and I’m not saying it, and then negative because there’s a negative connotation to the word trauma. But by trauma, I mean surgery can be because surgery is a trauma to the pelvis in a way. Sure. Child childbirth could be a trauma to the pelvis. Athletic activity could be a trauma to the pelvis, like gymnasts and then there’s a true trauma like accidents, et cetera. Yeah. Number two, I believe that people that have a true entrapment of the nerve, most likely they have it on one side. Because again, and I gave this example again to the patient today, a different patient today. And I say it’s very rare that you’re nervous untrapped on one side. What are the chances that is entrapped on both sides? So when the patient has pain on both sides, the chances that his or her nerves are untrapped are almost numb.

Speaker 1 (00:56:36):

So when they have clitoral pain or penile pain, it’s on one side of the clitoris or one side of the

Speaker 2 (00:56:42):

Penis. So patients can actually tell, most of the times they can tell. And I think if the pain is on both, and even if they can’t tell you examining the patient by, so there’s something is called a Tinel sign. Well Tinel sign is really with a nerve. But when you press by the initial spine where the nerve actually travels, patients say, you know, can elicit that pain, you can make the patient hurt. So you do that on one side, but they don’t hurt on the other side. And so if the pain is bilateral and if they don’t really have a traumatic event, the chances that the nerve compression the second are very low. Yeah. The second thing, the answer for that question, what this patient didn’t say, and that’s actually really important. The patient is strictly on the left side. The second thing, this patient had a Botox injection.

Speaker 2 (00:57:35):

And what is very important when the patient has Botox injection is that the patient has to go back to the physical therapist because the physical therapist has to make sure if the muscles have relaxed. Because if the muscles have not relaxed after Botox, that means that either the patient didn’t get enough Botox or it didn’t go in the right spot or the Botox didn’t go in the right spot. And so if the patient still has a spasm, I would say try more Botox. But if the spasm is gone and the patient still has pain and the pain is on one side, I read it

Speaker 1 (00:58:11):

Here. Yeah. Pain’s on the left side.

Speaker 2 (00:58:13):

Yes. Then there is a possibility that it is a pudendal nerve entrapment. It really depends what caused the pain. Radiofrequency is one of the options. Actually we stopped doing radiofrequency of the Pudendal nerve because we had some patients, I had some patients that whose pain actually got worse after radiofrequency and probably cryoablation is a better procedure. But generally the outcomes of both are not that great. Maybe about 25% of patients get better. So

Speaker 1 (00:58:46):

You’re saying she may have pudendal neuralgia on one side causing the pelvic floors spasm. Can the pelvic floors spasm cause the pain going down her left leg?

Speaker 2 (00:58:56):

So you

Speaker 1 (00:58:57):

Get sciatica from pelvic floor.

Speaker 2 (00:58:59):

There are two explanations to that. So if there’s a true nerve entrapment, and again it depends on the mechanism, how did that pain start in the first place? But if there’s a true nerve entrapment, the pudendal nerve and the sciatic nerve, they actually start in the same spot in the spinal cord. Yes. And it’s very common that patients with pudendal nerve entrapment will have the sciatica type of pain. So the pain will go the back of the leg all the way down to the foot. And that’s not uncommon. And of course if the patient has significant spasm of the pelvic floor muscles and other muscles in the pelvis leg, for example, piriformis muscle, then that would put the pressure on the sciatic nerve because the sciatic nerve runs right behind the piriformis muscle. And in a lot of these patients they actually piriformis syndrome. Yeah.

Speaker 1 (00:59:55):

So this lady needs to come see you sounds like, because this is not something that can just be randomly treated by someone who doesn’t specialize. It sounds very complicated.

Speaker 2 (01:00:04):

Yeah, I mean so it is absolutely it very important. So the question is, for example, I mean there’s many more questions I would need to ask that patient. For example, when she had a pudendal nerve block, did she have a temporary relief of pension? Super important. When she had a temporary relief of pain, did her leg pain even for few hours. Yes. Then the questions from physical therapist that examines her because I’m not a surgeon, I’m not a physical therapist, so I don’t know the examine the muscles, but that she had a lot of piriformis spasm. Because what I would do, what I would do in a patient like that, and I do that a lot, is to actually inject Botox into the piriformis muscle. I do it with the ultrasound and that takes off the pressure of the sciatic nerve.

Speaker 1 (01:00:53):

I may have to bring you back for another session of hernia talk because our time is up, but I’m still learning and there’s more questions I know we can’t answer though, so, so sorry,

Speaker 2 (01:01:02):

I would love to talk more and answer all the questions. I’m sorry, I get so passionate that I just cut so

Speaker 1 (01:01:08):

Much. I love it. I love it. I know we had a whole session last week with just me talking and questions after questions were coming and I eventually had to shut it down because I had to leave. It was actually my birthday. Oh, birthday. But thank

Speaker 2 (01:01:24):

You. And the beautiful

Speaker 1 (01:01:27):

Thank you from a grateful patient. Very nice. Beautiful. But you know what happens is I could have probably gone in front of the couple hours if I wanted

Speaker 2 (01:01:36):

To. Yeah.

Speaker 1 (01:01:38):

Okay. So on that note, thank you for your time. I know that your time is also precious and to be with your family and you work very hard. Thank you. I’d like to just end this all with thank you everyone who participated. Thank you for all your great questions. Very insightful. I learned a lot. Thank you to Dr. Michael Hibner. Follow me on all my social media platforms at Hernia Doc, on Twitter and Instagram at Dr. Towfigh on Facebook. And sometime tonight I will post the culmination of this hour on YouTube so you can watch it and share it with your friends. Thanks again and everyone have a great evening.

Speaker 2 (01:02:15):

Thank you. Thank

Speaker 1 (01:02:17):


Speaker 2 (01:02:17):

Very much. It was so nice meeting you and see you in person. But the closest we got to meeting in person.

Speaker 1 (01:02:24):

Yes. One day we’ll see each other. Oh,

Speaker 2 (01:02:26):

Absolutely. Thank you. Wonderful.

Speaker 1 (01:02:28):

Take care. Care.

Speaker 2 (01:02:29):

Bye-bye. Good night.