54-Year-Old Male with Right-Pelvic Pain

This case study focuses on a 54-year-old left-handed male with reports of pain in the right pelvic region for two years duration.

The patient had a long history of being physically active including cross-country skiing and biking – both of which he had not been able to continue performing.

He noted that initially his pain primarily followed long bike rides. He would experience right pelvic/pubic/testicular pain with frequent urination. He also reported of a medial buttock pain radiating anteriorly.

He had been evaluated by a urologist and diagnosed with possible prostititis; however, it did not improve. He underwent an epididymectomy with no improvements. In 2009 he had a denervation of the spermatic cord with no improvement.

The patient was later evaluated and diagnosed with pudendal nerve entrapment. The patient underwent pudendal blocks with fluoroscopic and CT guidance which provided only temporary relief. Pain persisted, and he managed it by avoiding sitting and exercising, utilizing a horseshoe shaped cushion when sitting to relieve the direct pressure to the perineum area. After a period of prolonged sitting, a sensation of numbness in the right lower extremity would develop. The patient was asymptomatic on the left and denied any loss of strength.

A MR Neurography exam of the pelvis was performed. The results showed “vein dilatation and pudendal nerve irritative change, with right sided greater than left, with significant focus at the level of the Alcock’s Canal on the right side.”

The MR Neurography findings are consistent with distal pudendal entrapment syndrome. The degree of abnormality suggests a clinical significant distal pudendal irritative abnormality. Additionally an abnormality associated with the S1 disc space was noted for which CT scanning was suggested to further assess the area.

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