Pharmacological therapy for pudendal neuralgia
Excruciating pain, difficult to manage, is a constant companion of pudendal nerve neuropathy. It is multifaceted - patients describe its character very differently - but all patients agree on one thing: it is agonizing. Pain can intensify in some positions and diminish in others, depending on the time of day and night, temperature exposure to the affected area, and other factors. All of this is not as important as the need to combat it so that people suffering from pudendal neuralgia can lead a normal life.
What to Expect from Pharmacotherapy:
Chronic pain syndrome affects the ability to engage in everyday activities, communicate with family and colleagues, perform any work, drive, take care of oneself, and hobbies. It can significantly limit a person's social activity, deprive them of new opportunities, and even earning money. Severe, constant pain often leads to depression, including severe depression.
Despite the desire to completely get rid of the pain, it is important to set realistic goals.
Sometimes patients come hoping for absolute "healing," but this is not always possible.
Sometimes patients come hoping for absolute "healing," but this is not always possible.
The primary goal of pharmacological therapy is to improve the quality of life of the person, reduce pain to an acceptable level that does not interfere with living a full, as far as possible, life. The first sign of successful treatment of pudendal neuralgia is when the patient resumes social connections, continues to work, and engages in other usual activities.
The
patient is clearly embarrassed. This is not uncommon: the problem is delicate,
and many find it difficult to talk about it. However, the issue needs to be
addressed - the young man clearly feels unwell. He was previously treated not
by me, he came from another city:
- Last time I was prescribed amitriptyline. But, honestly, I stopped taking it.
- What happened? Was there no improvement?
- At first, there was, but, you see... I started having constipation. And that literally nullified all the beneficial effects.
Such a side effect of amitriptyline is indeed possible. It does not occur in every patient and not too often, but constipation is something that any person with pudendal neuralgia must avoid. Defecation becomes torture, and even if the pain has diminished before, constant straining leads to increased inflammation and further damage to the already affected nerve.
- I tried taking lactulose, but it didn't help much. I know there are more powerful laxatives, but does therapy with amitriptyline mean I have to take them constantly?
- Yes, most likely. If the side effect is so pronounced, it is unlikely to disappear. Has your treatment plan been changed?
- Yes. I am taking "Lyrica" and "Cipralex" and overall feel better, meaning the pain is going away. But it seems that some side effects have cropped up again.
- What do you feel?
- I would say I don't feel anything at all. I am constantly drowsy and indifferent. Sometimes I have a feeling that I am not really here and everything is very distant. It's hard to describe. The walls seem cardboard-like. Could this be because of the pills?
- How long have you been taking "Cipralex"?
- Very recently, they prescribed it 5 mg per day literally a week ago.
- If you haven't taken antidepressants before, it's probably just an adjustment process. Unpleasant symptoms sometimes appear in the first couple of weeks after starting treatment and soon disappear. Can you wait for this moment?
- Well, if this goes away and it just needs to be endured, then I am ready. I also noticed that if I apply dry heat to some points, it gets easier. For example, a boiled egg to the coccyx. But isn't it harmful? Can inflammation intensify due to high temperature?
- This is a form of local anesthesia, quite effective. If it helps you, you can try heating patches, they are usually sold as a remedy for joint pain and are more convenient than boiled eggs. Another option is patches or ointments with lidocaine. They need to be updated periodically, but there are patients who feel much better with them.
Many also use homemade remedies for local pain relief. The simplest, which also costs almost nothing, is a bottle of ice-cold water wrapped in fabric (for example, an old T-shirt). Patients apply such "cold compresses" when reading, watching movies, or falling asleep. In combination with pharmacotherapy, such "home anesthesia" can increase the level of household comfort.
Medications used for pudendal nerve neuropathy.
Medications used in pudendal nerve neuropathy include various classes of drugs. The general mechanism of their action is to reduce the increased excitability of neurons, both peripheral and central.
Clinical trials provide recommendations for the use of medications, but predicting which specific drug will demonstrate the best results in your case is impossible, so often it's a matter of trial and error.
This necessitates close collaboration between the doctor and the patient during the selection of therapy: what works well for one person may be useless for another. Before finding the optimal regimen, it may be necessary to try several other options.
Local anesthetics and suppositories
The
advantage of local anesthetics is the absence of systemic toxicity. Various
preparations are used:
● Cream with chili pepper extract containing capsaicin, which depletes the substance P peptide involved in pain transmission with systematic use.
● Lidocaine (ointment or patch).
● Combination products.
Local anesthesia is often prescribed in conjunction with orally taken medications such as gabapentin. Vaginal and rectal suppositories also alleviate pain in the treatment of pudendal neuralgia, according to some patients. These suppositories include preparations with belladonna, opiates, and diazepam.
Antidepressants
Three
main classes of substances used in neuropathic pain therapy:
● Tricyclic antidepressants (amitriptyline, desipramine, nortriptyline).
● SSRIs - selective serotonin reuptake inhibitors (paroxetine, sertraline, escitalopram, citalopram, fluoxetine).
● SNRIs - "dual-action antidepressants" (duloxetine, venlafaxine).
The complexity of using antidepressants in the treatment of pudendal neuralgia lies in the numerous restrictions, side effects, and conditions of administration. For example, amitriptyline may cause dementia in elderly people, some other TCAs are proarrhythmic, and the action of SSRIs is highly individual. Among other things, specialists highlight the modern drug "Cymbalta" (duloxetine), which is widely used in the treatment of sexual neuropathy and demonstrates good results. The analgesic properties of antidepressants are independent of their effect on patients' mood.
Anticonvulsants
Anticonvulsant
drugs are considered second-line therapy for most neuropathies, including
sexual ones. The list includes:
● Pregabalin - most commonly prescribed, and there are studies suggesting that combination with duloxetine may provide more relief to patients than using only one of the drugs.
● Gabapentin - also frequently prescribed.
● Carbamazepine.
When prescribing medications of this line, the results of efficacy studies for a specific type of neuropathy are taken into account.
There is also a problem associated with the high number of side effects when using anticonvulsants. Among the adverse reactions are headache, dizziness, increased drowsiness, skin rashes, asthenia, and even (ironically) polyneuropathy.
Careful medical monitoring of the patient's condition is necessary when selecting medication.
Opioid Analgesics
The
use of opioids in neuropathic pain treatment has been the subject of debate for
the past 10-15 years. It used to be believed that such analgesics did not
relieve pain in patients suffering from neuropathic pain, but recently, there
have been studies proving the effectiveness of their use in helping patients
who have not been helped by other medications.
The
issue remains controversial. Patient reports of pudendal neuralgia indicate
that opioid treatment can alleviate pain but not completely relieve it. If
non-narcotic agents are not effective for you, the next step may be discussing
with your doctor the possibility of using opioids.
Tramadol
Among
narcotic analgesics, tramadol is of particular interest due to its ability to
exert effects similar to SSRIs, but the question remains insufficiently
studied. Like other opioids, it should be prescribed with great caution to
individuals with a history of substance abuse.
Benzodiazepines and their analogs
Benzodiazepines may be prescribed for neuralgia to reduce tension in the pelvic floor muscles through their muscle relaxant effects:
● diazepam;
● lorazepam;
● clonazepam.
There are also several drugs that are similar to benzodiazepines in their pharmacological effects and have shown results in therapy for patients with neuropathic pain caused by pudendal nerve entrapment:
● zolpidem - a sedative whose effect has been positively reported by patients experiencing sleep difficulties;
● cyclobenzaprine and carisoprodol - muscle relaxants that may be useful in reducing tension in the pelvic floor muscles in pudendal neuropathy.
Nonsteroidal anti-inflammatory drugs (NSAIDs)
NSAIDs are effective for pain syndromes depending on their nature. Doctors believe that such drugs as ibuprofen can help with genital neuralgia.
Other agents
Medications not belonging to any of the above categories may also be useful in the pharmacological treatment of pudendal nerve entrapment. These primarily include:
● baclofen - a centrally acting muscle relaxant;
● ketamine - an NMDA antagonist.
Both drugs are currently not sufficiently researched to speak of proven efficacy in the treatment of sexual neuropathy; however, they may have potential.
Some individuals suffering from pudendal nerve entrapment also report successful use of phytotherapy, which improves their well-being. However, before ingesting any compositions (even decoctions or herbal infusions), it is necessary to consult with a treating physician.
Combination with non-pharmacological therapy
As
seen from the list of agents, there is no single, effective medication for all
in combating pain syndromes in pudendal nerve entrapment. Research is ongoing,
but at present, doctors are forced to combine various methods and independently
analyze their effectiveness. Before prescribing a particular medication, it is
necessary to thoroughly weigh all pros and cons and ensure the absence of
contraindications, so only a doctor can prescribe and adjust pharmacotherapy.
In addition to pharmacological methods, non-pharmacological treatment methods are used:
● physiotherapy;
● radiofrequency ablation;
● pudendal nerve blockade;
● surgery aimed at releasing the nerve.
Years of practice show that successful therapy selection requires patient involvement in the process and patience if several attempts are needed. Neuropathic pain often requires the simultaneous application of several pain relief methods to achieve the best result.
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