(008) Intermittent Pudendal Nerve Steroid-lidocaine Injections for Region 2 Triggered Persistent Genital Arousal Disorder/Genito-pelvic Dysesthesia

Abstract Introduction The pudendal nerve lies in Alcock’s canal in close proximity to the ischiopubic ramus of the pelvic bone (Region 2; Pelvis/Perineum), making it susceptible to blunt trauma including straddle injuries, surgery, childbirth, and other trauma. Pudendal neuropathy induced by straddle injury is a known trigger of persistent genital arousal disorder/genito-pelvic dysesthesia (PGAD/GPD). To determine whether an individual has pudendal neuropathy-induced PGAD/GPD, a positive diagnostic pudendal nerve anesthesia test with lidocaine should result in clinically significant symptom reduction. Management options for pudendal neuropathy-induced PGAD/GPD include daily neuroleptic medication, intermittent pudendal lidocaine-steroid nerve injections or decompression surgery. Objective The aim of this study was to assess outcome of intermittent pudendal nerve lidocaine-steroid injections to manage pudendal neuropathy-induced PGAD/GPD. Methods Charts from patients identified as female at birth diagnosed with PGAD/GPD between 08/01/2007 and 10/31/2025 were reviewed to find patients who had a positive diagnostic pudendal nerve anesthesia test and underwent a minimum of 2 therapeutic pudendal nerve lidocaine-steroid injections. The therapeutic nerve injection was performed as follows. The patient was placed in stirrups in Trendelenburg position. The perineal region was cleaned with povidone-iodine (10%). Alcock’s canal was marked with a sterile marking pen. Using sterile gloves, digital examination was performed in one side of Alcock’s canal passing under the ischiopubic ramus aimed to the hip. If clinically significant tenderness was noted on that side, the injection was administered with 9 ml of 1% lidocaine and 1 ml (40 mg) of triamcinolone acetonide in a 10 ml syringe with a 1½-inch, 27-gauge needle (Fig. 1). The needle was advanced without fluoroscopic or ultrasound imaging using continuous injection medication delivery to help prevent needle injury to the pudendal nerve. If clinically significant tenderness was noted on the other side, the process is repeated. Results 10 patients met inclusion criteria. Their pudendal neuropathy was from straddle injury from a car accident (2), fall onto the perineum (2), bicycling, (2), spinning (1), motorcycle accident (1) and unknown (2). Mean age at presentation was 51.7 ± 15.5 years (range 30-76). In this cohort, a total of 41 injections were administered; 33 (80%) bilateral and 8 (20%) unilateral. Mean number of injections per patient was 4.1 ± 3.3 (range 2-10). Mean time between injections was 6.4 ± 9.1 months (range = 0.5–34.9). All 10 patients experienced clinically significant reduction in PGAD/GPD symptoms and improvement in quality of life; 3 who received an average of 6 injections (range 3-10) no longer have any symptoms and do not require any further injections. During administration of 11 (27%) injections patients experienced moderate pain with vasovagal reactions that resolved. On two occasions injections were attempted but could not be completed due to significant patient discomfort. There was no infection, bleeding, worsening of pudendal nerve pain, or systemic steroid effects such as weight gain or mood changes. Conclusions This is a selected patient cohort with Region 2 triggered PGAD/GPD symptoms secondary to pudendal neuropathy. Intermittent therapeutic pudendal nerve lidocaine-steroid injections in tender areas within Alcock’s canal provided safe and effective management of PGAD/GPD without surgical intervention. Disclosure No.