Dr. S. J. Antolak

Statement posted September 18, 2003 on the pudendal.de forum:

From Dr. S.J. Antolak
Re: Urologic and Pelvic Pain

I have decided to return to active practice. This is in response to many calls from patients and physicians who continue to need help because of pudendal neuralgia.

Pelvic pain is NOT only caused by pudendal neuralgia. Pudendal neuralgia has many causes. About 1 in 4 pelvic pain patients in my previous practice had pudendal neuralgia. I plan to reach out to all people with pelvic pain and treat them after gynecologic, colorectal, urology and other specialists have not succeeded and have not found other diseases to explain the pain.

Pudendal neuralgia has many causes and will respond to different treatments. Some patients have responses to sacral nerve electrical stimulation. Other treatments such as tibial nerve stimulation or magnetic stimulation may have short term responses. Some knowledgeable physicians treat pudendal neuralgia successfully by pelvic floor massage. There are many physical therapists around the country who treat pelvic floor muscle/nerve problems. In Rochester, Minnesota there is an entire program developed around the concept of pelvic floor tension myalgia. When appropriate, I sent patients to that clinic. They approach the patient in a manner similar to Dr. Jerome Weiss using pelvic floor massage and biofeedback. Naturally, I will not see successfully treated patients. I will see only those men or women who have not had relief from other treatments such as biofeedback, pelvic floor massage, etc. I saw only the failures of treatment of pelvic floor myalgia. There was no need for me to see the successes.

Future research will show why there are patient differences. Most people are not aware that the pelvic floor muscles have two separate nerve supplies. Most people are unaware that muscles themselves can produce signals to the nervous system that call in all the complaints of the person with pudendal neuralgia. Only a precise history of the symptoms and thorough examination will separate the various causes of pelvic pain.

Regarding pudendal neuralgia experience:
As my patients are aware, a self-care program will "cure" some of them (meaning normal, painfree lifestye). My longest improvement is about 48 months. My longest ABSOLUTE CURE (meaning no complaints) from self-care alone is 34 monhs. He was a dentist who was suicidal with pain. There are NO clinics that have established a self-care program and require a MEASURED response (good or bad) before proceeding to injection treatment. Self-care is an extremely conservative program. A self made sitting pad costs only about $4.00. It is very helpful. I use such a pad when I drive and sit.

The pudendal nerve perineural injections (PNPI) are important for diagnosis. PNPI are therapeutic and will control pain/symptoms. Injections can CURE pudendal neuralgia. In France about 70% of their patients are cured by injections. In my previous practice it was lower. This might be explained by the large number of individual radiologists doing the injections. They did over 2500 injections during three and one-half years. I saw almost every patient after injection. In France, Dr. Bensignor did the first two injections the series and he was a master. Only one radiologist did the third injection (it requires CT guidance).

My longest cure from injections is 34 months. This man had seen over 25 doctors and was threatening suicide. He is quite happy now, living in the North Woods of Minnesota. An attorney from Wisconsin has had a cure of is irritable bladder after injections. He called me on August 8th to thank me for one year of TOTAL RELIEF after 33 months of misery. Surgery must be approached carefully. Other treatments can be successful. Surgery is not always necessary.

Only when there is NOT a good relief of complaints I would recommend surgery. In my opinion, the doctors in France will receive a Nobel prize when the medical world is aware of their achievements. Dr. Amarenco in Paris also has great experince. He notes an overall successful control of pain in 68% of patients after injections or surgery. Dr. Shafik in Cairo deserves credit for his pioneering efforts also.

I have great love of my patients and concern about their welfare. I have ALWAYS sent patients to other doctors for surgery if the conservative neurosurgeon helping my patients denied them the opportunity for a surgical cure when I thought surgery was appropriate . ALL of these patients had undergone the stepwise treatments. They all had long term observation before surgery. Many continue to keep in touch with me. The measurement of their pain after surgery is important for teaching other doctors the value of this treatment.

I believe all of the patients I sent elsewhere for surgery were found to be appropriate surgical candidates. They have not all had complete relief. I receive calls from them and have arranged for postoperative injections. This will be an integral part of my practice. Is there a clinic for American patients operated elsewhere to have followup? Dr. Weiss is committed in a focused, non-surgical practice that provides long term followup for his patients. Surgery is important. More important however, is the availability of knowledgeable, committed physician care.

The failures of surgical interention MUST be evaluated to identify what processes are causing the continuation of complaints. Narcotics are not enough for that person.

Urologists are familiar with different operations on or around various nerves. For instance, when lymph node surgery for cancer of the testis is performed, we must carefully spare the nerves for ejaculation. This is delicate surgery near the aorta and vertebrae (back bone). When a man has prostate cancer surgery the urologist must spare the nerve for erection... again, a very delicate procedure done deep in the pelvis. In cancer operations in the pelvis the urologist always removes the lymph glands from around a major nerve to the leg.

At the Center for Urologic and Pelvic Pain, the surgical experience from every patient operated in Rochester and also during two visits to Nantes, France will be offered to patients and their doctors. It is only a small portion of the patient care to be given in a urologic and pelvic pain clinic.

It is difficult for physicians to understand pudendal neuralgia. It is more difficult for those laymen who suffer from the problem. Advice that is given by laymen may be important for guidance. Consider the source. Evaluate and decide YOUR choice of options.