Les douleurs périnéales chroniques

Chronic perineal pain must be approached by clinical process of elimination, based on ruling out local pathological lesions. In the absence of any visible cause, perineal pain may be related to a somatic nerve disorder of vegetative or musculoligamentary origin. The pudendal nerve is the main nerve in the perineum. Pudendal neuralgia is usually related to pudendal canal syndrome, caused either by entrapment between ligaments (sacrotuberous or sacrospinous ligaments) or by aponeuralgia (aponeuralgia of the internal obturator or of Alcock’s canal). The symptoms include positional perineal pain (aggravated when sitting) that is not sufficient to regularly wake the patient at night and is not associated with any objective sensory disorder. Nerve blocks confirm the diagnosis (Nantes criteria). Treatment can be through drugs for neuropathic pain, infiltrations and surgical nerve release. Entrapment of the ilio-inguinal or genito-femoral nerves is generally subsequent to pelvic surgery. In cases located in proximity to the abdomino-pelvic wall, an anaesthetic injection loco dolenti is easy to administer for diagnosis and treatment, with the addition of local cortico-steroids. Pain caused by the vegetative and sympathetic systems is much more diffuse than somatic neuropathic pain. Vulvar vestibulitis causes hypersensitivity of the vulva, making any contact, in particular sexual activity, unbearable. The mechanism is still unclear and treatment is purely symptomatic. Testicular pain can suggest post-operative nerve impairment, but the most frequent cause of chronic testicular pain, in the absence of any local lesions, is due to projected pain caused by minor intervertebral displacement in the thoraco-lumbar joint, which can be treated with manipulation, physiotherapy or injection. Musculoskeletal pain may include projected thoracolumbar pain and myofascial pain, which may be part of a wider context of fibromyalgia. Paroxysmal pain can suggest perfectly harmless pathologies, such as proctalgia fugax (occurring once a month and lasting an average of 15 minutes) or may possibly be caused by neurological tumours (sudden shooting pains) and a pelvic and lumbar sacral MRI scan should therefore ensue. Chronic perineal pain has a significant emotional effect, making semiological analysis more complicated. This emotional component is often a result of the chronic pain, but prior physical or sexual stress factors should not be ruled out when considering psycho-behavioural management. The complexity and multidimensional nature of chronic perineal pain require a multidisciplinary approach.