Ischiorectal Approach to Cryoablation of the Pudendal Nerve Using a Handheld Device: A Report of Two Cases

The pudendal nerve is situated deep within the pelvis and is a challenge to target for pain interventions due to the theoretical risk of incontinence with manipulation. The management of pudendal neuralgia using cryoablation is currently limited as it has historically required computed tomography (CT) guidance by interventional radiologists. Through this report, we describe a safe, reproducible, ischiorectal fossa approach to pudendal nerve cryoablation with a handheld device utilizing anatomical landmarks, nerve stimulation, and fluoroscopy. Two patients with longstanding pelvic pain and positive response to diagnostic pudendal nerve blocks underwent bilateral cryoablation of the pudendal nerves. This procedure was performed with the patients in prone positioning and percutaneous insertion of a cryoablation probe medial to the ischial tuberosity and lateral to the rectum. Correct positioning on the pudendal nerve was achieved with nerve stimulation eliciting visible anal sphincter contraction, and fluoroscopic imaging of the probe relative to the ischial spine. The probe was set to -88 Celsius for 108 seconds and a total of two cycles were performed. Pain reduction was reported for 3-4 months and repeat cryoablation was similarly efficacious with no evidence of incontinence. This technique, we believe minimizes risks and simplifies cryoablation to be performed on an outpatient basis by more pain physicians.