Individualized multimodal pain management for chronic perineal pain

RATIONALE: Persistent perineal pain is a challenging clinical condition that may substantially impair sleep, urination, daily activities, and psychological well-being. Accurate assessment and individualized multimodal management are essential for improving symptom control and patient participation in care. PATIENT CONCERNS: A 68-year-old woman presented with chronic perineal pain and tenderness that had persisted for 3 years. The pain significantly interfered with her sleep, urination, and daily activities. DIAGNOSES: Clinical assessment suggested chronic perineal pain with neuropathic involvement of the pudendal nerve and lumbosacral or sacral nerve roots. The diagnosis was established based on the patient's clinical manifestations, physical examination findings, and comprehensive evaluation. INTERVENTIONS: The patient received a multimodal pain management approach, including oral pregabalin, computed tomography-guided sacral canal catheterization with targeted nerve-root adhesiolysis and ozone injection, continuous pain assessment, psychological support, pelvic floor muscle training, and individualized rehabilitation guidance. OUTCOMES: At the two-week follow-up, the visual analog scale score decreased from 8/10 to 3/10, and the pain no longer interfered with sleep. Approximately 3 weeks after discharge, the pain temporarily increased to 5/10 and subsequently stabilized at 4/10 at the one-month follow-up while the patient continued oral pregabalin. LESSONS: Individualized multimodal pain management may effectively reduce pain intensity and improve sleep and daily functioning in patients with persistent perineal pain. Continuous assessment, patient participation, psychological support, and rehabilitation strategies are important components of comprehensive pain management.