{"paper_id":"b5124ddb-9e20-4a20-9300-64e328701165","body_text":"28\nCopyright© 2026 The Author(s). Published by Galenos Publishing House on behalf of International Society for Pelviperineology.  \nThis is an open access article under the Creative Commons AttributionNonCommercial 4.0 International (CC BY-NC 4.0) License.\nORIGINAL ARTICLE\nPelviperineology 2026;45(1):28-38\nAd dress for Cor res pon den ce: Jacques Beco, Department of Gynecology, Clinique Sainte-Elisabeth - CHC, Verviers, Belgium\nE-mail: jacques.beco@skynet.be ORCID ID: orcid.org/0000-0002-7538-2459\nReceived: 10 November 2025 Ac cep ted: 17 April 2026 Publication Date: 24 April 2026\nABSTRACT\nObjective: Chronic pelvic pain without a clear etiology remains a diagnostic challenge in gynecology. In many women, standard investigations \nare normal, yet symptoms persist. A substantial proportion of these cases may involve neuromuscular mechanisms, particularly obturator \nand pudendal neuralgias. The objective of this work is to propose a structured clinical framework to support diagnostic evaluation and \nmanagement.\nMaterials and Methods:  This article presents a narrative clinical framework derived from routine perineological practice. It describes a \nstepwise approach based on clinical history, pelvic nerve examination, assessment of sacroiliac stability, and evaluation of generalized \nhypersensitivity. Targeted treatment strategies are outlined using dextrose injections: low concentration (5%, perineural injection therapy) \nfor neural involvement and higher concentrations (15-25%, prolotherapy) for ligamentous instability. The identification of psycho-traumatic \nfactors is based on structured clinical history, and autonomic modulation strategies may be considered in selected patients.\nResults: This framework allows patients to be classified into clinically coherent profiles, including isolated neuralgia, generalized \nhypersensitivity associated with psycho-traumatic history, and sacroiliac instability. In clinical practice, dextrose injections may be associated \nwith symptom improvement and functional recovery, although responses vary and should be interpreted within an observational context. \nEvidence from other peripheral neuropathies provides indirect support for the proposed mechanisms.\nConclusion: This integrative clinical framework may help structure the evaluation and management of chronic pelvic pain by linking clinical \nfindings to targeted therapeutic strategies. It should be considered hypothesis-generating rather than confirmatory, and further controlled \nstudies are required to assess clinical effectiveness.\nKeywords: Pudendal neuralgia; obturator neuralgia; sacroiliac instability; post-traumatic stress disorders; pelvic pain; lower urinary tract \nsymptoms; urge incontinence; cystalgia; dyspareunia; PGAD\nCitation: Beco J, Simon A. Restoring pelvic stability and nerve function with dextrose injections: a clinical framework for chronic pelvic pain. \nPelviperineology. 2026;45(1):28-38\n1Department of Gynecology, Clinique Sainte-Elisabeth - CHC, Verviers, Belgium\n2Department of Gynecology, Liège University Faculty of Medicine, Liège, Belgium\n Jacques BECO1,  Aurélie SIMON2\nRestoring pelvic stability and nerve function with dextrose \ninjections: A clinical framework for chronic pelvic pain\nDOI: 10.34057/PPj.2026.45.01.35219\n\n29\nBeco and Simon. Dextrose therapy for chronic pelvic painPelviperineology 2026;45(1):28-38\nINTRODUCTION\nChronic pelvic pain is a frequent reason for consultation in \nperineology.1 In a significant proportion of patients, standard \ninvestigations (pelvic imaging, urological assessment, infectious \ndisease work-up) are normal, leading to diagnostic uncertainty \nand, at times, a psychogenic interpretation of symptoms.\nHowever, numerous clinical observations show that these \ncomplaints often correspond to pain of neuromuscular origin, \nprimarily obturator and pudendal neuralgia. Such neuralgia may \nbe accompanied by reflex myofascial contractures, functional \nurogenital disorders, and persistent perineal pain.\nBeyond these peripheral lesions, two major factors contribute \nto chronicity: firstly, sacroiliac instability, sometimes associated \nwith hyperlaxity or Ehlers-Danlos syndrome; and secondly, \ngeneralized hypersensitivity observed in patients with post-\ntraumatic stress disorder.2\nThe emergence and progressive validation of dextrose \ninjections—either at 5% around the nerve [perineural injection \ntherapy (PIT)] or at 15-25% within the ligaments (prolotherapy)—\nhave provided clinicians with a simple, inexpensive, and \npathophysiologically plausible tool for managing this patient \ngroup.3\nThe aim of this article is to describe an integrated clinical approach, \nbeginning with the patient’s history and physical examination \nand leading to targeted treatment with dextrose injections.\nMATERIALS AND METHODS\nStudy Design\nThis manuscript presents a narrative clinical framework \nintended to support structured diagnostic reasoning in chronic \npelvic pain. It is not designed as a formal case series with \npredefined inclusion criteria, standardized outcome measures, \nor protocolized follow-up.\nClinical Evaluation\nEvaluation of a patient presenting with unexplained chronic \npelvic or perineal pain is based on four complementary \ncomponents: targeted history taking, pelvic nerve examination, \nassessment of sacroiliac stability and evaluation of generalized \nhypersensitivity.\nTargeted History\nThe medical history aims to distinguish between pain of \npudendal origin and pain of obturator origin. Pudendal pain \nis typically aggravated by sitting or cycling and affects the \nsuperficial vulvo-anal or clitoral region. 4-6 The presence of a \nPGAD-SAS (persistent genital arousal disorder–sexual arousal \nsyndrome; intrusive sexual sensations occurring out of context) \nor proctalgia fugax is very suggestive.7,8 \nObturator pain is deeper, unaffected by position, and often \nassociated with inguinal, hip, or knee radiation, uterine pain \n(contractions) or sensations of a vaginal or rectal foreign body.9\nA systematic search for functional urinary disorders (pollakiuria, \nnocturia, dysuria, painful bladder), sometimes with recurrent \ncystitis, dyspareunia, coccygodynia, or anorectal disorders \n(dyschezia, incontinence), is essential, as these are often \nsecondary to pelvic nerve irritation rather than primary bladder \nor rectal pathology.\nThe history should also explore traumatic or psycho-\ntraumatic events such as assaults, harassment, sexual abuse, \nor car accidents. These elements are common in patients \nwith generalized cutaneous hypersensitivity or PTSD (post-\ntraumatic stress disorder) and should be considered as potential \ncontributing clinical factors requiring careful evaluation.\nFinally, complaints of low back pain, restless legs, leg pain or \nparesthesia, unsteadiness while walking, or difficulty turning \nover in bed suggest sacroiliac or pelvic instability, particularly in \nhypermobile individuals.\nThese four components are assessed sequentially to differentiate \nprimary neural pain from secondary musculo-ligamentary \nmechanisms and generalized autonomic hypersensitivity.\nClinical Examination\nPelvic Nerve Assessment \nThe examination is performed in the gynecological position and \nfollows a structured and standardized clinical sequence linking \nsymptoms to the structures involved.\nThe first step involves palpating the pudendal nerves vaginally \nor rectally at 5 and 7 o’clock, below the ischial spine and within \nAlcock’s canal (Figure 1).10,11 Sharp pain on pressure is suggestive \nof neuralgia. The compression test between the sacrospinous and \nsacrotuberous ligaments reproduces sitting pain and reinforces \nthe diagnosis. Para-urethral palpation of the pubis is frequently \npainful on the side of pudendal neuralgia and can serve as a \nscreening test.\nThe obturator nerves are palpated at 3 and 9 o’clock within the \nobturator foramen; provoked pain here also suggests neuralgia.9\nA skin-rolling test is then performed over the cutaneous \ninnervation territory: from the para-coccygeal to the para-\nclitoral region for the pudendal nerve, and along the medial \naspect of the knee for the obturator nerve. A painful skin-rolling \ntest is clinically suggestive of neuralgia (Figure 2).\n\n30\nBeco and Simon. Dextrose therapy for chronic pelvic pain Pelviperineology 2026;45(1):28-38\nPinprick sensitivity is also tested in the vulvo-perineal areas \n(pudendal nerve) and the inner knee (obturator nerve).12\nContractures and Myofascial Trigger Points\nPelvic neuralgia frequently induces reflex contraction, with \ntrigger points, of the obturator internus, piriformis and \npuborectalis muscles. Such secondary muscle spasm may \nmechanically irritate the adjacent pelvic nerve, leading to cross-\nirritation; pudendal neuralgia may therefore arise as an indirect \nconsequence of primary obturator neuralgia, and vice versa.\nStress may also contribute to sustained perineal muscle \ncontraction, potentially leading to mechanical irritation of the \nobturator nerve. The analogy of a terrified dog holding its tail \nbetween its hind legs illustrates this posture-related mechanism.13 \nIn humans, the coccyx represents the vestigial equivalent of \nthe tail, and chronic stress-related perineal contraction may \ncontribute to mechanical irritation of the obturator nerve. \nOf course myofascial trigger points can be induced by postural \nor podiatric disorders and may be treated manually (trigger \npoints release), but they have been observed to improve once \nthe neuralgia itself is treated with PIT, without establishing a \ndirect causal relationship.13\nAssessment of Sacroiliac Instability\nSacroiliac instability is evaluated using several simple signs: Pain \non palpation of the sacroiliac joints and/or pubic symphysis, \nunstable single-leg stance improved by a sacroiliac belt, and \nimprovement in the straight leg raise test (20°) under transverse \npelvic compression.\nThis instability should prompt active investigation for \nhypermobility or Ehlers-Danlos syndrome using the Hamonet \nquestionnaire (Table 1).14\nPercussion of the sacroiliac joints, sacrotuberous ligaments, \nor the pubic symphysis with a standard reflex hammer \nmay reproduce characteristic pain irradiation, supporting a \nligamentary contribution to neurological symptoms involving \nthe lower limbs, lumbar spine, or perineum.\nGeneralized Hypersensitivity (Polyneuralgia) and PTSD\nThe arm skin-rolling test is routinely performed: If painful, \nit suggests generalized cutaneous hypersensitivity related to \nsympathetic nervous system hyperactivity (Figure 3). When the \ntest is positive, skin sensitivity should also be assessed (skin \nrolling or pinch) at other body sites to rule out a localized \nupper-limb neuralgia, including reference areas such as the \nFigure 1. Clinical palpation of the pudendal and obturator nerves.\nReproduced from Simon A, Beco J. Gunaïkeia. 2025;30(1), with written permission from the publisher\n\n31\nBeco and Simon. Dextrose therapy for chronic pelvic painPelviperineology 2026;45(1):28-38\nacupuncture points CV6 and CV12, discussed later in this article. \nPatients with confirmed generalized hypersensitivity require \nspecific management incorporating autonomic nervous system \nmodulation. \nIn this observational framework, psycho-traumatic factors were \nidentified through structured clinical history-taking and, when \navailable, previously established psychiatric diagnoses reported \nby the patient. No standardized PTSD screening instrument \nwas systematically applied. The association described should \ntherefore be interpreted as a clinical correlation rather than as \nevidence of causation. \nThis structured clinical assessment allows patients to be classified \ninto clinically coherent profiles guiding therapeutic strategy.\nEthical Considerations\nAll patients received clear and comprehensive information \nregarding the diagnostic procedures and injection techniques \ndescribed in this article. Informed consent was obtained from all \nparticipants prior to treatment, in accordance with institutional \nand ethical requirements.\nThe study protocol and manuscript were approved by the \nEthics Committee of CHC Liège (Belgium; OM087 accreditation), \nreference number 25/43/1360.\nStatistical Analysis\nThis study is a descriptive and observational clinical work \nbased on routine medical practice. No randomization, control \nFigure 2. Skin-rolling test and pinprick sensitivity in pudendal and obturator nerve territories.\nReproduced from Simon A. Beco J. Gunaïkeia. 2025;30(1), with written permission from the publisher\nTable 1. Screening for Ehlers-Danlos syndrome: Hamonet ECSS-62\nNo. Symptom domain Typical clinical features (examples)\n1 Articular and peri-articular pain Multiple sites; neuropathic quality or paroxysmal crises on a background of \ncontinuous pain; worse the day after physical effort\n2 Marked fatigue Present on waking with a sensation of bodily heaviness; highly disabling; sometimes \nassociated with somnolence\n3 Impaired voluntary motor control \n(proprioceptive origin) Clumsiness; bumping into obstacles (“door sign”); gait deviation\n4 Joint instability Pseudo-sprains; subluxations or dislocations; joint cracking or locking episodes\n5 Thin, pale, translucent skin Visible venous network; electrostatic discharge sensations\n6 Joint hypermobility Past or present extreme flexibility; may be masked by pain and muscle contractures\n7 Gastro-oesophageal reflux Recurrent or persistent reflux symptoms\n8 Easy bruising/purpura Bruising after minimal trauma; miget sign after blood test\n9 Hyperacusis Noise intolerance; difficulty understanding speech in noisy environments\nA screening result is considered suggestive when more than 5 of the 9 symptom domains are present\n\n32\nBeco and Simon. Dextrose therapy for chronic pelvic pain Pelviperineology 2026;45(1):28-38\ngroup, or hypothesis-driven statistical testing was performed. \nConsequently, no inferential statistical analysis was applied.\nCLINICAL PROFILES AND THERAPEUTIC MANAGEMENT\nApplying this approach allows three main clinical profiles to be \ndistinguished:\n(1) isolated pudendal or obturator neuralgia;\n(2) polyneuralgic patients with a clinical history suggestive of \nPTSD or psycho-traumatic exposure; \n(3) patients with sacroiliac instability causing mechanical \nirritation of the pelvic nerves.\nIsolated Neuralgia: Perineural Injection Therapy (PIT)\nIsolated pudendal and obturator neuralgias are primarily treated \nwith 5% dextrose (D5W) injections using the PIT described by \nLyftogt.15 Dextrose is injected subcutaneously or perineurally \nalong the painful pathway and at points identified by the skin-\nrolling test (Figures 4-8). Three to four sessions, spaced 7-14 days \napart, are often followed by normalization of palpation findings \nand symptom reduction in clinical practice, although responses \nmay vary between patients. \nThe rapid analgesic effect has been hypothesized to relate to \ncorrection of C-fibers neuroglycopenia caused by compression \nof the vasa nervorum and/or to modulation of TRPV1-mediated \nnociceptive signaling. Randomized studies at other sites of \nperipheral neuropathy (e.g., carpal tunnel syndrome, ulnar \nnerve) suggest a potential benefit of D5W over corticosteroids \nor placebo, providing indirect biological plausibility for its \nuse; extrapolation to pelvic neuralgia should be interpreted \ncautiously.16,17\nOf course, in cases of pudendal neuralgia, protective strategies—\nsuch as using a U-shaped cushion when sitting, avoiding cycling \nor heavy lifting, and shifting backwards on the toilet seat in \ncases of perineal descent—should be combined with dextrose \ninjections. If these conservative measures fail to provide adequate \nsymptom relief, surgical pudendal nerve decompression may be \nconsidered.7,18,19\nGeneralized Hypersensitivity and PTSD: Anti-stress Point \nInjections\nIn patients with polyneuralgia, a positive arm skin-rolling test, \nand a history of trauma, it is useful to add, at the end of the \nsession, D5W infiltration of seven acupuncture points described \nby Wancura-Kampik, corresponding to the main sympathetic \nnerve relays (Figure 9).20\nThis technique, inspired by Mulvaney’s work on stellate ganglion \nblock in PTSD, represents an extrapolation of autonomic \nmodulation concepts to the pelvic context, and has been \nFigure 3. Arm skin-rolling test used to identify generalized cutaneous hypersensitivity and distinguish polyneuralgia from localized neuralgia.\nReproduced from Simon A, Beco J. Gunaïkeia. 2025;30(1), with written permission from the publisher\n\n33\nBeco and Simon. Dextrose therapy for chronic pelvic painPelviperineology 2026;45(1):28-38\nFigure 5. Perineural injection technique (PIT) applied to painful skin-rolling points in obturator neuralgia.\nReproduced from Simon A, Beco J. Gunaïkeia. 2025;30(1), with written permission from the publisher\nFigure 4. Perineural injection technique (PIT) targeting the main trunk of the obturator nerve.\nReproduced from Simon A, Beco J. Gunaïkeia. 2025;30(1), with written permission from the publisher\n\n34\nBeco and Simon. Dextrose therapy for chronic pelvic pain Pelviperineology 2026;45(1):28-38\nreported to provide relief, reduce hypervigilance, and enhance \nreceptivity to body-oriented psychotherapies.2,21\nSacroiliac Instability: Prolotherapy\nWhen clinical examination reveals sacroiliac instability, a \ntherapeutic option is prolotherapy with concentrated dextrose \ninjections (15-25%) into the sacroiliac and sacrotuberous \nligaments and the pubic symphysis (Figures 10 and 11). \nConcentrated dextrose is intended to induce controlled \ninflammation followed by fibroblast proliferation and collagen \nneosynthesis, thereby tightening the ligamentous structures. \nFour sessions spaced two to three weeks apart are commonly \nFigure 6. Transgluteal approach for perineural injection of the pudendal nerve main trunk.\nReproduced from Simon A, Beco J. Gunaïkeia. 2025;30(1), with written permission from the publisher\nFigure 7. Transperineal approach for perineural injection of the pudendal nerve main trunk.\nReproduced from Simon A, Beco J. Gunaïkeia. 2025;30(1), with written permission from the publisher\n\n\n35\nBeco and Simon. Dextrose therapy for chronic pelvic painPelviperineology 2026;45(1):28-38\nused in clinical practice. The patient can use a sacroiliac belt \nthroughout the duration of the treatment.22\nThese injections can also serve a diagnostic purpose, as lidocaine \nis always injected together with dextrose. If the pudendal and \nobturator nerves are not more painful after these injections, it \nsupports a sacroiliac contribution to the pain pattern, although \nit does not establish definitive causality. \nAnti-inflammatory drugs are contraindicated during the \ntreatment period because inflammation is essential for healing. \nSeveral studies have shown parallel improvement in pelvic, \nperineal, and leg pain, supporting a mechanical link between \npelvic instability and irritation of the pelvic nerves.23,24 \nFigure 9. Seven anti-stress acupuncture points used for autonomic modulation, including SP6, CV6, CV12, PC6, and CV17.\nReproduced from Simon A, Beco J. Gunaïkeia. 2025;30(1), with written permission from the publisher\nFigure 8. Perineural injection technique (PIT) at painful skin-rolling points in pudendal neuralgia.\nReproduced from Simon A, Beco J. Gunaïkeia. 2025;30(1), with written permission from the publisher\n\n\n36\nBeco and Simon. Dextrose therapy for chronic pelvic pain Pelviperineology 2026;45(1):28-38\nDISCUSSION\nThis examination-centered approach offers a framework in which \nsymptoms long considered “functional” may be interpreted in \nrelation to anatomical and pathophysiological mechanisms. \nDextrose injections serve a dual purpose: diagnostic and \ntherapeutic. Clinical improvement following perineural injection \nor prolotherapy may support a neuromuscular contribution to \nsymptoms but should not be considered diagnostic proof.\nThe safety profile and low cost of dextrose and the possibility \nof repetition make it particularly suitable for pelvic floor \nrehabilitation.\nFigure 10. Prolotherapy technique targeting the sacroiliac ligaments.\nReproduced from Simon A, Beco J. Gunaïkeia. 2025;30(1), with written permission from the publisher\nFigure 11. Prolotherapy technique targeting the sacrotuberous ligaments.\nReproduced from Simon A, Beco J. Gunaïkeia. 2025;30(1), with written permission from the publisher\n\n\n37\nBeco and Simon. Dextrose therapy for chronic pelvic painPelviperineology 2026;45(1):28-38\nThe mechanisms of action are proposed to differ according \nto concentration. At 5%, dextrose may restore nutrition of C \nfibers under compression, reduce intraneural oedema, and \nmodulate nociceptive discharge. At 15-25%, it is intended \nto induce a transient inflammatory response followed by \nligament regeneration, which is particularly valuable in \nsacroiliac instability. This dual action enables treatment of \nboth the painful nerve and the underlying mechanical source \nof irritation.\nThe sympathetic component should not be underestimated. \nMany patients with pelvic pain report chronic stress or a history \nsuggestive of PTSD, and the work of Mulvaney and Lipov \nsuggests that targeted sympathetic blockade can improve a \nrange of conditions (hot flushes, ulcerative colitis, CRPS).25 These \nobservations originate outside the field of pelvic neuralgia and \ntherefore serve as conceptual support rather than condition-\nspecific evidence. Infiltrating the seven anti-stress points with \n5% dextrose at the end of each session is a simple, minimally \ninvasive adaptation of this principle to perineological practice. 2 \nThis approach also facilitated timely referral of patients \nfor hypnotherapy and eye movement desensitization and \nreprocessing, both of which function as complementary \nmodalities to the seven-points anti-stress protocol.\nOf course, other nerves and ligaments can also contribute to \npelviperineal pain and should be treated accordingly—for \nexample, lax iliolumbar ligaments inducing testicular or vaginal \npain, or genitofemoral nerves causing anterior vulvar pain. 22,26 \nSimilar principles of mechanical and neural modulation may \nbe applied. Occasionally, a “sweet caudal” (caudal epidural with \n5% dextrose) has been described as potentially  beneficial by \ntargeting multiple sacral roots simultaneously.27 \nStudy Limitations\nThe limitations of this approach lie in the still largely \nobservational nature of the evidence. Most available data derive \nfrom case series or extrapolations from other fields and should \nbe regarded as indirect and hypothesis-generating. Randomized \ncontrolled trials incorporating quality-of-life scores and specific \npelvic pain assessments are required.\nOf course, true organic causes of pain—such as trans-obturator \nsurgery complications, endometriosis, abscesses or lichen \nsclerosus—must be excluded, as they may act as persistent \nnociceptive drivers and precipitate recurrent symptoms.\nFurthermore, several potential applications deserve exploration, \nincluding prolotherapy of the uterosacral ligaments in certain \ntypes of vulvar pain and lower urinary tract symptoms, or of the \npubo-urethral ligaments in stress incontinence.28-30\nCONCLUSION\nThe management of chronic pelvic pain must systematically \ninclude assessment of obturator and pudendal neuralgia, PTSD-\ntype hypersensitivity, and sacroiliac instability. By linking patient \nhistory, clinical examination, and targeted dextrose injections, \nthe perineologist gains a coherent and pathophysiological \nframework. This framework may help reduce diagnostic \nuncertainty and may support more targeted management \nstrategies in selected patients, while prospective controlled \nstudies are required to evaluate clinical effectiveness.\nETHICS\nEthics Committee Approval: The study protocol and manuscript \nwere approved by the Ethics Committee of CHC Liège (Belgium; \nOM087 accreditation), reference number 25/43/1360.\nInformed Consent:  Informed consent was obtained from all \nparticipants prior to treatment, in accordance with institutional \nand ethical requirements.\nFOOTNOTES\nContributions\nConcept: J.B., A.S., Design: J.B., A.S., Data Collection or Processing: \nJ.B., A.S., Analysis or Interpretation: J.B., A.S., Literature Search: \nJ.B., A.S., Writing: J.B., A.S.\nDISCLOSURES\nConflict of Interest: No conflict of interest was declared by the \nauthors.\nFinancial Disclosure:  The authors declared that this study \nreceived no financial support.\nREFERENCES\n1. 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