MISTAKES MISJUDGEMENTS AND DISAGREEMENTS ABOUT DR LARRY NASSAR DURING HIS SEXUAL MISCONDUCTS AND TRIALS

The Dr. Larry Nassar Sexual Misconduct trials are so complicated, convoluted and involve so many victims and venues that facts about the case and problems with the laws of the case are difficult to ascertain and communicate.

This article is an attempt to review the most important facts and laws of the cases and suggest the mistakes, misjudgements and disagreements uncovered.

The aims of us Child Athlete Safety advocates are the same i.e. child athlete safety 1st and the prevention of a case like Nassar’s and others from ever happening again.

This reporter will make corrections about the facts and laws of the case as they are discovered.

“All States prohibit and have jurisdiction regarding Child Sexual Rape, Violence, Assault and Abuse.

“The structures, wording and scope of sexual offenses vary considerably, so interested parties should always check local state statutes for specific questions.”

Every Adult and Child victim in the right place with family, in school or non-school Sports, Recreations and Exercise (SRE), or wrong place with offenders or by coercion, bad choice, inappropriate physical and mental examination, stabbed with a knife, shot by a gun, raped, sexually violenced, assaulted and/or abused by an assailant have commonalities. In varying degrees, they have been injured and their bodies have been violated and/or penetrated.

“Most rape, sexually violenced, assaulted and abused victims do not suffer visible physical injury.” On the surface they appear un-injured. But sexual offenses can result in instantaneous and/or delayed morbidity and/or mortality.

“Rape, sexual violence, assault and abuse can result in physical and mental trauma, tissue damage, infection, a multitude of morbidity and mortality, pathological traumas, which can only be determined by doctor and health care personnel examination. [Heterogeneity of Existing Research Relating to Sexual Violence, Sexual Assault and Rape Precludes Meta-analysis of Injury Data, Kennedy, K. M. (2013). Journal of Forensic and Legal Medicine. 20 (5): 447–459]

Child Sexual offenses, minors less than 18 in most states, should be reported to both Child Protective Services (CPS) and the County Attorney in every state, not the FBI. The County Attorney and CPS will determine the best course of action moving forward. [mbmsrmd 2009 C.A.R.E. Training]

Because federal jurisdiction for rape generally is limited to those committed on Indian Tribal or federal territory, federal prison, only a few rape cases are prosecuted in the federal courts and investigated by the FBI.  [REPORT TO CONGRESS: ANALYSIS OF PENALTIES FOR FEDERAL RAPE CASES Crime Control and Law Enforcement Act of 1994, Pub. L. No. 103-322, §40112, 108 Stat. 1796, 1903 (1994)]

Rape, sexual violence, assault and abuse victims cannot care for themselves or represent themselves correctly. First, victims must find a ‘safe place’.

Each and every victim should seek treatment or be referred for treatment by a Doctor or health care professional for their immediate and/or delayed injuries and/or disease.

Rape and sexual assault are medical emergencies and should be treated properly. Victims have been injured and cannot care for themselves or represent themselves correctly.

When in a ‘safe place’, step 1 following rape, sexual assault, violence and abuse is Doctor Examination and follow-up examination.

The Sexual Assault Medical Workup should proceed with the following guidelines:

Laboratory Studies

The Doctor or health care person should obtain urine or serum pregnancy tests in women of childbearing age.

Preexisting pregnancy may complicate management of coexisting injuries and is a contraindication to providing Ovral for pregnancy prevention.

Baseline screening for STDs includes the following:

  • Serologic tests for syphilis, hepatitis B, and HIV: HIV testing may be problematic in EDs because of laws in some states that stipulate mandatory counseling and follow-up care. However, the CDC recommends HIV screening for patients in all healthcare settings after the patient is notified that testing will be performed unless the patient declines (ie, opt-out screening). [9, 10] Policy and guidelines should be established in advance with local sexual assault aftercare groups and OB/GYN services in accordance with prevailing law and CDC guidelines.
  • Cultures of exposed body sites (eg, oral, throat, vaginal, rectal) as appropriate: Current Centers for Disease Control and Prevention (CDC) guidelines consider Food and Drug Administration (FDA)–approved nucleic acid amplification tests an acceptable substitute for culture, as long as positive test results are confirmed by a second study. [11] Other tests (EIA, nonamplified probes, direct fluorescent antibody tests) are not considered acceptable alternatives by the CDC because of unacceptable false-negative and false-positive result rates.
  • Wet mount and culture of a vaginal swab specimen to evaluate for Trichomonas vaginalis, bacterial vaginosis, and candidiasis
  • Patients are offered antibiotic prophylaxis regardless of results from the preliminary screening.
  • These points of routine baseline testing are vigorously advocated by this editor and most other doctors and health care persons. The CDC, in its most recent guidelines for the treatment and prevention of STDs, discusses the pros and cons of testing at some length.

Imaging studies are only indicated for evaluation of comorbid trauma.

Rape Kit

To collect evidence, most hospitals have a prepackaged rape kit with the necessary equipment and detailed instructions. However, if the sexual assault victim presents 72 hours after the event, the evidence collection kit is no longer needed for legal documentation of the case.

Procedures

Colposcopy, where available, may have considerable value in documentation because it allows photographic recording of injuries. Anoscopy may be performed in male victims, and it may be combined with colposcopy in female victims.

Evidence suggests that if speculum examination is performed before toluidine blue application to the posterior fourchette (to enhance small lesions that may occur during forceful genital penetration), the speculum itself may cause small lesions that will take up the dye. These iatrogenic lesions will be seen on colposcopy. Clinicians should consider deferring speculum examination until after external colposcopy if toluidine blue is to be used.

[Sexual Assault Workup by William Ernoehazy, Jr, MD, FACEP; Chief Editor: Gil Z Shlamovitz, MD, FACEP, Nov 10, 2015, Medscape]

Step 2 is Rape, sexual violence, assault and abuse reporting by mandated and non-mandated reporters, who have information on the sexual offense.

The legal case against Dr. Larry Nassar, the 54-year-old former MSU and USA Gymnastics doctor whose work took him to multiple Olympic Games, was an atypical, complicated case.

“”> Dr. Larry Nassar: A history of preying on people

Here’s a timeline of former Michigan State University doctor Larry Nassar’s decades–long career and the allegations against him resulting in multiple criminal cases and several lawsuits.

“ He has everything he needs to be an incredible leader. He has the personality. He has the skill. He has the knowledge. And he’s using that to prey on people… What a waste.” — Rachael Denhollander, alleged victim.

WHAT WE KNOW: LARRY NASSAR DO, was a Doctor of Osteopathy

Here’s what we know about the multiple criminal cases, lawsuits and more than 60 allegations related to sexual assault claims against former Michigan State University doctor Larry Nassar.

1978 Nassar begins working with gymnasts as a student athletic trainer at North Farmington High School in suburban Detroit. He earns a varsity high school letter in women’s artistic gymnastics in 1981 thanks to his work with the team.

1985 Nassar graduates from University of Michigan with a degree in kinesiology. During his time at Michigan he works with the football team and track and field program.

1986 Nassar joins the USA Gymnastics national team medical staff as an athletic trainer.

Dr. Larry Nassar, shown here in this 2008 file photo. (File photo)

1988 Nassar begins working with John and Kathryn Geddert, who later open Gedderts’ Twistars USA Gymnastics Club in Dimondale, Michigan.

1985-1989 Nassar works as a graduate assistant athletic trainer at Wayne State University while enrolled in a master’s degree program. He drops out when accepted to Osteopathic Medical School at Michigan State University.

1993 Nassar receives Osteopathic Medical Degree from Michigan State University.

1994 A gymnast, who later becomes an Olympic medalist, alleges Nassar begins to sexually abuse her in 1994, according to a 2016 lawsuit. The abuse allegedly continued for six years.

1996 Nassar completes family practice residency at St. Lawrence Hospital in Lansing, which has since merged with Sparrow Hospital.

{{{ Sparrow is an exciting, innovative office-based residency program located near our state capital. The program is dually accredited through both the Accreditation Council on Graduate Medical Education and through the American Osteopathic Association.}}}

Nassar is appointed national medical coordinator for USA Gymnastics. He attends the Olympic Games in Atlanta with gymnastics teams.

Gedderts’ Twistars USA Gymnastics Club opens in Dimondale.

1997 Nassar completes a MSU Primary Care Sports Medicine Fellowship.

Nassar is hired as an assistant professor at MSU’s Department of Family and Community Medicine in the College of Osteopathic Medicine.

Nassar begins working as team physician at Holt High School.<“”

[“”> — <“” Coverage by the Lansing State Journal and IndyStar of the USAToday Network]

In addition to Olympic athletes, some of Dr. Nassar’s victims were Michigan State students, and the university police have received more than 100 complaints about him. Until 2016, Dr. Nassar was a professor at M.S.U.’s College of Osteopathic Medicine, as well as a team physician for the MSU, university.<””

Nassar received an effective life sentence when a federal judge sentenced him to 60 years in federal prison on child pornography charges.

“He has demonstrated that he should never again have access to children,” U.S.

The District Judge said as she imposed a sentence that went beyond guidelines calling for 22 to 27 years in prison. He was sentenced to 20 years on each of three counts to which he’s admitted. The sentences are to be served consecutively.

The judge also ordered that his federal time would be served consecutively to his 2 state sentences for sexual assault to which he’s also admitted. He was sentenced a month latter on those charges.

Several victims said after the sentencing they were still trying to process their feelings, but it was a step toward justice. [Larry Nassar sentenced to 60 years in federal child pornography case, by Justin A. Hinkley and Beth LeBlanc, Lansing State Journal Dec. 7, 2017]

In the 1st state case, more than 150 women and girls publicly confronted Dr. Larry Nassar during a 7-day hearing in Ingham County Circuit Court in Lansing, Michigan, where he had pleaded guilty in November 2017 to 7 counts of sexual assault.

He was sentenced to 40 to 175 years for the charges in Ingham County. Famous Olympic Athletes were among his accusers.

In the 2nd state case “Nassar was sentenced for a 3rd prison term of 40 to 175 years, confessing in Eaton county, Michigan for molesting young girl Athletes by penetrating their vagina with ungloved hands while they were members at Twisters Gymnastic Club, managed by a 2012 Olympics Coach to be served at the same time with the previous state sentence.

Before serving his 2 state sentences he must serve his federal sentence, a 60 federal prison term for child pornography.

The Eaton County sentence will be served concurrently with the Ingham County sentence but after the child pornography sentence, the judge said.

60 women and girls have stated Nassar molested them dating back to the 1990’s.

Despite the dramatic numbers of victims, their concerns, questions and reports to the wrong authorities, mistakes, misjudgments about Dr. Nassar in years past, and statements currently, Nassar was not investigated by police until 2004. [David Eggert, AP, Feb 6, 2018]

The failure to appropriately report to proper authorities Dr. Larry Nassar’s suspected Sexual Misconducts was the reason for his continued Sexual Misconducts and delayed police investigation until 2004.  [IMHMO]

All the victims, who appeared in support of the sexual violations charges expressed the need “to make changes so that this never happens again.”

In quest of appropriate reporting to proper authorities and expeditious prosecution, each and every victim should 1st seek Doctor treatment or be referred for Doctor treatment for their immediate and/or delayed injuries and/or disease.

Rape, sexually violenced, assaulted and abused victims are medical emergencies and should be treated properly. Step 1 following rape is DOCTOR EXAMINATION.

“Once in a safe place, victims can call the National Sexual Assault Hotline at 800.656.HOPE (4673) to be connected with a local sexual assault service provider, who will direct the victim to the appropriate local health facility that can care for survivors of sexual assault.

“The HOPE provider can also send an advocate to answer questions, give advice and help walk the victim through the process of receiving medical care during this tough time.

“It is best for the victim to avoid showering or bathing before arrival at the health facility. The victim should take a change of clothing if able.”  [U. S. Department of Justice Office on Violence Against Women. (April 2013). A National Protocol for Sexual Assault Medical Forensic Examinations, Adults/Adolescents. Retrieved from A National Protocol for Sexual Assault Medical Forensic Examinations, Adults/Adolescents]

The implementation of an unusual medical treatment by Dr. Nassar, a team physician, on Child Athletes complicated the Nassar case and also created delays.

“Nassar fooled police officer parents, doctor parents and engineer parents.” He fooled all the parents, regardless of their professions and many, many other persons. He was convincing with his medical presentations and documentations. [David Eggert, AP, Feb 6, 2018]

  • In quest of the “most correct, honorable, trustworthy medico-professional procedure”
  • Doctors should always apply the principle of Informed Consent, aimed at lawful health assistance to all patients.
  • The local police were confused and deceived by the unconventional medical procedure and did not proceed with charges.
  • FYI: When a medical procedure is questionable and the resolution of the question is beyond the scope of law enforcement, CPS and the County Attorney, answers should be referred up the ladder to the local State Medical Association Ethics Committee and the Board of State Medical Licensure, located in every state.

Doctors and Health Care Personnel are mandated reporters of Child Sexual Abuse and Assault. [End violence against women International]

Child sexual abuse is a form of child abuse in which an adult or older adolescent abuses a child for sexual stimulation.[6][7]

Forms of child sexual abuse include asking or pressuring a child to engage in sexual activities (regardless of the outcome), indecent exposure of the genitals to a child, displaying pornography to a child, actual sexual contact against a child, physical contact with the child’s genitals, viewing of the child’s genitalia without physical contact or using a child to produce child pornography.[6][8][9]

  1. Child Sexual Abuse”. Medline Plus. U.S. National Library of Medicine,. 2 April 2008.
  2. “Guidelines for psychological evaluations in child protection matters”. American Psychologist. 54(8): 586–93. 1999. APA PsycNET(2008-05-07). Abuse, sexual (child): generally defined as contacts between a child and an adult or other person significantly older or in a position of power or control over the child, where the child is being used for sexual stimulation of the adult or other person
  3. Martin, Judy; Anderson, Jessie; Romans, Sarah; Mullen, Paul; O’Shea, Martine (1993). “Asking about child sexual abuse: Methodological implications of a two stage survey”. Child Abuse & Neglect. 17(3): 383–92. .
  4. the NSPCC. Archivedfrom the original on 7 February 2012

All States have jurisdiction over Child Sexual Assault. “Specific laws vary by state, but sexual assault generally refers to any crime in which the offender subjects the victim to sexual touching that is unwanted and offensive.

These crimes can range from sexual groping or assault/battery, to attempted rape. All states prohibit sexual assault, but the exact definitions of the crimes that fall within the category of sexual assault differ from state to state. The laws share some basic elements, but the structures, wording and scope of sexual assault offenses vary considerably, so always check your local statutes for specific questions.

“While the classification of sexual crimes is generally not too different from one U.S. state jurisdiction to the next, states often have slightly different sentencing guidelines and definitions. [Sexual Assault, FindLaw.]

Whether they know it or not, every sex crime victim has been injured. The victims’ minds and bodies have been violated and/or penetrated.

Most rape and sexual assault victims will not suffer visible physical injury.” 1. On the surface they appear un-injured, but Sexual assault can be instantaneously fatal.

In a more common scenario, “rape and other sexual assault can also result in physical trauma, tissue damage and infection, [Heterogeneity of Existing Research Relating to Sexual Violence, Sexual Assault and Rape Precludes Meta-analysis of Injury Data, Kennedy, K. M. (2013). Journal of Forensic and Legal Medicine. 20 (5): 447–459]

Rape and Concussions are similar in that immediately the victims might appear normal on the outside, but their tragic consequences are hidden, not readily apparent and can eventually become serious, even lethal

Some of the important points in this article justify repeating:  Victims cannot care for themselves or represent themselves correctly immediately following Sexual Crimes, the importance of the HOPE Provider, 800.656.HOPE (4673).

Each and every victim should seek treatment or be referred for treatment by a Doctor for their immediate injuries and/or delayed injuries and/or disease.

Rape and sexual assault are medical emergencies and should be treated properly.

Step 1 following rape and sexual assault, after positioned in a ‘safe place; is DOCTOR EXAMINATION

“”> Sexual Assault:  “ABSTRACT: Reproductive-aged victims of sexual assault are at risk of unintended pregnancy, sexually transmitted infections, and mental health conditions, including posttraumatic stress disorder.

Health care providers should screen routinely for a history of sexual assault and offer victims both emergency contraception and sexually transmitted infection prophylaxis. The health care provider who examines victims of sexual assault has a responsibility to comply with state and local statutory or policy requirements for the use of evidence-gathering kits.

“The health care provider should report the incident to the appropriate authorities as required by state law.

“The health care provider should document the emotional condition of the victim as judged by direct observation and examination.

If the victim is a minor or a vulnerable adult (those unable to care for their daily needs due to mental or physical disabilities, efforts should be made to involve a parent or caregiver unless that individual represents a security threat to the victim. [Committee Opinion, Committee on Health Care for Underserved Women, Number 592, April 2014 (Reaffirmed 2016. Replaces Committee Opinion Number 499, August 2011), The American College of Obstetricians and Gynecologists]


Pudendal Neuralgia / Sacrotuberous Massage and Manipulation

“”>  LANSING, Mich. (WILX) – The last victim to give a statement Tuesday in the Dr. Larry Nassar trial, was from Lindsey Schuett, she was abused by Larry Nassar at the age of 16 in 1999. Lindsey said, “I knew immediately that it was abuse.” She said that she had seen the movie “The Hand That Rocks The Cradle” and knew what he did was wrong. She said she cried at night and finally decided to tell her school counselor and her mother. They didn’t report the abuse and Lindsey was taken to see Nassar again. But this time, she screamed when he tried to abuse her again. She screamed and he chastised her, she said, he was stern with her and told her that she wasn’t allowed to refuse treatment.” When he started again, she screamed more and cried out until she could leave. Lindsey ended her statement by saying, “If anyone deserves to never see the light of day again, it is this man.”

“Anna Ludes prepared her statement on a disc that was played in the courtroom. Ludes said she was part of the MSU Rowing Team from 2010-2014 when she saw Nassar for treatment of back pain. Anna was between 18 and 22 years old when she saw Nassar and was assaulted during all four years. When she hurt her back she was devastated and wanted to see the best doctor for her pain so she could continue to row. Anna said that Nassar called the procedure “trigger point treatment,” and she says “I didn’t even know it was abuse at the time.” She said she thought the treatment was weird and added that now she knows his treatment was sexual assault. She said she was so “brainwashed by him that I didn’t know it.” Anna ended her statement by saying, “because of Nassar I have to spend the rest of my life trying to heal and I want nothing more for him then to spend the rest of his life behind bars.” The judge assured her that he would.

“The next few statements were read by the court. Brianne Randall was one of those statements. Randall saw Nassar for back pain. After a procedure, she knew it wasn’t right and filed a report with the Meridian Township police, which led to a hospital visit and a sexual assault kit. At the police station, Nassar and Randall’s parents met up and Nassar said it was a “misunderstanding” and no investigation was done. At the end of her statement the judge said, “the defendant became a good liar.”  [Day 1: Survivor: “I knew immediately that it was abuse”, WILX News 10]

“At least 14 Michigan State University staffers and representatives were warned about Larry Nassar’s sexual abuse over the course of two decades and allegedly did nothing to stop it, according to an explosive new report from the Detroit News.

“Accusations from eight young women about the former USA Gymnastics and MSU team doctor’s behavior reportedly reached trainers, coaches, an MSU police detective and MSU President Lou Anna Simon, dating back to 1997. Simon learned about the problem in 2014 when a Title IX complaint and a police report were filed against an unidentified doctor.

“I was informed that a sports medicine doctor was under investigation,” Simon told the News on Wednesday after she appeared in court for Nassar’s sentencing hearing. “I told people to play it straight up, and I did not receive a copy of the report. That’s the truth.”

MSU has repeatedly denied covering up Nassar’s behavior in any way.

“Any suggestion that the university covered up Nassar’s horrific conduct is simply false,” MSU spokesperson Jason Cody told HuffPost earlier this month. “Nassar preyed on his victims, changing their lives in terrible ways. As President Simon has said, MSU is truly sorry for the abuse all victims suffered, the pain it caused, and the pain it still causes.”

“According to the Detroit News, the people who were told of Nassar’s abuse include former MSU head gymnastics coach Kathie Klages, current volleyball team trainer Lianna Hadden, current gymnastics team trainer Destiny Teachnor-Hauk, former MSU clinical psychologist Dr. Gary Stollak and officers at the Meridian Township Police Department.  [By Alanna Vagianos, 01/18/2018, Huffington Post]

“2004: Brianne Randall-Gay, a 16-year-old soccer and tennis player, she filed a police report reported to Meridian Township police that Nassar touched her bare breast and put his hand between her legs during treatment for back pain, but the Police do not pursue charges against Nassar. alleging that he molested her during a 2004 doctor visit. She had a rape kit done. [Larry Nassar: A trail of sexual abuse, The Detroit News Jan. 17, 2018]

Her “second visit with Dr. Nassar, who was treating her for scoliosis, according to a police report.

“Nassar massaged her buttocks with his elbow and said, “I bet people at physical therapy don’t do this.” He also rubbed her breasts, cupped her vagina and tried to penetrate it but could not because she was wearing a tampon, the report said.

“Randall told an investigator she was “scared” and “uncomfortable” during the examination and that “it freaked her out.” She filed the police report after telling her mother what happened during that second visit. She also completed a rape kit examination at a hospital.

“When an investigator interviewed Nassar, the doctor admitted touching Randall in her vaginal area, saying it is a medical technique known as the “sacrotuberous ligament release,” the police report said. He said the technique “has been published in medical journals and training tapes,” and provided police a PowerPoint presentation detailing the procedure.

USA Gymnastics’ board steps down in wake of Nassar abuse scandal

The presentation, titled “The Sacrotuberous Ligament: The Grand Junction,” was written by Nassar and included photos of him performing the procedure.

The investigator then contacted Randall’s mother to tell her he was “closing the case with no prosecution being sought, due to the facts presented … by Dr. Nassar.”

Randall’s mother told the investigator she was concerned about the way Nassar explained the procedure to her daughter and that he was not wearing gloves during the examination.

“Please listen to all children when they report abuse and take action.” Brianne Randall-Gay.  [Brianne Randall’s victim impact statement at Nassar sentencing, Jan 23, 2018 WZZM 13 TV]

“”>  The same police department that declined to take a 17-year-old girl’s concerns about Larry Nassar to prosecutors in 2004 paid for her flight from Seattle to Michigan so she could speak at Nassar’s sentencing hearing Tuesday. Brianne Randall’s complaints prompted one of the first criminal investigations of Nassar in 2004.”  [Police pay for victim’s Seattle flight to testify against Nassar. By Beth LeBlanc, January 24, 2018, Lansing State Journal]

Brianne Randall, who reported her abuse by disgraced former USA Gymnastics doctor Larry Nassar to police in 2004, will receive a public apology from officials in Michigan for their handling of the case [http://cnn.it/2FwFP62 CNN International]

The sacrotuberous ligament (great or posterior sacrosciatic ligament) is situated at the lower and back part of the pelvis. It is flat, and triangular in form; narrower in the middle than at the ends.

The sacrotuberous ligament  runs from the sacrum (the lower transverse sacral tubercles, the inferior margins sacrum and the upper coccyx[1]) to the tuberosity of the ischium. It is a remnant of part of Biceps femoris muscle. The sacrotuberous ligament is attached by its broad base to the posterior superior iliac spine, the posterior sacroiliac ligaments (with which it is partly blended), to the lower transverse sacral tubercles and the lateral margins of the lower sacrum and upper coccyx.

Its oblique fibres descend laterally, converging to form a thick, narrow band that widens again below and is attached to the medial margin of the ischial tuberosity. It then spreads along the ischial ramus as the falciform process, whose concave edge blends with the fascial sheath of the internal pudendal vessels and pudendal nerve. The lowest fibres of gluteus maximus are attached to the posterior surface of the ligament; superficial fibres of the lower part of the ligament continue into the tendon of biceps femoris. The ligament is pierced by the coccygeal branches of the inferior gluteal artery, the perforating cutaneous nerve and filaments of the coccygeal plexus.[2]

Variation

The membranous falciform process of the sacrotuberous ligament was found to be absent in 13% of cadavers. When present it extends towards the ischioanal fossa travelling along the ischial ramus and fusing with the obturator fascia.

The lower border of the ligament was found to be directly continuous with the tendon of origin of the long head of the Biceps femoris in approximately 50% of subjects.[3] Biceps femoris could therefore act to stabilise the sacroiliac joint via the sacrotuberous ligament.

Function

The sacrotuberous ligament contains the coccygeal branch of the inferior gluteal artery.

Clinical significance

If the pudendal nerve becomes entrapped between this ligament and the sacrospinous ligament causing perineal pain, the sacrotuberous ligament is surgically severed to relieve the pain.

Legitimate ICD-10 Procedure Codes:

“”>  ICD-10-PCS Procedure Code 015C

Pudendal Nerve

ICD-10-PCS Procedure Code 018C

Pudendal Nerve

ICD-10-PCS Procedure Code 019C

Pudendal Nerve

ICD-10-PCS Procedure Code 01BC

Pudendal Nerve

ICD-10-PCS Procedure Code 01CC

Pudendal Nerve

ICD-10-PCS Procedure Code 01DC

Pudendal Nerve

ICD-10-PCS Procedure Code 01NC

Pudendal Nerve

ICD-10-PCS Procedure Code 01QC

Pudendal Nerve

ICD-10-PCS Procedure Code 01RC

Pudendal Nerve

ICD-10-PCS Procedure Code 01SC

Pudendal Nerve

ICD-10-PCS Procedure Code 01UC

Pudendal Nerve

ICD-10-PCS Procedure Code 01XC

Pudendal Nerve

ICD-10-PCS Procedure Code 015C0ZZ [convert to ICD-9-CM]

Destruction of Pudendal Nerve, Open Approach

ICD-10-PCS Procedure Code 015C3ZZ [convert to ICD-9-CM]

Destruction of Pudendal Nerve, Percutaneous Approach

ICD-10-PCS Procedure Code 018C0ZZ [convert to ICD-9-CM]

Division of Pudendal Nerve, Open Approach

ICD-10-PCS Procedure Code 018C3ZZ [convert to ICD-9-CM]

Division of Pudendal Nerve, Percutaneous Approach

ICD-10-PCS Procedure Code 019C0ZZ [convert to ICD-9-CM]

Drainage of Pudendal Nerve, Open Approach

ICD-10-PCS Procedure Code 019C3ZZ [convert to ICD-9-CM]

Drainage of Pudendal Nerve, Percutaneous Approach

ICD-10-PCS Procedure Code 01BC0ZZ [convert to ICD-9-CM]

Excision of Pudendal Nerve, Open Approach

ICD-10-PCS Procedure Code 01BC3ZZ [convert to ICD-9-CM]

Excision of Pudendal Nerve, Percutaneous Approach

ICD-10-PCS Procedure Code 01DC0ZZ [convert to ICD-9-CM]

Extraction of Pudendal Nerve, Open Approach

ICD-10-PCS Procedure Code 01DC3ZZ [convert to ICD-9-CM]

Extraction of Pudendal Nerve, Percutaneous Approach

ICD-10-PCS Procedure Code 01NC0ZZ [convert to ICD-9-CM]

Release Pudendal Nerve, Open Approach

ICD-10-PCS Procedure Code 01NC3ZZ [convert to ICD-9-CM]

Release Pudendal Nerve, Percutaneous Approach

ICD-10-PCS Procedure Code 01QC0ZZ [convert to ICD-9-CM]

Repair Pudendal Nerve, Open Approach

ICD-10-PCS Procedure Code 01QC3ZZ [convert to ICD-9-CM]

Repair Pudendal Nerve, Percutaneous Approach

ICD-10-PCS Procedure Code 01SC0ZZ [convert to ICD-9-CM]

Reposition Pudendal Nerve, Open Approach

ICD-10-PCS Procedure Code 01SC3ZZ [convert to ICD-9-CM]

Reposition Pudendal Nerve, Percutaneous Approach

ICD-10-PCS Procedure Code 01XC0ZB [convert to ICD-9-CM]

Transfer Pudendal Nerve to Lumbar Nerve, Open Approach

ICD-10-PCS Procedure Code 01XC0ZC [convert to ICD-9-CM]

Transfer Pudendal Nerve to Perineal Nerve, Open Approach

“”> The following code(s) above G58.8 contain annotation back-references

that may be applicable to G58.8:

G00-G99

Diseases of the nervous system

G50-G59

Nerve, nerve root and plexus disorders

Approximate Synonyms

Left femoral nerve palsy

Left femoral nerve paralysis

Motor polyneuropathy

Neuralgia iliohypogastric nerve

Neuralgia, pudendal

Neuropathy (nerve damage), multifocal motor

Neuropathy (nerve damage), phrenic

Paralysis of phrenic nerve

Phrenic nerve disorder

Phrenic nerve lesion

Right femoral nerve palsy

Right femoral nerve paralysis

ICD-10-CM G58.8 is grouped within Diagnostic Related Group(s) (MS-DRG v35.0):

073 Cranial and peripheral nerve disorders with mcc

074 Cranial and peripheral nerve disorders without mcc

______________________________________________

What is pudendal neuralgia?

“Pudendal neuralgia is a rare problem with the pudendal nerve that can affect both men and women. The pudendal nerve runs through your pelvic region, including your genitals, urethra, anus, and perineum. Your perineum is the area between your anus and genitals. The condition is also known as pudendal neuropathy, pudendal nerve entrapment, cyclist’s syndrome, pudendal canal syndrome, or Alcock’s syndrome.

“Pudendal neuralgia can cause pain, especially when you sit. Men with pudendal neuralgia may have pain in the buttocks, scrotum, penis, and perineum. Women with pudendal neuralgia may have pain in their buttocks, vulva, urethra, and perineum.  [Pudendal Neuralgia – Overview WebMD]

References

This article incorporates text in the public domain from page 309 of the 20th edition of Gray’s Anatomy (1918)

Marios Loukas, Robert G Louis Jr, Barry Hallner, Ankmalika A Gupta and Dorothy White. (2006) “Anatomical and surgical considerations of the sacrotuberous ligament and its relevance in pudendal nerve entrapment syndrome” Surg Radiol Anat 28(2): 163-169

Gray’s anatomy, 40 edition.

Vleeming, A., R. Stoeckart, et al. (1989). “The sacrotuberous ligament: a conceptual approach to its dynamic role in stabilizing the sacroiliac joint.” Clinical Biomechanics 4(4): 200-203.

[Successful treatment of refractory pudendal neuralgia with pulsed radiofrequency. Pain Physician.  2009; 12(3):633-8 MedLine Abstract

Rhame EE; Levey KA; Gharibo CG]

“Pudendal neuralgia (PN) involves severe, sharp pain along the course of the pudendal nerve, often aggravated with sitting. Current therapies include medication management, nerve blocks, decompression surgery, and neuromodulation. The ideal management for PN has not been determined. We present a case of a female with 1.5 years of sharp, burning pain of the left gluteal and perineal regions. She could not sit for longer than 10 to 15 minutes. Sacroiliac joint, epidural, and piriformis injections did not improve her pain. She had tried physical therapy, occupational therapy, massage, and acupuncture but the pain persisted. Medication treatment with oxycodone-acetaminophen, extended release morphine sulfate, amitriptyline, and gabapentin provided only minor relief and she had failed other multianalgesic therapy. She had been unable to work at her desk job for over a year. She had a positive response to 2 diagnostic pudendal nerve blocks with lidocaine that provided pain relief for several hours. This patient elected to undergo pulsed radiofrequency (PRF) of the left pudendal nerve in hopes of achieving a longer duration and improved pain relief. PRF was carried out at a frequency of 2 Hz and a pulse width of 20 milliseconds for a duration of 120 seconds at 42 degrees Celsius. After the procedure she reported tolerating sitting for 4 to 5 hours. Her multianalgesic therapy was successfully weaned. At 5 months follow-up she felt motivated to return to work. One and a half years after the procedure the patient is only taking oxycodone-acetaminophen for pain relief and still has good sitting tolerance. There were no procedure-related complications. To our knowledge PRF for the treatment of PN has not been reported elsewhere in the literature. PRF is a relatively new procedure and is felt to be safer than continuous radiofrequency. Current literature suggests that PRF delivers an electromagnetic field, which modifies neuro-cellular function with minimal cellular destruction. We conclude that PRF of the pudendal nerve offers promise as a potential treatment of PN that is refractory to conservative therapy.”

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Pudendal Neuralgia, Waseem Khoder, MD, Douglass Hale, MD, FACOG, FACS Correspondence information about the author MD, FACOG, FACS Douglass Hale Email the author MD, FACOG, FACS Douglass Hale, Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics and Gynecology, Indiana University School of Medicine, 1633 North Capitol Avenue, Suite 436, Indianapolis, IN 46202, USA

[Pudendal Neuralgia Khoder, Waseem et al. Obstetrics and Gynecology Clinics , Volume 41 , Issue 3 , 443 – 452]

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Refiew this case, which features a 14-year-old female gymnast with reports of burning, stinging, shooting, pain and numbness in the pelvis

Case Study: 14-Year-Old Female with Pelvic Pain

There are many research publications on Pudendal Neuropathy and the Sacrotuberous ligament.

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“Barry Komisaruk took the first steps to answering questions about the origin of female orgasms ”

The important fact related to Pudendal Neuropathy is that “the pudendal nerve carries sensations from the clitoris to the brain.”

“The famed “G-spot” was, for a long time, the prime target of research. The term was first coined in the early 80s, for the German obstetrician and gynaecologist, Ernst Gräfenberg. In 1950, he described an erogenous zone on the anterior, or front wall of the vagina, which correlated with the position of the urethra on the other side of that wall. Subsequent studies revealed a complex of blood vessels, nerve endings and remnants of the female prostate gland in the same area; and suggested that in a minority of women,  particularly those with strong pelvic floor muscles, stimulation of this area could trigger powerful orgasms and the release of a small amount of fluid from the urethra that was not urine.”

“Studies imply that there are multiple routes by which women can experience an orgasm, be it through vaginal stimulation, clitoral stimulation, or both at once. Further studies by Komisaruk have revealed that projections from different regions of the female genitals, even the nipples, all converge on the same general region of the brain, albeit in slightly different areas.

“There’s a good neuro-anatomical basis for different types of orgasms and different types of sensations,” Komisaruk says. “This could account for why combining clitoral, vaginal and cervical stimulation seems to produce these more intense, complex and pleasurable orgasms that women describe.”

Possibly, sacrotluberous ligment and pudendal nerve manipulation, massage and stimulation are actually forms of internal masturbation, G-spot and vaginal orgasm accompanied by the release of Dopamine by the Brain Dompaminergic Pathways for pleasure, the ‘feel good’ neurochemical and hormone.

The question might be, “are iatrogenic orgasms therapeutically beneficial for Athlete neuromuscular, lumosacral, exltremity and other injuries? [Standard Practice in Sexual Medicine, Hartmut Porst, Jacques Buvat, John Wiley & Sons, Apr 15, 2008 – Medical – 416 pages]

“A meta-analysis of several studies on the topic, published in the Clinical Journal of Sport Medicine in 2000, says that sexual activity does not have an impact on athletic performance.2 One study, done by Dr. Tommy Boone in 1995, measured men’s performance on a treadmill, and found no difference in aerobic power, oxygen pulse, or rate pressure product between men who had had sex twelve hours before and those who had not.3 Another study, published in the Journal of Sex Research all the  way back in 1968, found that men who had not had sex for six days did no better on a strength test than men who had had sex the previous night.4

“So, you need not worry about sex the day, week, or night before the game. Sex immediately before an athletic event, however, might be a different story. A study performed by four cardiologists in Switzerland – while confirming that sex several hours before a workout had no effect – suggested that athletic performance might be negatively affected by sex two hours before exercise.5 (Then again, how many athletes actually have sex right before a game?)

“Believe it or not, sex does not take up a huge amount of energy. On average, people only burn about fifty calories in a single act of sex, an amount that can be easily replenished.2 Men who are worried about depleting their testosterone levels need not worry; in fact, sex actually increases testosterone.6 On the female side of things, there is even better news: it has been argued that orgasms help women compete athletically. Physician Alexander Olshanietzky said, “We believe that a woman gets better results in sports competition after orgasm…The more orgasms, the more chances of winning a medal.”7

2. McGlone, Samantha, and Ian Shrier. “Does Sex the Night Before Competition Decrease Performance?” Clinical Journal of Sport Medicine 10.4 (2000): 233-34. Print.
3. Boone, Tommy, and S. Gilmore. “Effects of Sexual Intercourse on Maximal Aerobic Power, Oxygen Pulse, and Double Product in Male Sedentary Subjects.” The Journal of Sports Medicine and Physical Fitness 35.3 (1995): 214-17. Print.
4.Johnson, Warren R. “Muscular Performance following Coitus.” Journal of Sex Research 4.3 (1968): 247-48. Print.
5.Sztajzel, J., M. Périat, V. Marti, P. Krall, and W. Rutishauser. “Effect of Sexual Activity on Cycle Ergometer Stress Test Parameters, on Plasmatic Testosterone Levels and on Concentration Capacity. A Study in High-level Male Athletes Performed in the Laboratory.” The Journal of Sports Medicine and Physical Fitness 40.3 (2000): 233-39. Print.
6.Dabbs, James M., Jr. “Male and Female Salivary Testosterone Concentrations before and after Sexual Activity.” Physiology & Behavior 52.1 (1992): 195-97. Print.
7.Quinn, Jennifer. “The myths of sex before sport.” BBC News. British Broadcasting Corporation, August 12, 2004. Web. October 23, 2013.[SexInfo 24 Oct 2014]

“”>The top 10 benefits of orgasm for women

1.   Improves circulation to organs in the pelvic cavity, delivering nutrients, growing healthy tissues, and regulating your menstrual cycle. Women who have intercourse at least once a week are more likely to have normal menstrual cycles than women who are celibate or who have infrequent sex.

2.   Increases fertility and sense of wellness by energizing your hypothalamus gland, which regulates appetite, body temperature, emotions, and the pituitary gland, which in turn regulates the release of reproductive hormones that induce ovulation and cervical fluid.

3.   Provides overall lymphatic massage, helping your body’s natural detoxification process to improve digestion and mood and help prevent cancer.

4.   Promotes healthy estrogen levels to keep vaginal tissues supple and protect against osteoporosis and heart disease.

5.   Induces deep relaxation by boosting endorphin levels and flushing cortisol (an inflammatory hormone released by the adrenal glands) out of the body.

6.   Spikes DHEA levels in the body. DHEA hormone improves brain function, balances the immune system, helps maintain and repair tissue, and promotes healthy skin.

7.   Helps you look younger—studies show making love three times a week in a stress free relationship can make you look 10 years younger.

8.   Boosts infection-fighting cells up to 20%–helps fight colds and flu!

9.   Cures migraines and helps treat other types of pain by elevating pain thresholds (a bonus when preparing for childbirth!)

10.                Increases levels of the hormone oxytocin, which is linked to passion, intuition, and social skills—the hormone of bonding and success! [Flo Living}

On the male side. This editor knew a SEC Football Athlete, a lineman, who masturbated before each practice and game, because his father, an areospace engineer, claimed it would increase his testerone blood level and improve his performance.

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Unfortunately, demonic, wicked, abnormal human behaviors happen.

While there exist hypotheses, theories, established with certainty practices and procedures, and their contradistinctives, Dr. Larry Nassar appears to have deamonized the ethical practice of medicine, patient’s informed consent, the lawful health assistance to his patients and their humane care and dignity.

We advocates for Athlete Safety 1st and the Prevention of Child Athlete Physical and Psychological Maltreatment, Child Athlete Sexual Abuse and Chidren’s Human Rights Violations, pray and promote that “his kind never happen again.”

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