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Booking form

Booking form

Name and Contact Details

Patient Profile

Symptom’s evolution

Systematic review of the potential symptoms

Symptoms include at least one of the followed territory:
- the clitoris
- the gland of the penis
- the urethra
- the entrance of the vagina

YesNo
Do you have the impression of rectal or anal foreign body?
Do you try to defecate 3 times or more per day?
Do you have chronicle obstipation?
Do you have actually or a past story of hemorrhoids?
Have you been diagnosed with anism (spasm of the anus)?
YesNo
Do you have urinary urgencies?
Do you have a weak urinary stream?
Do you have burning when you urinate?
Do you present recurrent cystitis or prostatitis?
Do you have some urethral leak (not urine, like lubricant)?
YesNo
Do you have premature or delayed ejaculation?
Do you have a poor orgasmic sensation?
Do you have erectile dysfunction?
Do you have the penis shorter in the flaccid position?
Do you have sensation to have the gland colder?
Do you have a constant tumescence of your penis?
YesNo
Do you have painful sexual intercourse?
Do you have spontaneous sexual stimulation (arousal syndrome)?
Do you have vaginism (lack of perineal relaxation when penetration)?

Positive answer at the pudendal infiltration test ( Ct Scanner guided):
- An improvement during the first hours after infiltration
- A transitory worsening after one days and during the followed week
- An improvement after few weeks

Price: €70.00