Decompression of Inferior Rectal Nerve in Refractory Perianal Pain Caused by Pudendal Nerve Entrapment: A Case Report

Byung-chul Son,Chang-ik Lee 대한통증연구학회 2021 International Journal of Pain Vol.12 No.2

Pudendal neuralgia is a painful neuropathy involving the pudendal nerve. The pudendal nerve comprises sensory and motor fibers supplying the anal, perineal, and genital regions. It branches off into the inferior rectal and perineal branches, and the dorsal nerve of the penis or clitoris. Therefore, the pain associated with pudendal neuralgia is localized to the vulva, vagina, clitoris, perineum, and rectum in females and to the glans penis, scrotum, perineum, and rectum in males. Isolated perianal pain may manifest as a symptom of pudendal neuralgia caused by pudendal nerve entrapment, but the comprehensive clinical features and treatment have yet to be reported. A 67-year-old female patient presented with a two-year history of persistent stabbing and tingling pain involving her left perianal area. The pain was triggered by a blunt trauma to the buttock and was especially severe in the seated position. Transgluteal surgery confirmed the location of pudendal nerve superior to the sacrotuberous ligament in the form of inferior rectal and perineal and dorsal nerves, and along the pudendal canal. This case demonstrates the importance of accurate anatomical knowledge of the pudendal nerve and its branches in surgical decompression of pudendal nerve entrapment.

Decompression of Pudendal Nerve in Chronic Pudendal Neuralgia: A Case Report

Byung-chul Son 대한통증연구학회 2020 International Journal of Pain Vol.11 No.2

Pudendal neuralgia is a painful neuropathy involving the pudendal nerve. It is characterized by localized pain in the vulva, vagina, clitoris, perineum, and rectum in females and is often refractory to conservative treatment. A 71-year-old female patient presented with persistent stabbing and burning pain involving her right perineal and perianal area. The onset of pain was sudden and lasted all the time. It was more severe when lying down and sitting. No organic causes were detected in gynecological, urological, and colorectal investigations. However, the pain was refractory to various medications including anticonvulsants, analgesics, and opioids and nerve blocks. Fluoroscopy-guided pudendal nerve block resulted in temporary pain relief. Transgluteal decompression of the right pudendal nerve reduced the preoperative pain by 70%. The pain relief lasted 1 year after surgery. Chronic pudendal neuralgia that does not improve with conservative treatment suggests possible pudendal nerve entrapment.

Report of an inferior rectal nerve variant arising from the S3 ventral ramus

Graham Dupont,Joe Iwanaga,Rod J. Oskouian,R. Shane Tubbs 대한해부학회 2019 Anatomy & Cell Biology Vol.52 No.1

In surgical approaches to the perineum in general and anal region specifically, considering the possible variations of the inferior rectal nerve is important for the surgeon. Normally, the inferior rectal nerve originates as a branch of the pudendal nerve. However, during routine dissection, a variant of the inferior rectal nerve was found where it arose directly from the third sacral nerve ventral ramus (S3). Many cases have described the inferior rectal nerve arising independently from the sacral plexus, most commonly from the fourth sacral nerve root (S4); however, few cases have reported the inferior rectal nerve arising from S3. Herein, we describe a variant of the inferior rectal nerve in which the nerve arises independently from the sacral plexus.

Treatment of Postherpetic Pudendal Neuralgia Using Pudendal Nerve Block

( Taejun Hwang ),( Soon Oh Kwon ),( Hee Yong Kang ) 경희대학교 경희의료원 2023 慶熙醫學 Vol.38 No.1

Postherpetic neuralgia (PHN) is the most common complication of acute herpes zoster (AHZ). Patients with PHN have reduced quality of life, physical functioning, and psychological well-being. Current treatment options for PHN include pharmacologic agents, topical analgesics, and interventional therapies. However, few studies have reported the efficacy of interventional procedures for the treatment of PHN. Pudendal neuralgia is a painful neuropathic condition, involving the dermatome of the pudendal nerve. Diagnosis of pudendal neuralgia is made clinically. Nantes criteria can be helpful in making the diagnosis. Pudendal nerve block (PNB) is an effective diagnostic and treatment method for perineal pain. Here, we report a 63-year-old woman after AHZ. She was treated with pharmacologic agents and C-arm-guided PNB, and the pain was reduced satisfactorily. It is suggested that PNB using ropivacaine with triamcinolone is an effective treatment option in patients with chronic pudendal neuralgia after AHZ.

Modified Urethral Graciloplasty Cross-Innervated by the Pudendal Nerve for Postprostatectomy Urinary Incontinence: Cadaveric Simulation Surgery and a Clinical Case Report

Sakuma Hisashi,Yazawa Masaki,Hikosaka Makoto,Uchikawa-Tani Yumiko,Takayama Masayoshi,Kishi Kazuo 대한성형외과학회 2023 Archives of Plastic Surgery Vol.50 No.6

An artificial sphincter implanted in the bulbous urethra to treat severe postprostatectomy urinary incontinence is effective, but embedding-associated complications can occur. We assessed the feasibility, efficacy, and safety of urethral graciloplasty cross-innervated by the pudendal nerve. A simulation surgery on three male fresh cadavers was performed. Both ends of the gracilis muscle were isolated only on its vascular pedicle with proximal end of the obturator nerve severed and transferred to the perineum. We examined whether the gracilis muscle could be wrapped around the bulbous urethra and whether the obturator nerve was long enough to suture with the pudendal nerve. In addition, surgery was performed on a 71-year-old male patient with severe urinary incontinence. The postoperative 12-month outcomes were assessed using a 24-hour pad test and urodynamic study. In all cadaveric simulations, the gracilis muscles could be wrapped around the bulbous urethra in a γ-loop configuration. The length of the obturator nerve was sufficient for neurorrhaphy with the pudendal nerve. In the clinical case, the postoperative course was uneventful. The mean maximum urethral closure pressure and functional profile length increased from 40.7 to 70 cm H2O and from 40.1 to 45.3 mm, respectively. Although urinary incontinence was not completely cured, the patient was able to maintain urinary continence at night. Urethral graciloplasty cross-innervated by the pudendal nerve is effective in raising the urethral pressure and reducing urinary incontinence.

Defective Conduction of Anorectal Afferents Is a Very Prevalent Pathophysiological Factor Associated to Fecal Incontinence in Women

Lluís Mundet,Christopher Cabib,Omar Ortega,Laia Rofes,Noemí Tomsen,Sergio Marin,Carla Chacón,Pere Clavé 대한소화기 기능성질환∙운동학회 2019 Journal of Neurogastroenterology and Motility (JNM Vol.25 No.3

Background/AimsFecal incontinence (FI) is a prevalent condition among women. While biomechanical motor components have been thoroughlyresearched, anorectal sensory aspects are less known. We studied the pathophysiology of FI in community-dwelling women,specifically, the conduction through efferent/afferent neural pathways. MethodsA cross-sectional study was conducted on 175 women with FI and 19 healthy volunteers. The functional/structural study includedanorectal manometry/endoanal ultrasound. Neurophysiological studies including pudendal nerve terminal motor latency (PNTML) andsensory-evoked-potentials to anal/rectal stimulation (ASEP/RSEP) were conducted on all healthy volunteers and on 2 subgroups of 42and 38 patients, respectively. ResultsThe main conditions associated with FI were childbirth (79.00%) and coloproctological surgery (37.10%). Cleveland score was 11.39± 4.09. Anorectal manometry showed external anal sphincter and internal anal sphincter insufficiency in 82.85% and 44.00%,respectively. Sensitivity to rectal distension was impaired in 27.42%. Endoanal ultrasound showed tears in external anal sphincter(60.57%) and internal anal sphincter disruptions (34.80%). Abnormal anorectal sensory conduction was evidenced through ASEPand RSEP in 63.16% and 50.00% of patients, respectively, alongside reduced activation of brain cortex to anorectal stimulation. Incontrast, PNTML was delayed in only 33.30%. Stools were loose/very loose in 56.70% of patients. ConclusionsPathophysiology of FI in women is mainly associated with mechanical sphincter dysfunctions related to either muscle damage or, to alesser extent, impaired efferent conduction at pudendal nerves. Impaired conduction through afferent anorectal pathways is also veryprevalent in women with FI and may play an important role as a pathophysiological factor and as a potential therapeutic target.

Pudendal nerve entrapment syndrome caused by ganglion cysts along the pudendal nerve

( Young Je Kim ),( Du Hwan Kim ) 영남대학교 의과대학 2021 Yeungnam University Journal of Medicine Vol.38 No.2

Pudendal nerve entrapment (PNE) syndrome refers to the condition in which the pudendal nerve is entrapped or compressed. Reported cases of PNE associated with ganglion cysts are rare. Deep gluteal syndrome (DGS) is defined as compression of the sciatic or pudendal nerve due to a non-discogenic pelvic lesion. We report a case of PNE caused by compression from ganglion cysts and treated with steroid injection; we discuss this case in the context of DGS. A 77-year-old woman presented with a 3-month history of tingling and burning sensations in the left buttock and perineal area. Ultrasonography showed ganglion cystic lesions at the subgluteal space. Magnetic resonance imaging revealed cystic lesions along the pudendal nerve from below the piriformis to the Alcock’s canal and a full-thickness tear of the proximal hamstring tendon. Aspiration of the cysts did not yield any material. We then injected steroid into the cysts, which resolved her symptoms. Steroid injection into a ganglion cyst should be considered as a treatment option for PNE caused by ganglion cysts.

Ultrasound-guided pudendal nerve pulsed radiofrequency in patients with refractory pudendal neuralgia -Three cases report-

한성민,문동언,김영훈,박휴정,이민규,사계절 대한마취통증의학회 2014 Anesthesia and pain medicine Vol.9 No.4

Pudendal neuralgia is characterized by severe sharp pain along theinnervation area of pudendal nerve, which may be worsened whensitting position. Successful pudendal nerve block is crucial to thediagnosis of pudendal neuralgia. Although fluoroscopy-guided pudendalnerve blocks have traditionally been performed, recentlyultrasound-guided pudendal nerve blocks were reported. For thelong term effect of nerve block, pulsed radiofrequency was performedunder fluoroscopic guidance in some reports. We report oursuccessful experiences of three cases using ultrasound-guidedpulsed radiofrequency.

Pudendal Nerve Neurolysis in Patients Afflicted With Pudendal Nerve Entrapment: A Systematic Review of Surgical Techniques and Their Efficacy

Carlo Giulioni,Giacomo Maria Pirola,Martina Maggi,Lucia Pitoni,Demetra Fuligni,Mattia Beltrami,Vanessa Palantrani,Virgilio De Stefano,Valentina Maurizi,Daniele Castellani,Andrea Benedetto Galosi 대한배뇨장애요실금학회 2024 International Neurourology Journal Vol.28 No.1

To assess the effectiveness and safety of various techniques of pudendal nerve neurolysis (PNN) in patients with pudendal nerve entrapment (PNE). A comprehensive literature search was conducted on May 20th, 2023, using Scopus, PubMed, and Embase databases. Only studies in English involving adults were accepted, while meeting abstracts and preclinical studies were excluded. A total of 34 papers were included. Transperineal PNN emerged as a promising technique, demonstrating significant potential in alleviating pain, restoring erectile function in males, and improving the resolution of urinary stress incontinence in females. Furthermore, the bilateral approach consistently yielded positive outcomes in addressing urinary symptoms. The transgluteal technique appeared particularly suitable for cases of posterior PNE, situated between the sacrospinous ligament and the lesser sciatic foramen. A progressive amelioration of painful symptoms was observed during follow-up. Minimally invasive PNN is evolving and enables decompression along the entire proximal tract up to the Alcock canal, minimizing the risk of comorbidities. In addition to reducing pudendal neuralgia, robot-assisted and laparoscopic approaches determined a reduction in lower urinary tract symptoms and an improvement in erectile function, though further studies are required to corroborate these findings. PNN emerges as an effective treatment for PNE with minimal morbidity. Therefore, PNN should be tailored according to the site of PNE to enhance functional outcomes and improve patient quality of life.

Intrapelvic Nerve Entrapment Syndrome Caused by a Variation of the Intrapelvic Piriformis Muscle and Abnormal Varicose Vessels: A Case Report

Ahmet Kale,Gulfem Basol,Ahmet C. Topcu,Elif C. Gundogdu,Taner Usta,Recep Demirhan 대한배뇨장애요실금학회 2021 International Neurourology Journal Vol.25 No.2

Entrapment neuropathy of the sciatic nerve and pudendal nerve are painful syndromes that are often overlooked by physicians. Laparoscopic surgical interventions for nerve entrapment syndromes of the posterior pelvis focus on removing the compression lesion with the purpose of eliminating the suspected cause of sciatica, as well as pudendal neuralgia. Herein, the authors report the rare event of sciatic and pudendal nerve entrapment, which was caused by aberrant vessels and a variant piriformis muscle bundle, as a seldom-diagnosed cause of sciatica and pelvic pain, for both neurosurgeons and neuropelveologists. The authors present the laparoscopic decompression technique for the pudendal and sciatic nerves by giving our technical “tips and tricks” enriched by a surgical video.