Download PDF
J Reconstr Microsurg 2015; 31(04): 283-290
DOI: 10.1055/s-0034-1396896
Original Article
Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Pelvic Pain of Pudendal Nerve Origin: Surgical Outcomes and Learning Curve Lessons

A. Lee Dellon
1   Department of Plastic Surgery, Peripheral Nerve Surgery, Johns Hopkins University, Baltimore, Maryland
,
Deborah Coady
2   Department of Gynecology and Obstetrics, New York University Langone Medical Center, New York City, New York
,
Dena Harris
2   Department of Gynecology and Obstetrics, New York University Langone Medical Center, New York City, New York
› Author Affiliations
Further Information

Publication History

01 September 2014

08 October 2014

Publication Date:
28 January 2015 (online)

    Permissions and Reprints

Abstract

Purpose When pudendal nerve dysfunction fails to improve after medical and pelvic floor therapy, a surgical approach may be indicated. “Traditional,” “posterior,” transgluteal nerve decompression fails in an unacceptably high percentage of patients. Insights into pudendal neuroanatomy and pathophysiology offer improved microsurgical outcomes.

Methods To evaluate results of a peripheral nerve approach to the pudendal nerve, 55 patients were prospectively evaluated. This cohort included 25 men and 30 women. Surgical approach was posterior, transgluteal if symptoms included rectal pain; or “anterior,” inferior pubic ramus approach if symptoms excluded rectal pain. Surgical approach was “resection,” if trauma created a neuroma, and “decompression,” if there were no neuroma. Effect of comorbidities was analyzed.

Results At 14.3 months postoperatively, untreated anxiety/depression correlated with outcome failure, regardless of surgical approach, p < 0.002. There was no difference in results, men versus women, “anterior” versus “posterior” approach, or neuroma resection versus neurolysis. Success correlated with the “learning curve” of the surgeon. Self-rated success was significantly better (p < 0.0001) for patients operated on during the second year of the study than the first year of the study, and improved again in the final year of the study (p < 0.04), with 86% of the patients in final year achieving an excellent result and 14% achieving a good result.

Conclusion There is hope for surgical relief from pudendal nerve problems by distinguishing neuroma from compression in the diagnosis, and then choosing a site-specific surgical approach related to which pudendal nerve branches are involved.

Keywords

pudendal nerve - neurolysis - neuroma

Supplementary Material

 

  • References

  • 1 Ayestaray B, Proske YM. Perineal and posterior vaginal wall reconstruction with a superior gluteal artery dual perforator-pedicled propeller flap. Microsurgery 2014; ; doi: 10.1002/micr.22279
    PubMedGoogle Scholar
  • 2 Horch RE, Hohenberger W, Eweida A , et al. A hundred patients with vertical rectus abdominis myocutaneous (VRAM) flap for pelvic reconstruction after total pelvic exenteration. Int J Colorectal Dis 2014; 29 (7) 813-823
    CrossrefPubMedGoogle Scholar
  • 3 Qiu SS, Jurado M, Hontanilla B. Comparison of TRAM versus DIEP flap in total vaginal reconstruction after pelvic exenteration. Plast Reconstr Surg 2013; 132 (6) 1020e-1027e
    CrossrefPubMedGoogle Scholar
  • 4 Spyropoulou GA, Jeng SF, Demiri E, Dionyssopoulos A, Feng KM. Reconstruction of perineoscrotal and vaginal defects with pedicled anterolateral thigh flap. Urology 2013; 82 (2) 461-465
    CrossrefPubMedGoogle Scholar
  • 5 Rieger UM, Erba P, Pierer G, Kalbermatten DF. Hidradenitis suppurativa of the groin treated by radical excision and defect closure by medial thigh lift: aesthetic surgery meets reconstructive surgery. J Plast Reconstr Aesthet Surg 2009; 62 (10) 1355-1360
    CrossrefPubMedGoogle Scholar
  • 6 Mizukami T, Fujiwara M, Ishikawa K, Aoyama S, Fukamizu H. Reconstruction for extensive groin hidradenitis suppurativa using a combination of inferior abdominal flap and medial thigh lift: a case report. Aesthetic Plast Surg 2014; 38 (4) 745-748
    CrossrefPubMedGoogle Scholar
  • 7 Pantelides NM, Davies RJ, Fearnhead NS, Malata CM. The gluteal fold flap: a versatile option for perineal reconstruction following anorectal cancer resection. J Plast Reconstr Aesthet Surg 2013; 66 (6) 812-820
    CrossrefPubMedGoogle Scholar
  • 8 Grinsell DG, Morrison E, Tansley PD. The inferior gluteal artery myocutaneous flap with vascularized fascia lata to reconstruct extended abdominoperineal defects. Plast Reconstr Surg 2013; 132 (5) 836e-840e
    CrossrefPubMedGoogle Scholar
  • 9 Nosti PA, Stahl TJ, Sokol AI. Surgical repair of rectovaginal fistulas in patients with Crohn's disease. Eur J Obstet Gynecol Reprod Biol 2013; 171 (1) 166-170
    CrossrefPubMedGoogle Scholar
  • 10 Gilbert DA, Jordan GH, Devine Jr CJ, Winslow BH. Microsurgical forearm “cricket bat-transformer” phalloplasty. Plast Reconstr Surg 1992; 90 (4) 711-716
    CrossrefPubMedGoogle Scholar
  • 11 Dabernig J, Shelley OP, Schaff J. The innervated free toe web flap for clitoris reconstruction. J Plast Reconstr Aesthet Surg 2007; 60 (12) 1352-1355
    CrossrefPubMedGoogle Scholar
  • 12 Monstrey SJ, Ceulemans P, Hoebeke P. Sex reassignment surgery in the female-to-male transsexual. Semin Plast Surg 2011; 25 (3) 229-244
    Article in Thieme ConnectPubMedGoogle Scholar
  • 13 Mirzabeigi MN, Au A, Jandali S, Natoli N, Sbitany H, Serletti JM. Trials and tribulations with the inferior gluteal artery perforator flap in autologous breast reconstruction. Plast Reconstr Surg 2011; 128 (6) 614e-624e
    CrossrefPubMedGoogle Scholar
  • 14 LoTempio MM, Allen RJ. Breast reconstruction with SGAP and IGAP flaps. Plast Reconstr Surg 2010; 126 (2) 393-401
    CrossrefPubMedGoogle Scholar
  • 15 Morrison EJ, Shoukath S, Tansley P, Grinsell D. Donor site morbidity of an islanded inferior gluteal artery myocutaneous flap with vascularized fascia lata. J Plast Reconstr Aesthet Surg 2013; 66 (7) 962-967
    CrossrefPubMedGoogle Scholar
  • 16 Godbout E, Farmer L, Bortoluzzi P, Caouette Laberge L. Donor-site morbidity of the inferior gluteal artery perforator flap for breast reconstruction in teenagers. Can J Plast Surg 2013; 21 (1) 19-22
    PubMedGoogle Scholar
  • 17 Triana L, Robledo AM. Refreshing labioplasty techniques for plastic surgeons. Aesthetic Plast Surg 2012; 36 (5) 1078-1086
    CrossrefPubMedGoogle Scholar
  • 18 Hamori CA. Postoperative clitoral hood deformity after labiaplasty. Aesthet Surg J 2013; 33 (7) 1030-1036
    CrossrefPubMedGoogle Scholar
  • 19 Hashimoto I, Abe Y, Nakanishi H. The internal pudendal artery perforator flap: free-style pedicle perforator flaps for vulva, vagina, and buttock reconstruction. Plast Reconstr Surg 2014; 133 (4) 924-933
    CrossrefPubMedGoogle Scholar
  • 20 Lenz F, Doll S, Sohn C, Brocker KA. Anatomical position of four different transobturator mesh implants for female anterior prolapse repair. Geburtshilfe Frauenheilkd 2013; 73 (10) 1035-1041
    Article in Thieme ConnectPubMedGoogle Scholar
  • 21 Parnell BA, Johnson EA, Zolnoun DA. Genitofemoral and perineal neuralgia after transobturator midurethral sling. Obstet Gynecol 2012; 119 (2, Pt 2) 428-431
    CrossrefPubMedGoogle Scholar
  • 22 Rice NT, Hu Y, Slaughter JC, Ward RM. Pelvic mesh complications in women before and after the 2011 FDA public health notification. Female Pelvic Med Reconstr Surg 2013; 19 (6) 333-338
    CrossrefPubMedGoogle Scholar
  • 23 Gillitzer R, Hampel C, Wiesner C, Pahernik S, Melchior SW, Thüroff JW. Pudendal nerve branch injury during radical perineal prostatectomy. Urology 2006; 67 (2) 423.e1-423.e3
    PubMedGoogle Scholar
  • 24 Dellon AL, Wright EJ, Manson PN. Chronic pelvic pain after laser prostatectomy: treatment by resection of the perineal branches of the pudendal nerve. J Reconstr Microsurg 2014; 30 (8) 547-550
    Article in Thieme ConnectPubMedGoogle Scholar
  • 25 Mauillon J, Thoumas D, Leroi AM, Freger P, Michot F, Denis P. Results of pudendal nerve neurolysis-transposition in twelve patients suffering from pudendal neuralgia. Dis Colon Rectum 1999; 42 (2) 186-192
    CrossrefPubMedGoogle Scholar
  • 26 Bautrant E, de Bisschop E, Vaini-Elies V , et al. Modern algorithm for treating pudendal neuralgia: 212 cases and 104 decompressions [in French]. J Gynecol Obstet Biol Reprod (Paris) 2003; 32 (8, Pt 1) 705-712
    PubMedGoogle Scholar
  • 27 Beco J, Climov D, Bex M. Pudendal nerve decompression in perineology: a case series. BMC Surg 2004; 4: 15
    CrossrefPubMedGoogle Scholar
  • 28 Robert R, Labat JJ, Bensignor M , et al. Decompression and transposition of the pudendal nerve in pudendal neuralgia: a randomized controlled trial and long-term evaluation. Eur Urol 2005; 47 (3) 403-408
    CrossrefPubMedGoogle Scholar
  • 29 Popeney C, Ansell V, Renney K. Pudendal entrapment as an etiology of chronic perineal pain: Diagnosis and treatment. Neurourol Urodyn 2007; 26 (6) 820-827
    CrossrefPubMedGoogle Scholar
  • 30 Robert R, Labat JJ, Riant T, Khalfallah M, Hamel O. Neurosurgical treatment of perineal neuralgias. Adv Tech Stand Neurosurg 2007; 32: 41-59
    PubMedGoogle Scholar
  • 31 Filler AG. Diagnosis and treatment of pudendal nerve entrapment syndrome subtypes: imaging, injections, and minimal access surgery. Neurosurg Focus 2009; 26 (2) E9
    PubMedGoogle Scholar
  • 32 Hibner M, Desai N, Robertson LJ, Nour M. Pudendal neuralgia. J Minim Invasive Gynecol 2010; 17 (2) 148-153
    CrossrefPubMedGoogle Scholar
  • 33 Dellon AL. Chronic pelvic pain. In: Pain Solutions. Lightning Source Internet Publications; 2011: 308-384
    Google Scholar
  • 34 Furtmueller GJ, McKenna CA, Ebmer J, Dellon AL. Pudendal nerve 3-dimensional illustration gives insight into surgical approaches. Ann Plast Surg 2014; ; doi: 10.1097/SAP.0000000000000169
    PubMedGoogle Scholar
  • 35 Dellon.com, 3D of Pudendal Nerve, Master's Degree Project of Courtney A McKenna, accessed July 5, 2014
    PubMed
  • 36 Hruby S, Ebmer J, Dellon AL, Aszmann OC. Anatomy of pudendal nerve at urogenital diaphragm—new critical site for nerve entrapment. Urology 2005; 66 (5) 949-952
    CrossrefPubMedGoogle Scholar
  • 37 Hruby S, Dellon L, Ebmer J, Höltl W, Aszmann OC. Sensory recovery after decompression of the distal pudendal nerve: anatomical review and quantitative neurosensory data of a prospective clinical study. Microsurgery 2009; 29 (4) 270-274
    CrossrefPubMedGoogle Scholar
  • 38 Labat JJ, Riant T, Robert R, Amarenco G, Lefaucheur JP, Rigaud J. Diagnostic criteria for pudendal neuralgia by pudendal nerve entrapment (Nantes criteria). Neurourol Urodyn 2008; 27 (4) 306-310
    CrossrefPubMedGoogle Scholar
  • 39 Hummel-Berry K, Wallace K, Herman H. The reliability and validity of the Vulvar Questionnaire (VQ). J Women Health & Physical Ther 2007; 31: 28-33
    PubMedGoogle Scholar
  • 40 Rosen R, Brown C, Heiman J , et al. The Female Sexual Function Index (FSFI): a multidimensional self-report instrument for the assessment of female sexual function. J Sex Marital Ther 2000; 26 (2) 191-208
    CrossrefPubMedGoogle Scholar
  • 41 Litwin MS, McNaughton-Collins M, Fowler Jr FJ , et al; Chronic Prostatitis Collaborative Research Network. The National Institutes of Health chronic prostatitis symptom index: development and validation of a new outcome measure. J Urol 1999; 162 (2) 369-375
    CrossrefPubMedGoogle Scholar
  • 42 Block AR. Presurgical psychological screening in chronic pain syndromes: psychosocial risk factors for poor surgical results. In: Gatchel RJ, Turk DC, , eds., Psychosocial Factors in Pain: Critical Perspectives. New York: The Guildford Press; 1999: 390-400
    Google Scholar
  • 43 Singh G, Willen SN, Boswell MV, Janata JW, Chelimsky TC. The value of interdisciplinary pain management in complex regional pain syndrome type I: a prospective outcome study. Pain Physician 2004; 7 (2) 203-209
    PubMedGoogle Scholar
  • 44 Reed BD, Harlow SD, Sen A, Edwards RM, Chen D, Haefner HK. Relationship between vulvodynia and chronic comorbid pain conditions. Obstet Gynecol 2012; 120 (1) 145-151
    CrossrefPubMedGoogle Scholar
  • 45 Hampson JP, Reed BD, Clauw DJ , et al. Augmented central pain processing in vulvodynia. J Pain 2013; 14 (6) 579-589
    CrossrefPubMedGoogle Scholar
  • 46 Carroll I, Hah J, Mackey S , et al. Perioperative interventions to prevent chronic postsurgical pain. J Reconstr Microsurg 2013; 29 (4) 213-222
    Article in Thieme ConnectPubMedGoogle Scholar
  • 47 Follmar KE, Williams EH, Dellon AL. Rectal pain of neural origin: resection of sensory rectal branches of pudendal nerve. J Reconstr Microsurg 2014; ; PMID: 25192273 2014
    PubMedGoogle Scholar
  • 48 Colebunders B, Matthew MK, Broer N, Persing JA, Dellon AL. Benjamin Alcock and the pudendal canal. J Reconstr Microsurg 2011; 27 (6) 349-354
    Article in Thieme ConnectPubMedGoogle Scholar