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Original Article 283

Pelvic Pain of Pudendal Nerve Origin: Surgical


Outcomes and Learning Curve Lessons
A. Lee Dellon, MD, PhD1 Deborah Coady, MD2 Dena Harris, MD2

1 Department of Plastic Surgery, Peripheral Nerve Surgery, Johns Address for correspondence A. Lee Dellon, MD, PhD, 1122 Kenilworth
Hopkins University, Baltimore, Maryland Dr, Suite 18, Towson, MD, 21204 (e-mail: aldellon@dellon.com).
2 Department of Gynecology and Obstetrics, New York University
Langone Medical Center, New York City, New York

J Reconstr Microsurg 2015;31:283–290.

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Abstract Purpose When pudendal nerve dysfunction fails to improve after medical and pelvic
floor therapy, a surgical approach may be indicated. “Traditional,” “posterior,” trans-
gluteal nerve decompression fails in an unacceptably high percentage of patients.
Insights into pudendal neuroanatomy and pathophysiology offer improved microsurgi-
cal 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
Keywords excellent result and 14% achieving a good result.
► pudendal nerve Conclusion There is hope for surgical relief from pudendal nerve problems by
► neurolysis distinguishing neuroma from compression in the diagnosis, and then choosing a site-
► neuroma specific surgical approach related to which pudendal nerve branches are involved.

Reconstructive microsurgery may directly involve the puden- difficult to treat, with success rates for the most commonly
dal nerve during vaginal reconstruction,1–4 groin hydradenitis done surgical approach having an expectation that 70% of
suppurativa reconstruction,5,6 rectal reconstruction,7–9 trans- patients will improve by > 2 on a 10-point Likert scale, and
gender reconstruction,10–12 inferior gluteal artery perforator just 20% achieving an excellent result (►Table 1).25–32
flaps for breast reconstruction,13–16 labial reconstruction,17–19 Recognizing that peripheral nerve surgery is the basis for
salvage procedures after gynecologic mesh interventions for treatment of refractory pelvic pain related to the pudendal
urinary incontinence,20–22 and following urologic procedures nerve, it is incumbent for the reconstructive microsurgeon to
such as prostatectomy.23,24 Injury to the branches of the approach the problem from the standpoint of (1) determining
pudendal nerve results in pain syndromes that have proven that the pudendal nerve is the nerve primarily transmitting

received Copyright © 2015 by Thieme Medical DOI http://dx.doi.org/


September 1, 2014 Publishers, Inc., 333 Seventh Avenue, 10.1055/s-0034-1396896.
accepted after revision New York, NY 10001, USA. ISSN 0743-684X.
October 8, 2014 Tel: +1(212) 584-4662.
published online
January 28, 2015
284 Pudendal Nerve Surgical Outcomes Dellon et al.

Table 1 Results of pudendal nerve decompression33

Author (year) Surgical Structure No. of Excellent (%) Good (%) Failure Months
approach divided patients (%) to
recovery
Mauillon (1993)25 Prone TG SS, ST FP, A 12 25 9 66 3–12
Bautrant (2003)26 Lithotomy SS FP, A 104 62 25 13 0–12
Ischiorectal
Beco (2004)27 Lithotomy A 14 68 32 6–12
Ischiorectal
Robert (2005)28 Prone TG (M) ST SS, A 16 (70%  30% relief) 3–12
Ansell (2007)29 Prone TG SS, ST FP, A 58 44 (60%  50% relief) 23 33 NA
Robert et al (2007)30 TG (M) ST SS, A 170 40 30 30 4–18
31

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a
Filler (2009) Prone TG (H) P ST 147 20 (67%  40% relief) 67 13 4–12
Hibner (2010)32 Prone TG (M) STb A NA 70% > 20% 18–24
improvement

Abbreviations: FP, falciform process of ST ligament; P, piriformis muscle division; ST, sacrotuberous ligament; SS, sacrospinous ligament; A, Alcock
canal; NA, data not available; TG, transgluteal either (H) high and lateral or (M) medial, oblique over tuberosity.
a
Partial sacrotuberous ligament division was done in 12% of surgeries.
b
After ST division, pudendal nerve is wrapped in a collagen tube, which is then filled with platelet-rich plasma.

the perceived pain; (2) distinguishing whether the pudendal • Had their surgery between October 2010 and
nerve problem is related to compression versus neuroma; and October 2013
(3) intervening surgically using an approach that recognizes • Had a minimum of 12 months of postoperative follow-up
that the rectal, perineal, and dorsal branches of the pudendal
nerve may require separate anatomic approaches. It is the Patients’ demographics and accrual were as follows: Dur-
purpose of this report to describe our experience over ing the first year of the study, October 2010 to Septem-
the past 5 years of the surgical treatment of pudendal nerve ber 2011, 9 female patients were included from the Soho
problems utilizing these three concepts. This experience Obstetrics and Gynecology, PC (authors D. C. and D. H.), and
required reviewing the existing knowledge on chronic pelvic the remaining 17 patients, both female and male, were
pain,33 improving our understanding of pudendal nerve included from the Institute for Peripheral Nerve Surgery
anatomy by cadaver dissection and 3T-radiographic imag- (author A. L. D.). The remaining patients came from the
ing,34,35 and incorporating novel, anterior, approaches to the practice of author A. L. D., and included 25 patients accrued
perineal and dorsal branches of the pudendal nerve.36,37 from October 2011 to September 2012. During the first 2 years
of the study, the total patient population was composed of 27
women and 14 men, mean age 39.5 years, range 31 to 75 years.
Methods and Materials
Patients accrued from October 2012 to September 2013, the
This is a prospective cohort study. It was originally planned to extended third year of the study, included 3 women and 11
last for 2 years but was extended a third year once it was clear men. There was no significant difference in their mean age
that outcomes were improving with increasing experience in from the earlier group of patients. Patient selection differed
patient selection and surgical technique. Forty-one patients only in that these last 14 had their underlying anxiety/
were included in the first 2 years and another 14 in the third depression adequately treated by their psychiatrist prior to
year for a total of 55 patients. surgery.
Inclusion criteria were as follows: Patients with chronic Outcome analysis was designed to incorporate validated
(> 6 months) pelvic pain were consecutively included into instruments being used by Soho Obstetrics and Gynecology,
this study if they PC, comparing the results from these instruments with a
simpler numerical analog score (NAS), an 11-point
• Met the Nantes criteria38 for involvement of the pudendal scale ranging from 0 (no pain) to 10, with 10 being the worst.
nerve (►Table 2) A subgroup of women filled out the vulvar functional
• Had not improved with accepted gynecologic (for women) scale39,40 (VQ) (n ¼ 14) and the female sexual function
or urologic/colorectal (for men) treatment for their symp- index41 (FSFI) (n ¼ 9) prior to surgery and at the time of
toms, such as topical and oral medication and therapeutic final follow-up. A subgroup of men filled out the NIH
injections, including Botulinum toxin chronic prostate screening index42 (CPSI) (n ¼ 11) and
• Had not improved with  6 months of pelvic floor therapy the “male VQ” (n ¼ 12), the VQ modified for men
• Had their symptoms relieved temporarily by a pudendal (►Supplementary Table S1, see online) prior to surgery and
nerve block at the time of final follow-up. Each patient self-rated satisfaction

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Pudendal Nerve Surgical Outcomes Dellon et al. 285

Table 2 The Nantes criteria for pudendal nerve entrapment38

Essential criteria
1. Pain in the territory of the pudendal nerve; anus
to penis/clitoris
2. Pain is predominantly experienced while sitting
3. Pain does not awaken the patient at night
4. Pain with no objective sensory impairment
5. Pain relieved with diagnostic pudendal nerve block
Complementary diagnostic criteria
1. Burning, shooting, stabbing pain, numbness
2. Allodynia or hyperpathia
Fig. 1 Relationship between postoperative numerical analog score

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3. Rectal or vaginal foreign body sensation
and patient self-rated outcome for pudendal nerve surgery.
4. Worsening of pain during the day
5. Predominantly unilateral pain
6. Pain triggered by defecation Results
7. Presence of exquisite tenderness on In the initial cohort of 41 patients, there was a significant
palpation of ischial spine
correlation between the patients’ self-rated outcome analysis
8. Clinical neurophysiology findings in men or with the postoperative NAS, p < 0.003 (►Fig. 1). There was a
nulliparous women
correlation that approached statistical significance at
Exclusion criteria p < 0.07 for improvement in symptoms (change in NAS)
1. Exclusively coccygeal, gluteal, pubic, or with the change in the VQ (►Fig. 2). There was a significant
hypogastric pain correlation, p < 0.015, between improvement in symptoms
2. Pruritus (change in NAS) and the change in the FSFI (►Fig. 3). There
was a significant correlation, p < 0.02, between improve-
3. Exclusively paroxysmal pain
ment in symptoms (change in NAS) and the change in the
4. Imaging abnormalities able to account for the pain VQ for men (►Fig. 4). There was a significant correlation,
Associated signs not excluding the diagnosis p < 0.002, between improvement in symptoms (change in
1. Buttock pain on sitting NAS) and the change in the CPSI (►Fig. 5). Therefore, just the
self-rated outcome score was used for assessment in the
2. Referred sciatic pain
patients accrued in the final year of the study.
3. Pain referred to the medial aspect of the thigh
In the patients accrued in the first 2 years of the study,
4. Suprapubic pain there were no significant differences in the outcomes related
5. Urinary frequency and/or pain after sexual intercourse to whether the surgery was done using the anterior approach
6. Pain occurring after ejaculation or the posterior approach, or whether the diagnosis was
neuroma, requiring resection, or compression, requiring neu-
7. Dyspareunia and/or pain after sexual intercourse
rolysis. The satisfaction score for the first 41 patients was
8. Erectile dysfunction excellent in 42% (17/41), good in 7% (3/41), poor in 18% (7/41),
9. Normal clinical neurophysiology

with a score after surgery of excellent, good, fair, or poor. In the


patients accrued in the third year, the outcome measure was the
satisfaction score, since data analysis of the earlier patients
showed good correlation between the NAS and this patient
self-rated measurement (►Fig. 1).
Statistical analysis: Comparisons were made between
actual NAS scores and the gender-specific questionnaire
outcomes, comparing the preoperative to postoperative
change from the questionnaires with the preoperative to
postoperative change in NAS. A chi-square test was used to
compare the patients’ self-rated analysis of an excellent result
comparing the patients stratified by which of the three years Fig. 2 Relationship between change in numerical analog score after
of the study they were accrued. pudendal nerve surgery and the vulvar functional index (VQ).

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286 Pudendal Nerve Surgical Outcomes Dellon et al.

Fig. 3 Relationship between change in numerical analog score after Fig. 5 Relationship between change in numerical analog score after
pudendal nerve surgery and the female sexual function index (FSFI). pudendal nerve surgery and the chronic prostatitis symptom index

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(CPSI).

whether the surgery was a neuroma resection or a neurolysis,


went from 12 to 72 to 86% (►Table 3). Utilizing an unpaired
Student t-test to compare the mean numerical value of the
self-rated outcome scale, there was a significant improve-
ment in successful outcomes between the first 2 years
(p < 0.0001) and a p < 0.04 between the second and third
years. The percentage of patients with good to excellent
outcomes increased from 30 to 76 to 100% in patients
operated upon in the beginning of the study, the middle of
the study, and the end of the study. ►Fig. 6 depicts this
learning curve.

Discussion
Fig. 4 Relationship between change in numerical analog score after This study demonstrated that improved outcomes of the
pudendal nerve surgery and the male penile functional index (VQ surgical treatment of pelvic pain of pudendal nerve origin
modified for men). are achieved by using diagnostic categories related to
known peripheral pathophysiology, and then choosing either
an “anterior” or a “posterior” surgical approach based upon
and failure in 37% (14/41). The percentages for excellent site-specific pudendal nerve branch involvement in the pain
results for surgical approach subgroups are given mechanism. This successful approach would replace the
in ►Table 3, from which it can be noted that the percentage traditional, almost standard, “posterior” transgluteal ap-
of patients achieving good to excellent was 70% in the proach for “pudendal neuralgia” or “vulvodynia.”
anterior/resection group, 66% in the anterior/neurolysis This surgical experience supports an update of terminolo-
group, 75% in the posterior/resection group, and 59% in the gy, nomenclature, and surgical treatments for female chronic
posterior/neurolysis group. vulvar and pelvic pain as follows:
With respect to the impact of surgical experience upon the
outcomes, when the patients were stratified by which of the 1. “Recurrent or persistent pain after vestibulectomy” would
three years of the study the surgery was done, the percentage be diagnosed as neuroma of the perineal branches of the
of excellent results, regardless of the surgical approach and pudendal nerve, and treated by an “anterior” inferior pubic

Table 3 Percentage excellent results improvement with experience stratified by surgical approach and type of surgery

Anterior approach Posterior approach


Neuroma Compression Neuroma (rectal branch) Compression
(perineal branch) (perineal and (entire pudendal
dorsal branches) nerve)
1st year 0% (0/6) 28% (2/7) NA 0% (0/3)
2nd year 70% (7/10) 67% (4/6) 75% (3/4) 60% (3/5)
3rd year 72% (5/7) 100% (3/3) 100% (2/2) 100% (2/2)

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Pudendal Nerve Surgical Outcomes Dellon et al. 287

without clitoral symptoms, would be diagnosed as “com-


pression of the pudendal nerve at the sacrotuberous
ligament” and treated by a “posterior approach” neurolysis
of the pudendal nerve beneath the sacrotuberous ligament
(►Fig. 8D).

A similar strategy would be recommended for males with


chronic pelvic pain:

1. “Recurrent or persistent pain after prostatectomy” would


be diagnosed as neuroma of the perineal branches of the
pudendal nerve, and treated by an “anterior” inferior pubic
ramus approach with resection of the perineal branches
and implantation of these nerves into the obturator inter-
nus muscle near the end of the canal of Alcock.

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2. “Cyclist syndrome” would be diagnosed as compression of
the dorsal branch of the pudendal nerve and treated by an
“anterior” inferior pubic ramus approach with neurolysis
of this dorsal branch.
Fig. 6 Learning curve with improved results over time as the study 3. Posterior to the perineum, (3) and (4) above for females
progressed.
would apply also to males. Other combinations and etiol-
ogies also can be incorporated into this paradigm.

ramus approach with resection of the perineal branches Undertreated anxiety/depression was a predictor of failure
and implantation of these nerves into the obturator inter- in our study, and has been recognized as a critical confounder
nus muscle near the end of the canal of Alcock (►Fig. 7A). of treatment success by others working with patients with
2. “Persistent genital arousal disorder (PGAD)” and clitoro- complex regional pain syndrome as well as those working
dynia would be diagnosed as compression of the dorsal with pudendal nerve/pelvic pain problems.42,43 An important
branch of the pudendal nerve and treated by an “anterior” finding of this study, as well as a major weakness, relates to
inferior pubic ramus approach with neurolysis of this the degree of anxiety/depression present in patients with
dorsal branch (►Fig. 7B). surgically untreated pudendal nerve pain. Surgeon-identified
3. “Rectal pain” after hemorrhoidectomy or other rectal untreated anxiety/depression was the highest correlation
procedures through an ischiorectal approach would be with a poor outcome from surgery, p < 0.002. The peripheral
diagnosed as “neuroma of the sensory rectal branches of nerve surgeon (A. L. D.), during intake history and physical
the pudendal nerve” and treated by an “posterior ap- examination, recognized and recorded signs of anxiety and
proach” beginning in the ischiorectal fossa to identify depression inadequately treated by patients’ current medi-
these branches and then proceeding proximally to include cations prescribed by their personal physicians. A weakness
neurolysis of the pudendal nerve beneath the sacrotuber- of this study was that a validated instrument for evaluating
ous ligament if this were found to be tight (►Fig. 8A–C). depression/anxiety was not incorporated into the prospective
4. “Pudendal neuralgia” that includes symptoms of primarily study design. At the start of year two of the study, patients
the rectal branch and also of the perineal branch, with or were treated, if indicated, with an antianxiety medication,

Fig. 7 A female patient in lithotomy position, with (A) a blue vessel loop and a clamp on a cut end of two perineal branches of the pudendal nerve
in a woman who had a vestibulectomy. (B) The white arrow points to the site of narrowing and compression of the dorsal branch of the pudendal
nerve as it exits the inferior pubic ramus canal. Note the red inflamed distal branches. Note a remaining perineal branch with blue vessel loop in the
inferior portion of incision, where it exited the canal of Alcock.

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288 Pudendal Nerve Surgical Outcomes Dellon et al.

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Fig. 8 A male patient prone, with (A) drawing on the right buttock of the ischial tuberosity joined to sacrum by sacrotuberous ligament. Note at
the black arrow, an incision from previous ischiorectal fossa approach to divide the sacrospinous ligament that caused a neuroma of the rectal
sensory branch of the pudendal nerve. (B) The rectal sensory branches are white and glistening at the black arrow. (C) These branches have been
resected and the incision with the opening into the ischiorectal space is noted, and the extension to approach the sacrotuberous ligament is seen.
(D) The double white arrows mark the medial and lateral divided edges of the sacrotuberous ligament, with the small white arrow at the pudendal
nerve, with branches being visible.

such as a benzodiazepam, like clonazepam, or were referred will result in excellent outcomes if preoperative selective
their psychiatrist or neuropharmacologist, to have their criteria are fully appreciated and nerve compression versus
medication regime optimized prior to surgery. Patients neuroma are distinguished as the neuropathology. Knowl-
who were “failures” continued under the care of their gyne- edge of the correct anatomic site of the pudendal nerve
cologist receiving supportive medical care and counseling. pathophysiology allows the surgeon to choose a site-specific
The presence of depression/anxiety in patients with vulvar approach for the surgery, either an anterior, inferior pubic
and pelvic pain raises the possibility that there is underlying ramus incision or a posterior, transgluteal incision. The two
central sensitization in many sufferers.44,45 It is therefore changes in surgical technique that permitted improved out-
critical to obtaining the best outcome from surgery comes in the third year were (1) awareness that there are
that central sensitization be recognized and that perioper- usually three different perineal sensory branches24 and two
atively psychological and pharmacologic treatment be used rectal sensory branches,47 so that the surgeon should not stop
appropriately.46 This includes assessing sleep quality and operating when the first sensory branch is found, and (2) that
treating as needed with sleep medication, as well as optimiz- there are usually two distinct sites of entrapment, and not
ing preoperative pain control with neuropathic pain medi- just one along the inferior pubic ramus, one at the exit of
cations, and opioid pain relievers as needed, which can be Alcock canal48 and the other more distally at the junction of
tapered beginning 3 to 6 weeks after surgery. During surgery, the inferior pubic ramus with the pubic symphysis. While this
“preventive anesthesia” is used to protect the central nervous study demonstrates a learning curve for the surgical skills
system from pain impulses, including using local anesthetic that need to be acquired, we now believe there is hope for
placed into the skin prior to making incisions, and local improved outcomes in the surgical treatment of chronic
anesthesia placed into nerves prior to their resection. Ad- painful pudendal nerve conditions.
ministering ketamine with induction and during the proce-
dure at low dose, 0.25 to 0.5 mg/kg, and toradol at the end of
the procedure, with gabapentin for the first week after Acknowledgment
surgery, has been helpful in our experience. We thank Norman Dubin, PhD, biostatistician, from the
The results of this study demonstrate that a surgical Gynecology Department of the Medstar Hospital System,
approach to chronic pelvic pain related to the pudendal nerve for the data analysis.

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Pudendal Nerve Surgical Outcomes Dellon et al. 289

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