Endoscopic transperineal pudendal nerve decompression: operative pudendoscopy

Abstract

Background: Pudendal nerve entrapment can produce a pudendal syndrome comprising perineodynia together with urinary, sexual, and anorectal symptoms. This syndrome can be treated surgically by the transperineal approach. By using an endoscope during the procedure ("operative pudendoscopy"), the surgeon has close-up visual control of each decompression steps, demonstrates the different levels of entrapment, and cuts the sacrospinous ligament under visual control. The aim of this study was to describe the technical details of this new technique and its outcome in the treatment of the pudendal syndrome.

Methods: A series of 113 patients with severe pudendal syndrome underwent operative pudendoscopy. A complete history, pain visual analog scale (VAS) for perineodynia, and four scores evaluating the main symptoms (ICIQ-SF, NHI-CPSI, St Mark's, and Wexner) were obtained before and at least 24 months after surgery. The three clinical signs of pudendal syndrome (abnormal pinprick sensitivity, painful skin rolling test, and painful pudendal nerve) and perineal descent were analyzed before and after surgery in 91 patients.

Results: The mean operating time per side was 50.3 ± 15.2 min and the average hospital stay was 2.1 ± 0.4 days. Perineodynia VAS dropped from 7.2 ± 1.4 to 4.5 ± 2.9 after surgery (p < 0.0001) and the symptoms scores significantly improved. Frequency of sexual arousal syndrome, dyspareunia, and cystalgia was also significantly reduced. Pathological perineal descent (≥ 1.5 cm measured with a Perineocaliper®) observed in 13 patients was reduced from 1.81 to 0.77 cm after surgery (p < 0.0001). The only significant complication was severe hemorrhage in one patient induced by an inferior gluteal vessel laceration and successfully treated by arterial embolization.

Conclusions: A complete pudendal nerve decompression, from the distal branches to the sacral foramina, safely performed under visual control by using operative pudendoscopy markedly improves clinical signs and symptoms of the pudendal syndrome.

Keywords: Descending perineum syndrome; Endoscopy; Incontinence; Perineal pain; Perineology; Pudendal nerve.