Robot-assisted pudendal neurolysis in the treatment of pudendal nerve entrapment syndrome

Management of pudendal neuralgia with electrical stimulation. A systematic review

INTRODUCTION AND OBJECTIVE

Pudendal neuralgia is a severely intense, painful, neuropathic condition, involving the dermatome of the pudendal nerve (S2, S3, S4). The diagnosis is complex and usually takes many years to be made. Techniques that use electrical current have been shown to decrease pain and improve quality of life in patients with this condition. The aim of this review was to analyze the existing literature on the effects of electrical current in the treatment of patients with pudendal neuralgia.

MATERIAL AND METHODS

A literature search was carried out in PubMed, Cinahl, Medline, Cochrane Library, ENFISPO, PEDro, Scopus and Web of Science databases, using the search terms "Electric Stimulation Therapy", "pudendal neuralgia" and "pudendal nerve entrapment".

RESULTS

The most frequently repeated intervention is pulsed radiofrequency. Other techniques used are transcutaneous electrical nerve stimulation, pulsed electromagnetic field therapy and neuromodulation. All studies show significant improvement in pain, analgesic intake, depression-anxiety or quality of life.

CONCLUSIONS

The application of electrical current seems to be effective in the management of pudendal neuralgia. The scientific evidence is scarce, of poor methodological quality, and its use is based on the efficacy demonstrated in other indications of chronic pain.

Surgical approaches for pudendal nerve entrapment: insights from a systematic review and meta-analysis

BACKGROUND

Pudendal nerve entrapment (PNE) is an underdiagnosed condition affecting a spectrum of pelvic functions, primarily pain, as outlined by Nantes diagnostic criteria. Although numerous surgical decompression techniques are available for its management, consensus on efficacy and safety is lacking. This study conducts a systematic review and meta-analysis to assess the efficacy and complication rates of the main surgical decompression techniques.

METHODS

A comprehensive literature search was conducted in PubMed®, Embase®, Web of Science®, and ClinicalTrails.gov® on 19th of April 2023. Initial screening involved title and abstract evaluation, with subsequent retrieval and assessment of abstracts and full-text articles. Studies assessing pain outcomes before and after surgical release of the pudendal nerve were included. Studies without full-text, focusing on diagnostic methods or with outcomes relating solely to LUTS, digestive symptoms, or sexual dysfunction, were excluded. Risk of bias assessement was conducted using the National Institute of Health (NIH) Study Quality Assessment tool. Studies were categorized based on three surgical techniques: perineal, transgluteal, and laparoscopic transperitoneal. Random-effects meta-analysis with subgroup analysis were used. Meta-regression analyses were conducted to investigate the influence of covariates on the observed outcomes.

RESULTS

Nineteen studies, comprising 810 patients, were included. The overall significant pain relief rate across all techniques was estimated at 0.67 (95% CI 0.54 to 0.78) with considerable heterogeneity (I2 = 80.4%). Subgroup analysis revealed success rate for different techniques: laparoscopic (0.91, 95% CI 0.64 to 0.98), perineal (0.69, 95% CI 0.52 to 0.82), and transgluteal (0.50, 95% CI 0.37 to 0.63). The laparoscopic technique exhibited a complication rate of 16.0%. Meta-regression indicated that patient age and median follow-up significantly influenced outcomes.

CONCLUSION

While comparing surgical techniques is challenging, this meta-analysis highlights important outcome differences. The laparoscopic technique appears most promising for pain improvement. However, the study also emphasizes the need for further robust, long-term research due to significant heterogeneity across studies and prevelent risk of bias. PROSPERO database: CRD42023496564.

Diagnostic and therapeutic algorithm for pudendal nerve entrapment syndrome

Pudendal nerve entrapment syndrome is widely unknown and often misdiagnosed or confused with other pelvic floor diseases. The aim is to develop a diagnostic and therapeutic algorithm based on a review of the existing literature. For its diagnosis, an anamnesis will be carried out in search of possible aetiologies, surgical history, and history of pain, assessing location and irradiation, intensity on the visual analogue scale, timing, triggering factors and rule out alarm signs. A physical examination will be performed, looking for trigger points or areas of fibrosis with transvaginal / transrectal palpation of the terminal branches of the nerve. With a doubtful diagnosis, an anaesthetic block of the pudendal nerve can be performed. Once the diagnosis is confirmed, the treatment will begin staggered with lifestyle changes, drug therapy and physiotherapy. In view of the failure of these measures, invasive therapies such as botulinum toxin injection, pulsed radiofrequency and decompression surgery or spinal cord stimulation will be used.

Erectile function recovery after laparoscopic decompression of pudendal artery and nerve: a documented case report

The aim of this article is to report the effectiveness of laparoscopic decompression of pudendal artery (PA) and nerve for erectile dysfunction (ED) restoration. A 32-year-old man presented with a long-term complaint of ED not responsive to medical therapy. Endocrine screening and neurological evaluation did not show any abnormalities. Color Doppler ultrasound revealed the absence of blood flow in the right PA. After failure of conservative treatments and in accordance to the patient's desire, laparoscopic pudendal artery decompression was performed. The patient reported significant amelioration of ED one month after surgery. At 8-months follow-up, Doppler ultrasound showed complete revascularization of the right PA.