Laparoscopic treatment of pudendal nerve and artery entrapment improves erectile dysfunction in healthy young males

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.

Lifelong LUTS: Understanding the bladder's role and implications across transition phases, a comprehensive review

INTRODUCTION

Lower urinary tract symptoms (LUTSs) are a diverse array of urinary and pelvic dysfunctions that can emerge from childhood, extend through adulthood, and persist into older age. This narrative review aims to provide a comprehensive perspective on the continuum of LUTS and shed light on the underlying mechanisms and clinical implications that span across the lower urinary tract.

METHODS

A panel of five experts from Belgium, the Netherlands, India, Denmark, and the United States participated in an intensive research to explore and pinpoint existing insights into the lifelong concept of LUTS, particularly at the pelvic level. The experts reviewed the existing literature and held a webinar to discuss their findings.

RESULTS

Childhood LUTS can persist, resolve, or progress into bladder underactivity, dysfunctional voiding, or pain syndromes. The Lifelong character can be explained by pelvic organ cross-talk facilitated through complex neurological and nonneurological interactions. At the molecular level, the role of vasopressin receptors in the bladder's modulation and their potential relevance to therapeutic strategies for LUTS are explored. Frailty emerges as a parallel concept to lifelong LUTS, with a complex and synergistic relationship. Frailty, not solely an age-related condition, accentuates LUTS severity with insufficient evidence regarding the effectiveness and safety profile of the available therapeutic modalities.

CONCLUSION

Understanding lifelong LUTSs offers insights into genetic, anatomical, neurological, and molecular mechanisms. Further research could identify predictive biomarkers, elucidate the role of clinically translatable elements in pelvic cross-talk, and uncover molecular signatures for personalized management.

Pudendal nerve neurolysis outcomes for urogenital and rectal disorders in patients suffering from pudendal nerve entrapment: A systematic review

PURPOSE

Pudendal neuropathy is an uncommon condition that exhibits several symptoms depending on the site of nerve entrapment. This study aims to evaluate the efficacy of pudendal nerve neurolysis (PNN) in improving lower urinary tract symptoms, anal and/or urinary incontinence, and sexual dysfunctions.

MATERIALS AND METHODS

A systematic literature search was performed on 20 May 2023 using Scopus, PubMed, and Embase. Only English and adult papers were included. Meeting abstracts and preclinical studies were excluded.

RESULTS

Twenty-one papers were accepted, revealing significant findings in the field. The study identified four primary sites of pudendal nerve entrapment (PNE), with the most prevalent location likely being at the level of the Alcock canal. Voiding symptoms are commonly exhibited in patients with PNE. PNN improved both urgency and voiding symptoms, and urinary and anal incontinence but is less effective in cases of long-standing entrapment. Regarding sexual function, the recovery of the somatic afferent pathway results in an improvement in erectile function early after neurolysis. Complete relief of persistent genital arousal disorder occurs in women, although bilateral PNN is necessary to achieve the efficacy. PNN is associated with low-grade complications.

CONCLUSIONS

PNN emerges as a viable option for addressing urinary symptoms, fecal incontinence, erectile dysfunction, and female sexual arousal in patients suffering from PNE with minimal postoperative morbidity.

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

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.

Efficacy of Respiratory Training in Relieving Postoperative Pain in Patients with Spinal Nerve Root Entrapment Syndrome

Background

Breathing exercise can help patients with dyspnea to change the wrong breathing pattern, improve the degree of freedom of respiratory muscles, increase alveolar ventilation, promote breathing, and relieve the symptoms of dyspnea patients. Therefore, this study is aimed at investigating the role of breathing training in alleviating postoperative pain in patients with spinal nerve root entrapment syndrome.

Objective

To explore the effect of respiratory training in relieving postoperative pain in patients with spinal nerve root entrapment syndrome.

Methods

Fifty-eight patients with spinal nerve root entrapment syndrome treated in our hospital from May 2020 to May 2021 were analyzed retrospectively. The patients were randomly divided into a control group (n = 29) and an observation group (n = 29). The control group was given routine postoperative pain nursing, and the observation group was given respiratory training on the basis of the control group. The scores of visual analogue scale (VAS), self-rating anxiety scale (SAS), Oswestry dysfunction index questionnaire (ODI), the dosage of postoperative analgesics, and the time of first out-of-bed activity were recorded before pain nursing intervention and 3 days and 7 days after intervention.

Results

The VAS, SAS, and ODI scores of the observation group after 3 d and 7 d of intervention were lower than those of the control group. Compared with the same group, the scores of VAS, SAS, and ODI after 3 d and 7 d of intervention were lower than those before intervention, and those after 7 d of intervention were lower than those after 3 d of intervention (P < 0.05). The dosage of postoperative analgesics and the time of first out-of-bed activity in the observation group were lower than those in the control group (P < 0.05).

Conclusion

Respiratory training can effectively relieve postoperative pain, reduce anxiety, and improve spinal function in patients with spinal nerve root entrapment syndrome, which is beneficial to the prognosis of patients and is worthy of promotion.

Sexual dysfunction due to pudendal neuralgia: a systematic review

Background

The pudendal nerve is considered as the main nerve of sexuality. Pudendal neuralgia is an underdiagnosed disease in clinical practice. The aim of this systematic review is to highlight the role of pudendal neuralgia on sexual dysfunction in both sexes.

Methods

A PubMed search was performed using the following keywords: “Pudendal” AND “Sexual dysfunction” or “Erectile dysfunction” or “Ejaculation” or “Persistent sexual arousal” or “Dyspareunia” or “Vulvodynia”. The search involved patients having sexual dysfunction due to pudendal neuralgia. Treatment received was also reported.

Results

Five case series, seven cohort studies, two pilot studies, and three randomized clinical trials were included in this systematic review. Pudendal nerve and/or artery entrapment, or pudendal neuralgia, is a reversible cause of multiple sexual dysfunctions. Interventions such as anesthetic injections, neurolysis, and decompression are reported as potential treatment modalities. There are no studies describing the role of pudendal canal syndrome in the pathophysiology or treatment of delayed ejaculation or penile shortening.

Discussion

Pudendal neuralgia is an underestimated yet important cause of persistent genital arousal, erectile dysfunction (ED), premature ejaculation (PE), ejaculation pain, and vulvodynia. Physicians should be aware of this entity and examine the pudendal canal in such patients before concluding an idiopathic cause of sexual dysfunction.

Is pudendal nerve entrapment a potential cause for weak ejaculation?

Ejaculatory dysfunction is one of the most common complaints of patients with sexual disorders. While it encompasses several ejaculatory disorders, weak ejaculation is seldom described in the literature. Since the pudendal nerve is the main nerve of ejaculation, we aim to hypothesize that pudendal nerve entrapment could be a cause of weak ejaculation, and that pudendal nerve release could contribute to the improvement of the ejaculatory stream. We presented two cases suffering from a weak ejaculatory stream and sensation of incomplete semen emptying, accompanied with clinical features of pudendal nerve entrapment. Both cases improved after pudendal nerve block and then laparoscopic transperitoneal pudendal release, with a sustained amelioration of the ejaculatory stream after 3 weeks of surgery. Pudendal canal entrapment is therefore a potentially curable cause for weak ejaculation.

Laparoscopic transperitoneal pudendal nerve and artery release for pudendal entrapment syndrome

INTRODUCTION

Pudendal nerve and artery entrapment is an underdiagnosed pathology responsible of several urinary, sexual and anorectal complaints. The aim of our study was to evaluate safety and feasibility of laparoscopic transperitoneal pudendal nerve and artery release in a large retrospective cohort of patients with pudendal nerve entrapment syndrome with both a short and long-term follow-up. Technical details and outcomes are also reported.

METHODS

A series of 235 patients with pudendal syndrome underwent laparoscopic transperitoneal pudendal canal release between June 2015 and February 2020. Operative data were recorded prospectively for all patients. A complete history, pain visual analog scale (VAS) for perineodynia, and three scores evaluating the main symptoms (USP, IIEF-5, PAC-SYM) were obtained before and at least 24 months after surgery for 32 patients only. Post-operative complications were also evaluated using Clavien-Dindo classification at regular interval.

RESULTS

The mean operating time per side was 33.9 ± 6.8 min and the average hospital stay was 1.9 ± 0.3 days. Blood loss was 20 cc ± 10 cc with no patients needing transfusion. The only significant per-operative complication was hemorrhage (600 ml) in one patient induced by a pudendal artery laceration, successfully treated by laparoscopic suturing. Post-operative complications were noted in 18.7% of patients with no serious Clavien-Dindo complications. Perineodynia VAS dropped from 6.8 ± 0.9 to 2.2 ± 1.8 after surgery (p < 0.001). Mean IIEF-5 scores significantly improved one month after the surgery (15.2 vs 19.3, p = 0.036). Mean USP scores significantly improved for the dysuria domain (4.2 vs 1.6, p = 0.021) but not for stress urinary incontinence (3.9 vs 4.1, p = 0.082) or overactive bladder symptoms (14.1 vs 13.8, p = 0.079). Mean PAC-SYM scores significantly improved after the procedure (1.8 vs 1.1, p < 0.001).

CONCLUSION

A complete laparoscopic pudendal nerve and artery release, from the sciatic spine through the Alcock's canal, is a fast and safe surgery with promising functional results. A large prospective trial is needed to validate such an approach.