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Giulioni C, Pitoni L, Fuligni D, Beltrami M, Passarella V, Palantrani V, De Stefano V, Castellani D, Galosi AB. Pudendal nerve neurolysis outcomes for urogenital and rectal disorders in patients suffering from pudendal nerve entrapment: A systematic review. Investig Clin Urol 2024; 65:230-239. [PMID: 38714513 PMCID: PMC11076799 DOI: 10.4111/icu.20230402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Revised: 01/28/2024] [Accepted: 02/15/2024] [Indexed: 05/10/2024] Open
Abstract
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.
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Affiliation(s)
- Carlo Giulioni
- Urology Unit, Azienda Ospedaliero-Universitaria delle Marche, Polytechnic University of Marche, Ancona, Italy.
| | - Lucia Pitoni
- Urology Unit, Azienda Ospedaliero-Universitaria delle Marche, Polytechnic University of Marche, Ancona, Italy
| | - Demetra Fuligni
- Urology Unit, Azienda Ospedaliero-Universitaria delle Marche, Polytechnic University of Marche, Ancona, Italy
| | - Mattia Beltrami
- Urology Unit, Azienda Ospedaliero-Universitaria delle Marche, Polytechnic University of Marche, Ancona, Italy
| | - Valeria Passarella
- Urology Unit, Azienda Ospedaliero-Universitaria delle Marche, Polytechnic University of Marche, Ancona, Italy
| | - Vanessa Palantrani
- Urology Unit, Azienda Ospedaliero-Universitaria delle Marche, Polytechnic University of Marche, Ancona, Italy
| | - Virgilio De Stefano
- Urology Unit, Azienda Ospedaliero-Universitaria delle Marche, Polytechnic University of Marche, Ancona, Italy
| | - Daniele Castellani
- Urology Unit, Azienda Ospedaliero-Universitaria delle Marche, Polytechnic University of Marche, Ancona, Italy
| | - Andrea Benedetto Galosi
- Urology Unit, Azienda Ospedaliero-Universitaria delle Marche, Polytechnic University of Marche, Ancona, Italy
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Giulioni C, Pirola GM, Maggi M, Pitoni L, Fuligni D, Beltrami M, Palantrani V, De Stefano V, Maurizi V, Castellani D, Galosi AB. Pudendal Nerve Neurolysis in Patients Afflicted With Pudendal Nerve Entrapment: A Systematic Review of Surgical Techniques and Their Efficacy. Int Neurourol J 2024; 28:11-21. [PMID: 38569616 PMCID: PMC10990758 DOI: 10.5213/inj.2448010.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Accepted: 02/04/2024] [Indexed: 04/05/2024] Open
Abstract
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.
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Affiliation(s)
- Carlo Giulioni
- Urology Unit, Azienda Ospedaliero-Universitaria delle Marche, Polytechnic University of Marche, Ancona, Italy
| | | | - Martina Maggi
- Department of Maternal-Infant and Urological Sciences, Umberto I Polyclinic Hospital, Sapienza University, Rome, Italy
| | - Lucia Pitoni
- Urology Unit, Azienda Ospedaliero-Universitaria delle Marche, Polytechnic University of Marche, Ancona, Italy
| | - Demetra Fuligni
- Urology Unit, Azienda Ospedaliero-Universitaria delle Marche, Polytechnic University of Marche, Ancona, Italy
| | - Mattia Beltrami
- Urology Unit, Azienda Ospedaliero-Universitaria delle Marche, Polytechnic University of Marche, Ancona, Italy
| | - Vanessa Palantrani
- Urology Unit, Azienda Ospedaliero-Universitaria delle Marche, Polytechnic University of Marche, Ancona, Italy
| | - Virgilio De Stefano
- Urology Unit, Azienda Ospedaliero-Universitaria delle Marche, Polytechnic University of Marche, Ancona, Italy
| | - Valentina Maurizi
- Department of Clinical and Molecular Sciences, Ospedaliero-Universitaria delle Marche, Polytechnic University of Marche, Ancona, Italy
| | - Daniele Castellani
- Urology Unit, Azienda Ospedaliero-Universitaria delle Marche, Polytechnic University of Marche, Ancona, Italy
| | - Andrea Benedetto Galosi
- Urology Unit, Azienda Ospedaliero-Universitaria delle Marche, Polytechnic University of Marche, Ancona, Italy
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Huang GQ, Gong T, Wang SS, Xia QH, Lin LJ, Wang GB. Pudendal nerve lesions in young men with erectile dysfunction: imaging with 3T magnetic resonance neurography. Asian J Androl 2023; 25:367502. [PMID: 36629161 PMCID: PMC10521948 DOI: 10.4103/aja202293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2022] [Accepted: 11/15/2022] [Indexed: 01/12/2023] Open
Affiliation(s)
- Guo-Quan Huang
- Department of MR, Shandong Provincial Hospital, Shandong University, Jinan 250021, China
- Department of Radiology, Wuhu Hospital, East China Normal University (The Second People’s Hospital, Wuhu), Wuhu 241000, China
| | - Tao Gong
- Departments of Radiology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan 250021, China
| | - Shan-Shan Wang
- Departments of Radiology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan 250021, China
| | - Qin-Hua Xia
- Department of Andrology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan 250021, China
| | | | - Guang-Bin Wang
- Departments of Radiology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan 250021, China
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Oles N, Preston S, Leto Barone AA, Khan A, Coon D. Sensate total clitoris reconstruction via microneurovascular dorsal foot web space flap with pudendal nerve coaptation. Microsurgery 2021; 41:787-791. [PMID: 34655246 DOI: 10.1002/micr.30814] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Revised: 02/07/2021] [Accepted: 09/02/2021] [Indexed: 11/06/2022]
Abstract
Revision surgery after gender-affirming genitoplasty is becoming more and more common as more patients gain access to surgical treatment. The complexity of genitoplasty and extensive dissection of delicate tissues predisposes patients to necrosis of the flap(s) employed, which can leave patients with complications ranging from poor aesthetics to total lack of genital sensation. The purpose of this report is to detail the revision surgery of a 32-year-old transgender woman who underwent vaginoplasty at an outside institution and presented to our clinic for clitoral reconstruction following necrosis and near-total loss of the neoclitoris. Physical exam showed extensive necrosis, and 3-Tesla magnetic resonance (MRI) revealed significant scarring of the pudendal nerve branches at the level of the pubic symphysis. Healthy nerve was identified at the level of the right inferior pubic ramus, and total clitoral reconstruction with an innervated first dorsal web space free flap anastamosed to the deep inferior epigastric vessels was performed. Complications included donor site cellulitis with partial loss of the skin graft and formation of hypertrophic scar tissue. This was treated 6 months postoperatively with excision of scar tissue in the webspace and placement of an additional full-thickness skin graft. At follow-up, the patient reported tactile and erogenous sensation of the neoclitoris itself and subjective satisfaction with the aesthetic outcome. Our results provide evidence that this flap is a feasible option to create an aesthetic and sensate neoclitoris in the setting of previous neoclitoral necrosis. This case report also describes the novel use of 3-Tesla MRI in target selection for nerve coaptation.
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Affiliation(s)
- Norah Oles
- Department of Plastic Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.,Center for Transgender Health, Johns Hopkins Medicine, Baltimore, Maryland, USA
| | - Stephanie Preston
- Department of General Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Angelo A Leto Barone
- Department of Plastic Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.,Center for Transgender Health, Johns Hopkins Medicine, Baltimore, Maryland, USA
| | - Aadil Khan
- Targeted Therapy Team, Division of Radiotherapy and Imaging, The Institute of Cancer Research, London, UK.,Department of Plastic Surgery, The Royal Marsden Hospital, London, UK
| | - Devin Coon
- Department of Plastic Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.,Center for Transgender Health, Johns Hopkins Medicine, Baltimore, Maryland, USA
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Aoun F, Alkassis M, Tayeh GA, Chebel JA, Semaan A, Sarkis J, Mansour R, Mjaess G, Albisinni S, Absil F, Bollens R, Roumeguère T. Sexual dysfunction due to pudendal neuralgia: a systematic review. Transl Androl Urol 2021; 10:2500-2511. [PMID: 34295736 PMCID: PMC8261452 DOI: 10.21037/tau-21-13] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Accepted: 01/26/2021] [Indexed: 01/16/2023] Open
Abstract
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.
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Affiliation(s)
- Fouad Aoun
- Urology Department, Hôtel Dieu de France, Université Saint Joseph, Beirut, Lebanon.,Urology Department, Institut Jules Bordet, Université Libre de Bruxelles, Brussels, Belgium
| | - Marwan Alkassis
- Urology Department, Hôtel Dieu de France, Université Saint Joseph, Beirut, Lebanon
| | - Georges Abi Tayeh
- Urology Department, Hôtel Dieu de France, Université Saint Joseph, Beirut, Lebanon
| | - Josselin Abi Chebel
- Urology Department, Hôtel Dieu de France, Université Saint Joseph, Beirut, Lebanon
| | - Albert Semaan
- Urology Department, Hôtel Dieu de France, Université Saint Joseph, Beirut, Lebanon
| | - Julien Sarkis
- Urology Department, Hôtel Dieu de France, Université Saint Joseph, Beirut, Lebanon
| | - Raymond Mansour
- Urology Department, Hôtel Dieu de France, Université Saint Joseph, Beirut, Lebanon
| | - Georges Mjaess
- Urology Department, Hôtel Dieu de France, Université Saint Joseph, Beirut, Lebanon.,Urology Department, Cliniques Universitaires de Bruxelles, Hôpital Erasme, Université Libre de Bruxelles, Brussels, Belgium
| | - Simone Albisinni
- Urology Department, Cliniques Universitaires de Bruxelles, Hôpital Erasme, Université Libre de Bruxelles, Brussels, Belgium
| | - Fabienne Absil
- Urology department, Centre Hospitalier EpiCURA, Site de Ath, Ath, Belgium
| | - Renaud Bollens
- Urology department, Centre Hospitalier de Wallonie Picarde, Tournai, Belgium
| | - Thierry Roumeguère
- Urology Department, Institut Jules Bordet, Université Libre de Bruxelles, Brussels, Belgium.,Urology Department, Cliniques Universitaires de Bruxelles, Hôpital Erasme, Université Libre de Bruxelles, Brussels, Belgium
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Nath RK, Somasundaram C. Long-term Improvements of Neuroplasty and Scalene Muscle Resection in LTN-injured Winged Scapula Patients. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2021; 9:e3408. [PMID: 33680659 PMCID: PMC7929713 DOI: 10.1097/gox.0000000000003408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Accepted: 12/10/2020] [Indexed: 11/25/2022]
Abstract
Injuries to the long thoracic nerve, which directly branches off of the C6, C7, and C8 brachial plexus nerve roots, can cause scapular winging and affect shoulder movements. Long thoracic nerve injuries resulting from accidents, violence, or overuse can be severe lesions requiring challenging surgeries. We evaluated the long-term functional outcomes of neuroplasty and the scalene muscle resection procedures in patients with long thoracic nerve injury and winging scapula. Methods All 15 patients who underwent scalene muscle resection with decompression and neurolysis of the long thoracic nerve in a single institution to treat winged scapula and limited shoulder movements between March 2007 and May 2020 with follow-up over 2 years were included in the study. Results Shoulder abduction and arm flexion improved significantly to 158 ± 52 degrees and 165 ± 53 degrees from a mean of 108 ± 54 degrees and 104 ± 52 degrees (P < 0.02) over 2 years after surgery (mean 3.4 years). Overall, there was a significant reduction in the scapular winging, as assessed by estimating the decrease in the angle between the scapular plane and the posterior chest wall. The extent of the score greatly improved post-surgically from a mean of 1.2 ± 0.4 to 3.5 ± 0.9 (range 1-4; 1-severe, 2-moderate, 3-mild, and 4-minimal) (P < 0.01). Conclusion The improvement in shoulder movements and reduced scapular winging was significant and stable over 2 years of surgery in 81% of our study patients.
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Affiliation(s)
- Rahul K Nath
- Texas Nerve and Paralysis Institute, Research Division, Houston, Tex
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