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BACKGROUND Patients with pudendal neuralgia (PN) experience long-lasting chronic pain, hyperalgesia, and comorbid emotional disorders, such as depression and anxiety. Treatment via conventional pulsed radiofrequency (PRF) current carries a significantly high rate of failure. OBJECTIVE To determine the safety and clinical efficacy of high-voltage, long-duration PRF application to the pudendal nerve in patients with PN. STUDY DESIGN Observational retrospective design, self before-after controlled clinical trial. MATERIALS AND METHODS We analyzed the records of 70 patients of our hospital with diagnosed PN. Treatment consisted of PRF application to the pudendal nerve, using computed tomography guidance to target the pudendal nerve at the level of the ischial spine or ischial tuberosity of the affected side. PRF was applied with the following parameters: temperature 42°C, frequency 2 Hz, pulse width 20 ms, field intensity ramped gradually from 40 to 90 V, duration 900 sec. The therapeutic effect was evaluated by collecting patient scores for the visual analog scale (VAS), SF-36 health survey questionnaire (SF-36), and patient health questionnaire (PHQ-9) before treatment and at 1-, 4-, and 12-week follow-ups after PRF treatment. Data were analyzed by paired t-test with p

Summary The scrotum is supplied by ilioinguinal, genital branch of genitofemoral, perineal branch of the posterior cutaneous nerve of the thigh and the posterior scrotal branches of the pudendal nerve. We report an extremely rare innervation of the anterior part of the scrotum by the anterior division of the right obturator nerve. The genital branch of genitofemoral nerve did not reach the scrotum. The ilioinguinal nerve did not supply the scrotum. The anterior division of the obturator nerve gave a branch which ascended superomedially in the thigh, crossed superficial to the spermatic cord and communicated with the right ilioinguinal nerve. As it crossed the spermatic cord, it gave a scrotal branch which descended over the spermatic cord and ramified to supply the anterior part of the scrotum. Knowledge of this variation could be important to anaesthesiologists, urologists and surgeons in general.

This report describes an approach to regional anaesthesia of the dorsal nerves of the penis in a Great Dane, as part of an anaesthetic protocol for surgical urethral resection and anastomosis. Bupivacaine (0.5%) was infiltrated around the left and right dorsal nerves of the penis, with ultrasound guidance. The locoregional approach was trans-perineal, with the ultrasound probe orientated at a right angle to the anus, at the level of the ischial symphysis. The described technique provided good visualisation of the urethra and dorsal arteries of the penis. No adverse events relating to the nerve blockade were encountered and no additional analgesia, other than the methadone premedication, was required intra-operatively. The locoregional approach was subsequently repeated on a cadaver using the same technique and, on dissection, demonstrated deposition of injectate next to the target neurovascular bundles. The technique described may provide a simple method of distal penile anaesthesia in the dog, where ultrasound is available.

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.

Aims To map sensory and pelvic postganglionic neurons from three different regions of the female rat urethra. Methods The neuronal tracer True Blue (TB) was injected into the pre-pelvic, pelvic, and clitoral regions of the urethra from female Wistar rats. Seven days after TB injection, TB+ cells from the dorsal root ganglia (DRGs) and the major pelvic ganglion (MPG) were examined. The number and morphometry of TB+ cells were determined. Results TB+ cells were mainly distributed in lumbar 1 (L1), lumbar 2 (L2), lumbar 6 (L6), and sacral 1 (S1) DRGs, and in the MPG. The mean number of sensory neurons was 1200 ± 143. TB injection in pre-pelvic and pelvic urethra labeled neurons in L1, L2, L6, and S1 DRGs. TB injection in clitoral urethra labeled neurons in L6 and S1 DRGs. L6 DRG contained >50% of the total urethral TB+ neurons, and ~80% of the clitoral region. The mean value of the total number of MPG TB+ neurons was 1217 ± 72. DRG and MPG neurons projecting to the urethra presented a somatotopic distribution. Conclusions The results demonstrated that L6 DRG is the major supplier of afferent innervation to the urethra, and that the distal urethral region is exclusively innervated by lower lumbosacral DRGs. Considering that electrical stimulation of sensory pudendal nerve improves overactive bladder, and that most of the sensory neurons in the distal urethra are from L6 DRG, electrical stimulation of this ganglion may be an innovative and effective neuromodulation therapy for neurogenic urinary dysfunctions.

Entrapment neuropathy of the sciatic nerve and pudendal nerve are painful syndromes that are often overlooked by physicians. Laparoscopic surgical interventions for nerve entrapment syndromes of the posterior pelvis focus on removing the compression lesion with the purpose of eliminating the suspected cause of sciatica, as well as pudendal neuralgia. Herein, the authors report the rare event of sciatic and pudendal nerve entrapment, which was caused by aberrant vessels and a variant piriformis muscle bundle, as a seldom-diagnosed cause of sciatica and pelvic pain, for both neurosurgeons and neuropelveologists. The authors present the laparoscopic decompression technique for the pudendal and sciatic nerves by giving our technical “tips and tricks” enriched by a surgical video.

BACKGROUND Persistent pelvic pain (PPP) remains an important cause of morbidity. Pelvic floor muscle spasm is an important contributor to PPP. AIMS The study's primary aim was to assess if botulinum toxin (BoNT) injection to pelvic floor muscles altered pain scores or quality of life (QoL) at six, 12 and 26 weeks. Secondary aims included investigating the impact of BoNT on opiate usage, examining the role of pain catastrophising, and assessing for complications. MATERIALS AND METHODS A single-centre prospective cohort study enrolled 21 patients with PPP who had failed physiotherapy techniques. Each participant underwent BoNT injection to muscles of the pelvic floor and pudendal nerve block. Questionnaires and digital vaginal examinations were conducted at baseline, six, 12 and 26 weeks. Pain score quantification used visual analogue scales (VAS) and numerical rating scales (NRS). Other outcome assessments included The World Health Organization Quality of Life instrument (WHOQoL-BREF), Pain Catastrophising Scale (PCS), and modified Australian Pelvic Floor Questionnaire (APFQ). ACTRN12620000067976. RESULTS Following BoNT injection, median VAS scores decreased for all domains at six and 12 weeks, with VAS for dyspareunia significant at six weeks (P = 0.026). Scores returned to baseline by 26 weeks. Opiate usage was significantly less following BoNT injection, with a percentage reduction of 23.8% (95% CI -48.3 to 0.7, P = 0.06). Sexual function improved significantly (P

Hip arthroscopy for the treatment of femoroacetabular impingement syndrome with anti-sliding techniques and without the use of a perineal post to achieve hip distraction has increased greatly in the past 5 to 10 years. To access the hip joint, distraction is mandatory to treat intra-articular disorders such as labral tears, acetabular cartilage defects, loose bodies, ligamentum teres tears, and avascular necrosis of the hip. In hip distraction, counter-distraction is needed, and this is achieved with a bulky and cushioned perineal post. Most of the described techniques in hip arthroscopy worldwide use a perineal post, but iatrogenic pudendal nerve, genital lacerations, hematomas, and groin complications have been reported to occur. In Latin American countries, disposable hip pad devices are expensive, and not all the arthroscopic companies provide them. Our yoga mat technique provides enough countertraction to achieve adequate hip distraction. Labral repair, labral reconstruction, and decompression of femoroacetabular impingement syndrome have been achieved properly, reliably, and reproducibly, and no Trendelenburg position is needed. Postless hip arthroscopy is made simple, and positioning the patient is not difficult. Hip surgeons can adapt this technique to a fracture table, a hip distractor, and a standard operating room table., Technique Video Video 1 The yoga mat technique in postless hip arthroscopy. This technique was developed due to the high cost of the disposables hip pads in hip arthroscopy (pink, Stryker, etc.) in our country. A simple yoga mat that we use for exercise ($10-30 USD) is attached on a standard OR table and placed under the posterior trunk of the patient. The mat is cut in half, and one half is placed on the OR table and the other one is placed in the bony prominences of the patient for protection and prevent nerve dysfunction, HA is performed with the patient in the modified supine position and 3 portals are used, the anterolateral portal for vision and the peritrochanteric space portal and the MA as working portals. Our technique can be used in severe cases of FAIS and in any patient (thin, obese, and normal weight). A trial manual traction and also a trial traction with the distractor or fracture table are always performed before surgery. This technique is very helpful in hip injections. Our yoga mat technique provides enough countertraction to achieve adequate hip distraction. None of our patients has ever slid from the OR table during surgery. Labral repair, labral reconstruction, and decompression of FAIS have been achieved properly, reliably, and reproducibly. We believe that postless hip arthroscopy is made simple with the yoga mat, which is also cost-effective. Positioning the patient is not difficult, and the surgeon can adapt this technique to a fracture table, a hip distractor, or a standard OR table. Adequate hip distraction is achieved, and the surgeon can perform anything from a basic FAIS decompression to a complex labrum reconstruction. (FAIS, femoroacetabular impingement syndrome; OR, operating room.)

Pelvic entrapment neuropathies represent a group of chronic pain syndromes that significantly impede the quality of life. Peripheral nerve entrapment occurs at specific anatomic locations. There are several causes of pelvic entrapment neuropathies, such as intrinsic nerve abnormality or inflammation with scarring of surrounding tissues, and surgical interventions in the abdomen, pelvis and the lower limbs. Entrapment neuropathies in the pelvic region are not widely recognized, and still tend to be underdiagnosed due to numerous differential diagnoses with overlapping symptoms. However, it is important that entrapment neuropathies are correctly diagnosed, as they can be successfully treated. The lateral femoral cutaneous nerve, ischiadic nerve, genitofemoral nerve, pudendal nerve, ilioinguinal nerve and obturator nerve are the nerves most frequently causing entrapment neuropathies in the pelvic region. Understanding the anatomy as well as nerve motor and sensory functions is essential in recognizing and locating nerve entrapment. The cornerstone of the diagnostic work-up is careful physical examination. Different imaging modalities play an important role in the diagnostic process. Ultrasound is a key modality in the diagnostic work-up of pelvic entraptment neuropathies, and its use has become increasingly widespread in therapeutic procedures. In the article, the authors describe the background of pelvic entrapment neuropathies with special focus on ultrasound-guided injections.

Pudendal nerve entrapment (PNE) syndrome refers to the condition in which the pudendal nerve is entrapped or compressed. Reported cases of PNE associated with ganglion cysts are rare. Deep gluteal syndrome (DGS) is defined as compression of the sciatic or pudendal nerve due to a non-discogenic pelvic lesion. We report a case of PNE caused by compression from ganglion cysts and treated with steroid injection; we discuss this case in the context of DGS. A 77-year-old woman presented with a 3-month history of tingling and burning sensations in the left buttock and perineal area. Ultrasonography showed ganglion cystic lesions at the subgluteal space. Magnetic resonance imaging revealed cystic lesions along the pudendal nerve from below the piriformis to the Alcock’s canal and a full-thickness tear of the proximal hamstring tendon. Aspiration of the cysts did not yield any material. We then injected steroid into the cysts, which resolved her symptoms. Steroid injection into a ganglion cyst should be considered as a treatment option for PNE caused by ganglion cysts.

Penile dorsal nerve somatosensory evoked potential (DNSEP) is a scientific and objective technique that provides effective and objective data to establish the diagnosis of premature ejaculation (PE).To explore differences in DNSEP between patients with primary premature ejaculation (PPE) and those with secondary premature ejaculation (SPE), in order to investigate the clinical value of DNSEP in the diagnosis of PE.The participants were divided into a PPE group (34 cases), an SPE group (25 cases) and a healthy control group (18 cases). All participants underwent DNSEP testing, and the latencies and amplitudes of DNSEP were recorded.Differences in the latencies and amplitudes of DNSEP were compared among the PPE, SPE, and healthy control groups.The latencies of DNSEP in the PPE and SPE groups were shorter than those in the healthy control group, and these differences were statistically significant (P0.01). However, there was no statistically significant difference between the PPE and SPE groups (P0.05). The amplitudes of DNSEP in the PPE group were significantly higher than those in the healthy control group (P0.01). However, the amplitudes of DNSEP in the SPE group were significantly lower than those in the healthy control group (P0.05).PPE and SPE can be differentiated based on differences in the amplitudes of DNSEP, providing an objective basis for treatments and follow-up examinations.We evaluated differences in the amplitudes of DNSEP between PPE and SPE patients, which were rare in the published literature. However, specific causes of these differences are still unclear. SEP only reflects afferent pathways in the ejaculatory reflex arc, and role of the brain as a higher center should not be ignored.Both PPE and SPE patients are characterized by an increased excitability of the penile sensory nerves. Sun Z, Liao Z, Zheng Q, et al. A Study of Differences in Penile Dorsal Nerve Somatosensory Evoked Potential Testing Among Healthy Controls and Patients With Primary and Secondary Premature Ejaculation. J Sex Med Rev 2021;18:732-736.

Background Injury to the posterior femoral cutaneous nerve (PFCN) produces sitting pain in the buttock, posterior thigh, and/or the ischial tuberosity. The anatomy of the PFCN has not been well described, and just one small cohort of patients has been reported to have resection of the PFCN. Methods Retrospective review of all patients undergoing resection of the PFCN for sitting pain by the senior author between 2012 and 2019 was performed. Evaluation was done by chart review, intraoperative description of the anatomy of the PFCN, and the outcome of resection of the PFCN with implantation of the proximal nerve into the gluteus muscle. Outcome was determined by direct patient examination, email reports, and telephonic interview. Results Fifty-two patients were included in this study, of which nine were bilateral operative procedures. Thirty-four patients had sufficient follow-up data at a mean of 23 months (3–85 months, range). MRI evidence of hamstring injury was present in 50% of the patients. The classic PFCN anatomy was present in 44% of limbs with the other 56% having a high division permitting branches to the lateral buttock and posterior thigh to be preserved. In patients with bilateral anatomy observations, symmetry was present in 67%. An excellent result (absence of sitting pain, normal activities of daily living [ADL]) was obtained in 53%, a good result (some residual sitting pain with some reduction in ADL), was obtained in 26% and no improvement was observed in 21% of patients. Conclusion Sitting pain due to injury to the PFCN can be relieved by the resection of the PFCN with implantation of the proximal end into muscle. Presence of an anatomical variation, a high division of the PFCN, can permit preservation of sensation in the lateral buttock and posterior thigh in the patient whose symptoms involve just the perineum and ischial tuberosity.

This narrative review discusses recent evidence surrounding the use of regional anaesthesia in the obstetric setting, including intrapartum techniques for labour and operative vaginal delivery, and caesarean delivery. Pudendal nerve blockade, ideally administered by an obstetrician, should be considered for operative vaginal delivery if neuraxial analgesia is contraindicated. Regional techniques are increasingly utilised in clinical practice for caesarean delivery to minimise opioid consumption, reduce pain, improve postpartum recovery and facilitate earlier discharge as part of enhanced recovery protocols. The evidence surrounding transversus abdominis plane and quadratus lumborum blockade supports their use when: long-acting neuraxial opioids cannot be administered due to contraindications; if emergency delivery necessitates general anaesthesia; or as a postoperative rescue technique. Current data suggest quadratus lumborum blockade is no more effective than transversus abdominis plane blockade after caesarean delivery. Transversus abdominis plane blockade, wound catheter insertion and single shot wound infiltration are all effective techniques for reducing postoperative opioid consumption, with transversus abdominis plane blockade favoured, followed by wound catheters and then wound infiltration. Ilio-inguinal and iliohypogastric, erector spinae plane and rectus sheath blockade all require further studies to determine their efficacy for caesarean delivery in the presence or absence of long-acting neuraxial opioids. Future studies are needed to: compare approaches for individual techniques; determine which combinations of techniques and dosing regimens result in optimal analgesic and recovery outcomes following delivery; and elucidate the populations that benefit most from regional anaesthesia in the obstetric setting.

Examination for fecal incontinence is performed in order to evaluate the condition of each patient. As there is no single method that perfectly assesses this condition, there are several tests that need to be conducted. These are as follows: anal manometry, recto anal sensitivity test, pudendal nerve terminal motor latency, electromyogram, anal endosonography, pelvic magnetic resonance imaging (MRI) scan, and defecography. In addition, the mental and physical stress most patients experience during all these examinations needs to be taken into consideration. Although some of these examinations mostly apply for patients with constipation, we hereby describe these tests as tools for the assessment of fecal incontinence. Conservative therapies for fecal incontinence include diet, lifestyle, and bowel habit modification, pharmacotherapy, pelvic floor muscle training, biofeedback therapy, anal insert device, trans anal irrigation, and so on. These interventions have been identified to improve the symptoms of fecal incontinence by determining the mechanisms resulting in firmer stool consistency; strengthening the pelvic floor muscles, including the external anal sphincter; normalizing the rectal sensation; or periodic emptying of the colon and rectum. Among these interventions, diet, lifestyle, and bowel habit modifications and pharmacotherapy can be performed with some degree of knowledge and experience. These two therapies, therefore, can be conducted by all physicians, including general practitioners and other physicians not specializing in fecal incontinence. However, patients with fecal incontinence who did not improve following these initial therapies should be referred to specialized institutions. Contrary to the initial therapies, specialized therapies, including pelvic floor muscle training, biofeedback therapy, anal insert device, and trans anal irrigation, should be conducted in specialized institutions as these require patient education and instructions based on expert knowledge and experience. In general, conservative therapies should be performed for fecal incontinence before surgery because its pathophysiologies are mostly attributed to benign conditions. All Japanese healthcare professionals who take care of patients with fecal incontinence are expected to understand the characteristics of each conservative therapy, so that appropriate therapies will be selected and performed. Therefore, in this chapter, the characteristics of each conservative therapy for fecal incontinence are described.

Premature ejaculation (PE) is the most common self-reported male sexual disorder estimated to occur in approximately 5% of men in the general community. Penile hypersensitivity is thought to be an etiologic factor of lifelong PE. The role of glans penis augmentation using injectable hyaluronic acid (HA) for the treatment of PE is debatable and remains to be confirmed. The creation of a barrier at the level of the glans, by the bulking agent blocking accessibility and inhibiting the tactile stimuli to reach the dorsal nerve of the penis (branch of the pudendal nerve) receptors, is the theory behind the effectiveness of HA in the field of PE. We reviewed the literature using PubMed and searched for the following keywords: premature ejaculation, glans penis and HA, over the last 20 years. Five studies were found. These studies showed that HA injection could significantly increase IELT (2.43- to 4.46-fold), and this increase could persist for long term (up to 5 years). No serious adverse reactions were reported besides transient discoloration and swelling of the glans that recovered to normal within 2 weeks. Many techniques were discussed, their effectiveness remains to be proved. However, proper patient selection and mastering the esthetics of the technique, by adequate surgical training, is necessary in order to achieve the optimal results.

Objective To test the hypothesis that preoperative pelvic floor muscle injections and pudendal nerve blocks with bupivacaine and dexamethasone would decrease postoperative pain after vaginal native tissue prolapse repairs, compared with saline and bupivacaine. Methods We conducted a three-arm, double-blind, randomized trial of bilateral transobturator levator ani muscle injections and transvaginal pudendal nerve blocks before vaginal reconstructive and obliterative prolapse procedures (uterosacral ligament suspension, sacrospinous ligament fixation, levator myorrhaphy, or colpocleisis). Women were randomized to one of three study medication groups: 0.9% saline, 0.25% bupivacaine, or combination 0.25% bupivacaine with 4 mg dexamethasone. Our primary outcome was a numeric rating scale pain score on postoperative day 1. Using an analysis of variance evaluated at the two-sided 0.05 significance level, an assumed variance of the means of 0.67, and SD of 1.75, we calculated 21 women per arm to detect a 2-point change on the numeric rating scale (90% power), which we increased to 25 per arm to account for 20% attrition and the use of nonparametric statistical methods. Results From June 2017 through April 2019, 281 women were screened and 75 (26.7%) were randomized with no differences in baseline demographics among study arms. There was no significant difference in median pain scores on postoperative day 1 among study groups (median [interquartile range] pain score 4.0 [2.0-7.0] for placebo vs 4.0 [2.0-5.5] for bupivacaine vs 4.0 [1.5-5.0] for bupivacaine with dexamethasone, P=.92). Conclusion Preoperative pelvic floor muscle injections and pudendal nerve blocks with bupivacaine and dexamethasone did not improve postoperative pain after vaginal native tissue prolapse procedures. Clinical trial registration ClinicalTrials.gov, NCT03040011.

In conus medullaris and cauda equina surgery, identification of the sacral nerve roots may be uncertain in spite of their anatomical/radiological landmarks. Mapping the sacral roots by recording the muscular responses to their stimulation may benefit from EMG recording of the External Anal sphincter (EAS) in addition to the main muscular groups of the lower limbs. In a consecutive series of 27 lumbosacral dorsal rhizotomy (DRh), authors carried out a prospective study on the reliability of the EMG recording of the EAS for identification of the S1 and S2 sacral roots. An EAS-response was recorded in all the 27 (bilaterally) explored individuals, testifying good sensitivity and selectivity of the method. EAS-responses were obtained in 96.3% of the 54 stimulated sides of the S2 root versus in only 16.66% for the S1 root, so that an absence of response would indicate S1 rather than S2 level. Furthermore, comparison between myotomal distribution of the S1 and S2 roots showed a significant difference (p

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. 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. 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

Background Pudendal neuropathy is a chronic, disabling form of perineal pain that involves the pudendal nerve, a mixed somatic and autonomic nerve that originates from sacral nerve roots. Peripheral nerve stimulation of the pudendal nerve can be useful to decrease symptom burden in patients who have failed initial conservative treatment modalities. Methods In this manuscript, we describe an approach to the placement of a peripheral nerve stimulator for the treatment of pudendal neuralgia. We present a case of complex pelvic neuropathy and review the factors that lead to successful placement. Technical aspects of stimulator placement and ultrasound landmarks are reviewed. Results A lateral to medial approach with ultrasound guidance at the level of the ischial spine is likely to facilitate proper lead placement along the course of the pudendal nerve. Aftercare and adherence to postimplant activity restrictions–particularly avoiding use of the extremes of hip flexion and extension for four weeks—lead to the absence of lead migration. Conclusions Pudendal nerve stimulation is an emerging technique for neuromodulation of refractory pudendal neuralgia. Ultrasound-guided pudendal nerve stimulation is a viable technique for neuromodulation of pudendal neuralgia. Optimization of patient selection, ultrasound guidance, and proper adherence to postimplant activity restrictions may be helpful for long-term therapeutic success.

Objective To provide an anatomical atlas made of serially sectioned images of a female cadaver that clearly demonstrated the pudendal nerve. Materials and Methods The courses of the pudendal nerve, internal pudendal artery, and internal pudendal vein were observed on the sectioned images of a female cadaver. The spatial relationship between the nerve and blood vessels was interpreted. Results Traces of the structures on the sectioned images showed that the sources of the sciatic and pudendal nerves were the fourth lumbar nerve to the second sacral nerve and the second to the fourth sacral nerves, respectively. As the borderline, the second sacral nerve showed a remarkable variation. The pudendal nerve gave off the internal rectal nerve proximal to the pudendal canal and it gave off the muscular branch to the urogenital triangle in the pudendal canal. It was divided into the posterior labial nerve and the dorsal nerve of clitoris distal to the pudendal canal. Inside the pudendal canal, the internal pudendal vein, internal pudendal artery, and pudendal nerve were arranged from superomedial to inferolateral order. In other words, the pudendal nerve was the farthest from the uterus. Conclusion The sorted sectioned images with labels, accompanied by the schematic drawings, could serve as references for interpreting clinical images and conducting procedures related to pudendal nerve conditions.

OBJECTIVE: To determine the relationship between various parameters of high-frequency biphasic stimulation (HFBS) and the recovery period of post-HFBS block of the pudendal nerve in cats. MATERIALS AND METHODS: A tripolar cuff electrode was implanted on the pudendal nerve to deliver HFBS in ten cats. Two hook electrodes were placed central or distal to the cuff electrode to stimulate the pudendal nerve and induce contractions of external urethral sphincter (EUS). A catheter was inserted toward the distal urethra to slowly perfuse the urethra and record the back-up pressure generated by EUS contractions. After determining the block threshold (T), HFBS (6 or 10 kHz) of different durations (1, 5, 10, 20, 30 min) and intensities (1T or 2T) was used to produce the post-HFBS block. RESULTS: HFBS at 10 kHz and 1T intensity must be applied for at least 30 min to induce post-HFBS block. However, 10 kHz HFBS at a higher intensity (2T) elicited post-HFBS block after stimulation of only 10 min; and 10 kHz HFBS at 2T for 30 min induced a longer-lasting (1–3 h) post-HFBS block that fully recovered with time. HFBS of 5-min duration at 6 kHz produced a longer period (20.4 ± 2.1 min, p < 0.05, N = 5 cats) of post-HFBS block than HFBS at 10 kHz (9.5 ± 2.1 min). CONCLUSION: HFBS of longer duration, higher intensity, and lower frequency can produce longer-lasting reversible post-HFBS block. This study is important for developing new methods to block nerve conduction by HFBS.

Injury to the pudendal nerve leads to bowel/bladder incontinence which compromises the quality of life in these patients. Many peripheral nerves have been used to neurotize the pudendal nerve in order to regain bladder continence. The aim of this study was to assess the anatomic feasibility, by ultrasound, of transfer of the femoral nerve’s motor branch to the vastus lateralis (MNVL) to the pudendal nerve for restoring continence. Thirty healthy male volunteers were randomly selected, irrespective of age. The origin of MNVL was traced in the distal thigh, to the level the nerve was visible using high-frequency ultrasound probe. The length of the nerve was measured with the help of a measuring tape. The pudendal nerve was identified just medial to the ischial tuberosity on the same side. The distance between the origin of MNVL and the pudendal nerve was measured. The same procedure was performed in the opposite side. MNVL has enough length and calibre to neurotize the pudendal nerve in 28/30 (93.33%) individuals on the right side, and in 29/30 (96.66%) individuals on the left side. On ultrasonography, length of MNVL was found sufficient to reach the pudendal nerve in majority of the patients. USG can be a tool to assess the feasibility of transfer of MNVL to the pudendal nerve. Level of evidence: Level IV, risk/prognostic study.

The standard level for lesioning in a functional posterior rhizotomy (FPR) ranges from L2 to S1/S2. Lesioning of the S1 and S2 rootlets strongly correlates with a reduction in ankle spasticity. In the Japanese population, the S2 root often shows the highest dorsal root action potentials (DAPs) in the afferent fibers of the pudendal nerve and is not lesioned to preserve postoperative urinary function. Thus, cutting of the S1 root plays a key role in reducing ankle spasticity in FPR. However, on rare occasions, even an S1 root may show high DAP in the afferent fibers of the pudendal nerve. The present, brief, technical note aimed to describe how an S1 root with a relatively high DAP in the afferent fibers of the pudendal nerve may be handed. In the procedure, the S1 root is divided into several rootlets, and each rootlet is tested for the pudendal mapping. A train of electrical stimuli is delivered to each rootlet in the standard FPR. If electromyography (EMG) findings after electrical stimulation are highly abnormal while the pudendal mapping demonstrates no or a relatively low DAPs, the rootlet is cut. In contrast, even if the rootlet shows highly abnormal EMG findings, it is preserved if mapping demonstrates a relatively high DAP. The S1 pudendal mapping is combined with EMG findings to achieve satisfactory reduction in ankle spasticity while preserving urological function.

Intraspinal epidermoid/dermoid cysts are very rare, benign tumors arising from pathological displacement of epidermal cells into the spinal canal. Literature data about the long-term outcome after microsurgical resection with multimodal intraoperative neurophysiological monitoring (IONM) are lacking. We analyzed one of the largest case series with special regard to intraoperative characteristics and long-term outcome after IONM-aided surgery. All 12 patients (m:f = 1.4:1) who underwent microsurgical tumor resection with multimodal IONM for intraspinal epidermoid/dermoid tumors between 1998 and 2019 in our university hospital were included. We retrospectively investigated the patients’ characteristics, imaging/surgical parameters, and postoperative long-term outcomes. Symptomatic tumor manifestation was seen during adulthood in 4 patients (median age 33.0 years) and during childhood in 8 patients (median age 4.3 years). Spinal dysraphism was the most often comorbidity (75%). The most frequent symptoms at diagnosis were spastic pareses (75%), ataxia (58%), and vegetative disorders (42%). Tumors were most often lumbosacral (L1–L5 42%, L5–S3 50%) and intradural-extramedullary (92%). For microsurgical resection, IONM with EMG, SSEPs, and TcMEPs of the limbs and pudendal nerve/anal sphincter was always applied and feasible; intraoperative corrective actions were initiated in three cases due to transient IONM deterioration. None of the patients showed a postoperative deterioration of the neurological status with a gross total resection rate of 92%. Pain situation, McCormick grade, and mJOA Score were improved at long-term follow-up (median 4.8 years). IONM-aided resection of intraspinal epidermoid/dermoid tumors is feasible both in adult and pediatric cases and enables a satisfying clinical and surgical outcome.

Injury to the pudendal nerve in men presents with pain, paresthesia, or numbness of the perineum, and/or scrotum, and/or penis. There is evidence implicating the brachytherapy seeds used to treat prostate cancer as source of pudendal nerve injury. Compared to surgical prostatectomy, brachytherapy has the advantage of being less invasive, but seeds may not only lead to well-established complications such as urinary, bowel, and erectile dysfunction, but also injury to the sensory branches of the pudendal nerve. We report and document a case of pudendal nerve injury secondary to brachytherapy seeds diagnosed with magnetic resonance (MR) neurography, nerve blocks, and histopathological examination; and successful treatment via sensory branch neurectomy.

Summary Purpose Female cyclists undergo a perineal compression of the pudendal nerve and genital-perineal area, with underexplored effects on genital injuries and sexual dysfunctions. This study tests the effects of a new geometric bicycle saddle (SMP) on perineal compression, blood perfusion, genital sensation and sexual function. Methods Thirty-three professional female athletes were monitored when using both the new saddle and a traditional professional saddle, in a randomized order. Short-term effects are estimated by measuring the partial pressure of vagina transcutaneous oxygen (PtcO2) before using the saddle, after 10 minutes of static sitting, after riding 20 minutes. Long-term effects are estimated by measuring athletes Female Sexual Distress Scale (FSDS) before using the new saddle and after 6 months using it. Results From an initial average of 70 mmHg, PtcO2 decreases by 30 mmHg after riding on a traditional saddle, 10 mmHg on the new saddle (respectively 20 and 7 after just sitting). When using the traditional saddle all FSDS scores are well over the 12 “normality” threshold, with an average of 41, while after using the new saddle the average falls to 12. All differences between the saddles are strongly significant: paired t-tests > 6; P Conclusion Traditional saddles have strong negative effects on the vascular perfusion of the vulva, with possible consequences on female sexual functions. The SMP saddle reduces the compression on the pelvic floor and can help reducing the incidence of urogenital pathologies for female cyclists.

Deep gluteal syndrome is an increasingly recognized disease entity, caused by compression of the sciatic or pudendal nerve due to non-discogenic pelvic lesions. It includes the piriformis syndrome, the gemelli-obturator internus syndrome, the ischiofemoral impingement syndrome, and the proximal hamstring syndrome. The concept of the deep gluteal syndrome extends our understanding of posterior hip pain due to nerve entrapment beyond the traditional model of the piriformis syndrome. Nevertheless, there has been terminological confusion and the deep gluteal syndrome has often been undiagnosed or mistaken for other conditions. Careful history-taking, a physical examination including provocation tests, an electrodiagnostic study, and imaging are necessary for an accurate diagnosis. After excluding spinal lesions, MRI scans of the pelvis are helpful in diagnosing deep gluteal syndrome and identifying pathological conditions entrapping the nerves. It can be conservatively treated with multidisciplinary treatment including rest, the avoidance of provoking activities, medication, injections, and physiotherapy. Endoscopic or open surgical decompression is recommended in patients with persistent or recurrent symptoms after conservative treatment or in those who may have masses compressing the sciatic nerve. Many physicians remain unfamiliar with this syndrome and there is a lack of relevant literature. This comprehensive review aims to provide the latest information about the epidemiology, aetiology, pathology, clinical features, diagnosis, and treatment. Cite this article: Bone Joint J 2020;102-B(5):556–567.

Study Design: Narrative review with a case illustration.Purpose: The purpose of this study was to evaluate the pathogenesis and outcome of therapy for walking-evoked erection in patients with lumbar degenerative diseases.Overview of Literature: Cauda equina compression due to lumbar degenerative diseases rarely cause a walking-evoked erection; however, no review has been undertaken of walking-evoked erection in patients with lumbar degenerative diseases.Methods: A total of 1,570 male patients with lumbar degenerative diseases, who underwent surgery between April 2003 and June 2017, were evaluated; from these patients, participants with walking-evoked erection were selected. Preoperative clinical data of walking-evoked erection, paresthesia, and bladder and bowel function were assessed. In our study, the neurological status and the erectile function of each participant were retrospectively evaluated before and after surgery using the Japanese Orthopedic Association score and the Overactive Bladder Symptom Score.Results: Among the 1,570 male patients screened in our department, eight patients (0.51%, 8/1,570) presented with walking-evoked erection accompanied by cauda equina symptoms. In six of the patients, the erectile symptoms were associated with paresthesia in the genitalia or perianal region. Of the six patients evaluated for bladder dysfunction, all were diagnosed with prostatic hyperplasia, while four were diagnosed with an overactive bladder. In all patients, walking-evoked erection disappeared entirely after surgery.Conclusions: This study comprises the first review of walking-evoked erection in patients with lumbar degenerative diseases. We speculate that sensory input, such as paresthesia in the genitalia or perianal region stimulates the pelvic or perineal nerves through the pudendal nerve and induces reflexogenic erections.

AIMS: Neuromodulation (nerve stimulation) can produce analgesia. One form, bilateral pudendal nerve stimulation (bPNS), suppresses responses to urinary bladder distension (UBD) in hypersensitive rats. Drugs can modify this effect (e.g., benzodiazepines, but not opioids, suppress bPNS effects). Prior to a clinical trial of bPNS effects on bladder pain, we felt it was prudent to survey the effects of medications commonly used in patients with bladder disorders. METHODS: Bladder hypersensitivity was produced by neonatal bladder inflammation in rat pups coupled with a second inflammatory insult as an adult. Antimuscarinic (oxybutynin), β(3)-adrenoceptor agonist (mirabegron, CL316243), α(1)-adrenoceptor antagonist (tamsulosin), antidepressant (amitriptyline), muscle relaxing (baclofen), and sedative (propofol) agents were administered and effects of bPNS on responses to UBD assessed. bPNS consisted of bilateral biphasic electrical stimulation of the mixed motor/sensory component of the pudendal nerves. Visceromotor responses (VMRs; abdominal muscle contractile responses) were used as nociceptive endpoints. RESULTS: Many of these drugs directly inhibited the VMRs to UBD, but only mirabegron, at the doses employed, significantly reduced inhibitory effects of bPNS. In the presence of the other drugs, bPNS continued to produce statistically significant inhibition of VMRs to UBD. CONCLUSIONS: This study suggests that concurrent therapy with drugs used to treat bladder disorders could affect assessment of the effects of bPNS on bladder hypersensitivity. This study gives guidance to clinical trials using bPNS for the treatment of painful bladder syndromes and suggests potential clinical use of some of these medications in the treatment of these same disorders.

Objective To describe a novel technique of using peripheral nerve neuromodulation (PNNM) for the treatment of refractory, mesh-induced chronic pelvic pain. Chronic pelvic pain associated with mesh can be a debilitating complication and there is currently no consensus on treatment. PNNM has been shown to be successful in the treatment of post-traumatic neuralgias but has yet to be studied in mesh complications. Materials and Methods We present a case of a 50-year-old woman who had unrelenting pelvic pain after retropubic sling placement. She failed multiple therapies including medications, mesh removal, pelvic floor physical therapy, pudendal neuromodulation, and pelvic floor onabotulinumtoxinA trigger point injections. Results The only treatment that provided temporary relief of this patient's pain was transvaginal trigger point injections along with a right pudendal nerve block using 40 mg triamcinolone and 0.5% ropivacaine. To help define if treatment at the site of her pain would provide relief, a series of blocks were done by advancing a needle retropubically to her area of pain and injecting triamcinolone and 0.5% ropivacaine. This injection, which corresponded to the previous tract of her retropubic sling, provided temporary, but profound, relief. PNNM was then done with placement of the electrode in the retropubic space at the site of her pain. This provided instantaneous relief of almost all of her pain symptoms. Twelve months postoperatively, the patient continued to have >90% improvement in her pain. Conclusion Focused PNNM is a simple procedure and can provide symptomatic relief for refractory postvaginal mesh pain.

Background Loss of penile sensation or development of a painful penis and erectile dysfunction can occur after injury to the dorsal branch of the pudendal nerve. Although recovery of genital sensibility has been discussed frequently in transmen, this subject has been reported rarely in cismen. The purpose of this report is to review our experience with recovery of sensation in men after decompression of the dorsal branch of the pudendal nerve after trauma. Methods A retrospective chart review of men who have had decompression of the dorsal branch of the pudendal nerve was carried out from 2014 to 2018. Patients were included in the cohort if they had a loss of penile sensation or the development of a painful penis after trauma. Primary outcomes measured were the change in penile symptoms, including erection, ejaculation, ejaculatory pain, erogenous sensation, numbness, and penile pain. Results For the 7 men included in this study, the mean follow-up time was 57 weeks (range, 28-85 weeks). Bilateral surgery was done in 71% (5/7). Of the 6 patients with loss of penile sensation, complete recovery of erogenous sensibility occurred in 5 (83%) patients, with partial relief in 1 (17%) patient. Of the 3 men who had erectile dysfunction, normal erections were restored in 2 (67%) patients. Of the 2 patients unable to ejaculate, 1 (50%) patient regained ejaculatory function. Of the 4 patients with ejaculatory pain, complete relief of pain occurred in 2 (50%) patients, with partial relief in 2 (50%) patients. Of the 6 patients with penile pain in the absence of ejaculation, complete relief of pain occurred in 3 (50%) patients, with partial relief in 3 (50%) patients. Conclusion Neurolysis of the dorsal nerve to the penis at the inferior pubic ramus canal can be successful in relieving pain, and restoring sensation and erectile function in men who sustained an injury along the inferior pubic ramus.

Peripheral nerve damage, such as that found after surgery or trauma, is a substantial clinical challenge. Much research continues in attempts to improve outcomes after peripheral nerve damage and to promote nerve repair after injury. In recent years, low-intensity pulsed ultrasound (LIPUS) has been studied as a potential method of stimulating peripheral nerve regeneration. In this review, the physiology of peripheral nerve regeneration is reviewed, and the experiments employing LIPUS to improve peripheral nerve regeneration are discussed. Application of LIPUS following nerve surgery may promote nerve regeneration and improve functional outcomes through a variety of proposed mechanisms. These include an increase of neurotrophic factors, Schwann cell (SC) activation, cellular signaling activations, and induction of mitosis. We searched PubMed for articles related to these topics in both in vitro and in vivo animal research models. We found numerous studies, suggesting that LIPUS following nerve surgery promotes nerve regeneration and improves functional outcomes. Based on these findings, LIPUS could be a novel and valuable treatment for nerve injury-induced erectile dysfunction.

Stress urinary incontinence (SUI) is a common and bothersome problem among middle-aged women. However, there are few useful drugs for SUI. Urethral hypermobility and intrinsic sphincter deficiency are two main causes of SUI. Various animal models of SUI, such as vaginal distention, pudendal nerve injury, or ovariectomy, have been developed to study the pathophysiology of SUI. In addition, we have previously reported that cerebral infarction rats also induce SUI. Leak point pressure measurements are the most commonly used methods to evaluate the urethral dysfunction in SUI animal models. Originally, we have developed microtransducer-tipped catheter measurements of urethral activity during sneezing. Previous or our basic research has clarified potential strategies for pharmacotherapy of SUI in the central nervous system. Therapeutic targets include adrenergic and serotonergic (5-HT) receptors in the spinal cord, which stimulate pudendal nerve innervating the external urethral sphincter and/or sympathetic nerve innervating urethral smooth muscle. Activation of α1-adrenoceptors, 5-HT2C, or 5-HT7 receptors enhances the reflex at the spinal cord level whereas pre- or postsynaptic α2-adrenoceptors and/or 5-HT1A receptors inhibit the reflex. We have recently reported that stimulation of the spinal μ-opioid receptors by tramadol also enhances the reflex. Thus, we review the recent advances in basic SUI research and potential targets for pharmacotherapy of SUI in the central nervous system.

INTRODUCTION Recent neuroimaging studies have indicated that some brain areas are involved in the sexual behavior process. Pre-mature ejaculation patients exhibit altered brain activation and abnormal cortical structures. However, there has been no research evaluating the topological organization of structural brain network in anejaculation (AE). METHODS We employed diffusion tensor imaging data and graph theory to examine the whole-brain structural networks among 16 AE patients and 23 healthy controls. In addition, the results of sexual function assessment were also obtained from each patient for symptom assessment. Moreover, the relationships between these clinical features and the altered topological characteristics of AE patients were also explored. RESULTS Decreased clustering coefficient was found in the right amygdala, inferior temporal gyrus, and left pallidum of AE. AE also showed increased path length in the right post-central gyrus, supramarginal gyrus, putamen, pallidum and left heschl gyrus, temporal pole (superior temporal gyrus); however, these altered brain regions showed no significant differences after false discovery rate correction. Moreover, the path length between subcortical and frontal regions was increased in AE. In addition, negative correlations were found between the altered nodal parameters and the amplitudes of somatosensory evoked potentials of dorsal nerve, sympathetic skin response located in the penis. CONCLUSION Together, our results suggest that AE was associated with disruptions in the topological organization of structural brain networks. The decreased clustering coefficient in temporal and subcortical regions and the increased path length between subcortical and frontal regions may contribute to AE. These findings provide new insights into the pathophysiological mechanisms of AE.

El prolapso rectal es una patología poco frecuente, de fisiopatología no clara; pero que incluye un trastorno del piso pélvico; además es una enfermedad con un gran impacto en el estilo de vida de los pacientes que lo padecen. Típicamente ocurre en mujeres adultas mayores, pero puede ocurrir en hombres y mujeres de todas las edades. Dentro de las manifestaciones clínicas más frecuentes se incluyen la incontinencia fecal, estreñimiento y la sensación de masa rectal. El diagnóstico puede hacerse únicamente por examen físico o bien, en casos sospechosos puede confirmarse con una defecografía; a su vez, se pueden realizar múltiples estudios complementarios dentro de los que se encuentran: Resonancia Magnética,cistografía,tránsito colónico, manometría anal, latencia del motor terminal del nervio pudendo y una colonoscopia. El envío de estos estudios debe valorarse en forma independiente en cada caso. La piedra angular del tratamiento del prolapso rectal es la cirugía con abordaje abdominal, por su mayor efectividad; o en su defecto, el abordaje perineal. A pesar de ser el tratamiento de elección, a todos los pacientes se les debe instruir de forma inicial sobre el manejo médico, ya que, se disminuyen los síntomas y es posible mejorar la calidad de vida del paciente.

INTRODUCTION Urological chronic pelvic pain syndrome (UCPPS) represents a group of pain symptoms relating to patients with pelvic pain for which treatment is largely unsatisfactory. The objective of this study is to analyze the effects of a novel treatment strategy in males suffering from UCPPS. METHODS This retrospective, institutional review board-approved study analyzed eight male patients aged 24 to 61 with UCPPS. All the patients had a trial of antibiotic therapy, NSAIDs, and pelvic floor physical therapy before the study. The Visual Analog scale (VAS) and Functional Pelvic Pain scale (FPPS) were collected pretreatment. While continuing physical therapy, patients underwent weekly ultrasound-guided pelvic floor trigger point injections to the iliococcygeus, pubococcygeus, and puborectalis with lidocaine 1%. Concomitantly, patients received peripheral nerve hydrodissection performed on the pudendal nerve and the posterior femoral cutaneous nerve. The first two injections combined 1% lidocaine with dexamethasone, while the next four injections consisted of 1% lidocaine with traumeel (a homeopathic, plant-derived anti-inflammatory medication). At the 6-week follow-up, each patient retook the VAS and FPPS. RESULTS The mean age of our patients was 31.8 years and the average duration of symptoms of the UCPPS was 21 months. Pretreatment, the mean VAS was 3.3 (STD 1.7) and the mean VAS posttreatment was 1.8 (STD 1.4); P

Age‐related changes in the lower urinary tract (LUT) can affect the coordination of reflexes and increase the incidence of bladder disorders in elderly. This study examines the age‐related loss of urethral signaling capability by measuring the afferent activity directly. We find that less urethral pressure develops in response to fluid flow in old rats compared to young rats and that pressure and flow evoke less urethral afferent activation. These findings are consistent with our previous study demonstrating that the urethra‐to‐bladder reflex, which is required for efficient voiding, becomes weaker with age. We measured the pudendal afferent response in young (4–7 months) and old (18–24 months) rats to fluid flow in the urethra across a range of flow rates. We used paraffin embedding and hematoxylin and eosin staining to quantify age‐related changes in the sensory branch of the pudendal nerve. Urethral afferent signaling in response to the same urethral flow rates was weaker in older animals. That is, the sensitivity of urethra afferents to flow decreased with age, and higher flow rates were required in older animals to recruit urethra afferents. There was also a reduction in the myelin thickness of pudendal afferents in old rats, which is a possible contributing factor to the sensory activity. Furthermore, the same flow rates evoked less pressure in the urethras of old animals, indicating there is an age‐related change of the urethral tissue that reduces the pressure stimulus to which these afferents respond. These results help characterize the underlying changes in LUT system with age., The prevalence of underactive bladder (UAB) symptoms increases with age; however, the underlying mechanism of age‐related bladder dysfunction is unclear. In this study on rats, we found age‐related reductions of overall urethral sensory outflow, urethral pressure development during fluid flow, and myelin present in urethral afferents, suggesting urethral neuropathy plays a role in UAB.

Background The literature regarding the route of the dorsal nerve of the clitoris is sparse and lacks surgical focus. With an increasing number of procedures being performed on the labia, it is important to elucidate the route and note any variation from normal of the nerve. Methods Fifty-one cadavers were dissected to yield 97 dorsal nerve of the clitoris samples. Measurements were taken from (1) the dorsal nerve of the clitoris penetration point of the perineal membrane to the urethra, (2) the nerve's penetration point of the perineal membrane to the pubic bone, (3) the angle of the clitoris to the branch point of the dorsal nerve of the clitoris, and (4) the branch point of the nerve to the distalmost point of the glans clitoris. Any anomalous branching patterns of the dorsal nerve of the clitoris were recorded and classified. Results The means and standard deviations of each measurement were used to create a surgical danger zone. The mean of each measurement was (1) 34.63 mm, (2) 5.74 mm, (3) -3.07 mm, and (4) 30.40 mm, respectively. In addition, six distinct branching patterns were observed, organized, and classified based on the location and number of branches observed. Conclusions The dorsal nerve of the clitoris has multiple branching patterns and typically travels along the same course in most women. Further investigation of the course and three-dimensional position of the dorsal nerve of the clitoris is warranted to preserve sexual sensation as the frequency of procedures involving the female pudendum increases.

Background Obstructed defecation is a common pelvic floor medical problem among adult population. Pelvic floor disorders were reported to be associated with sexual dysfunction including erectile dysfunction among male patients. The aim was to determine the relation between pelvic floor neurophysiological abnormalities and erectile dysfunction in male patients with obstructed defecation. Methods This cross-sectional study included 65 married male patients with obstructed defecation and a control group consisted of 15 apparently healthy married males. Assessment of obstructed defecation severity was done by using modified obstructed defecation score, time of toileting and Patient Assessment of Constipation-Quality of Life questionnaire. Assessment of erectile functions was done using erectile function domain of International Index of Erectile Function questionnaire and Erectile Dysfunction-Effect on Quality of Life Questionnaire. Anal manometry and dynamic pelvis magnetic resonance imaging were done. Electrophysiological studies included pudendal nerve motor conduction study and needle electromyography of external anal sphincter, puborectalis and bulbocavernosus muscles. Results There were 32 patients (49.2%) who had erectile dysfunction. The maximum straining anal pressure was significantly higher among patients with erectile dysfunction. Pudendal nerve terminal motor latency was significantly delayed and the percentage of bilateral pudendal neuropathy was significantly higher among patients with erectile dysfunction. The percentage of electromyography evidence of denervation with chronic reinnervation in the external anal sphincter and bulbocavernosus muscles were significantly higher among patients with erectile dysfunction. Regression analysis detected three co-variables to be associated with significantly increasing the likelihood of development of erectile dysfunction. These were maximum straining anal pressure (odd ratio = 1.122), right pudendal nerve terminal motor latency (odd ratio = 3.755) and left pudendal nerve terminal motor latency (odd ratio = 3.770). Conclusions Erectile dysfunction is prevalent among patients with obstructed defecation. It is associated with characteristic pelvic floor electrophysiological abnormalities. Pelvic floor neurophysiological changes vary from minimal to severe neuromuscular abnormalities that usually accompanying erectile dysfunction. Pudendal neuropathy and increased maximum straining anal pressure are essential risk factors for increasing the likelihood of development of erectile dysfunction in patients with obstructed defecation.

AIM The dorsal nerve of the penis (DNP) is the terminal branch of the pudendal nerve which is responsible for the somatic innervation of the penis. This study aims to outline any direct role of the DNP in the hemodynamics of erection histologically and physiologically. MATERIALS AND METHODS Fifteen Wistar albino rats were sorted into the electrical activity (n = 6), intracavernous pressure (n = 4), and control (n = 5) groups. The dorsal nerve was electrostimulated and the simultaneous changes in intracavernous pressure and smooth muscle activity were recorded. Penile tissues were collected, fixed, and sectioned, the slides were stained with either hematoxylin-eosin for morphological evaluation or using the indirect immunoperoxidase technique to analyze the distributions of eNOS, iNOS, and nNOS. RESULTS During electrostimulation, there was a simultaneous statistically significant decrease in the electrical activity inside the corpora in electromyography and an increase in intracavernous pressure. eNOS and iNOS immunoreactivities were higher in the study group than in the control group. nNOS immunoreactivity was moderate in both study and control groups. CONCLUSION Some fibers in the dorsal nerve of penis continue into the corpora cavernosa through the tunica albuginea and have an active, direct role in the hemodynamic process of erection, which may be complementary to the main route of innervation.

Surgical excision of the groin and vulva is a painful procedure. Traditionally following general or regional anaesthesia, local anaesthetic was infiltrated around the wound. The distribution varied and the somatic pain control was not reliable. Inspired by the success of the application of peripheral nerve blocks for postoperative pain control with open abdominal procedures, we introduced blockade of the ilioinguinal nerve(IIN) and pudendal nerve(PN) into our vulval surgery to assess the requirement for parenteral and oral analgesia in the postoperative period. This is an observational study of all patients undergoing major vulval and/or related groin surgery. Sampling biopsies were excluded. Levobipuvicaine 0.25%(2.5mg/ml) or 0.5%(5mg/ml) was used for and dosage was calculated based on the patient’s weight with no more than 2mg/kg. For example, using 0.25% of levobupivacaine (2.5mg/ml) for a 70kg patient, 56 ml is administered divided into 4, giving 14mls at each site (2 sites abdominally for IIN block and 2 sites for pudendal block). Eighteen women were included in the analysis. Median age was 67 (range 34-81) years and thirteen (72%) were >60 years. Visual analogue scores(VAS) ranged from 0 to 3 for seventeen patients from day 0 to day 1 and fifteen patients from day 2 to day 5. Two patients had pain scores >4 on one or more postoperative days: one had chronic arthralgia and one had received a lower volume of bupivacaine. This observational study demonstrates that ilioinguinal and pudendal nerve LA blocks may be a valuable addition to the multimodal postoperative analgesic pathway for women undergoing major surgical excision in the vulva and groin.

Sacroiliac joint (SIJ) dysfunction has been increasingly recognized as the underlying pathology responsible for a significant percentage of cases of chronic lower back pain and radiculopathy. Diagnosis of SIJ dysfunction involves multiple provocation tests followed by serial injections of anesthetic, with significant alleviation of pain indicating that the SIJ is the pain generator. One documented complication of SIJ injections is extravasation of injected material from the SIJ capsule, resulting in unintended symptoms. We report the case of a patient who reported experiencing an orgasm following each of her three diagnostic SIJ injections. We hypothesize that this unusual symptom was caused by extravasation of injected material ventrally to the nearby pudendal nerve, a nerve responsible for sensory innervation of the perineum and a mediator of sexual arousal and orgasm.

Study Objective Some articles have reported the surgical management of Alcock canal syndrome (ACS) using the transperineal [1] , transgluteal [2] , or conventional laparoscopic approach [ 3 , 4 ]. In 2015, Rey and Oderda [5] reported the first robotic neurolysis of the pudendum, providing the advantages of robot-assisted surgery: magnified and 3-dimensional vision and greater precision of movements. However, to our knowledge, there have been no reports on the use of a robotic platform for the treatment of ACS in the field of gynecology. Therefore, the objective of this video is to describe the anatomic and technical highlights of robotic exploration of the somatic nerves in the pelvis and transection of the sacrospinous ligament (nerve decompression) for ACS. Design Stepwise demonstration of the technique with narrated video footage. Setting An urban general hospital. A 48-year-old woman who had no previous surgical history was referred for severe pain when sitting, cyclic pelvic pain, and gluteal and perineal pain, all of which were resistant to medication therapy. Her pain radiated to the posterior aspect of the thigh. Before coming to our hospital, she visited an orthopedic surgeon a few years earlier and was diagnosed with sciatic neuralgia. Magnetic resonance imaging revealed adenomyosis with neither deep endometriosis nor vascular entrapment. On the basis of neuropelveologic evaluation, the patient was suspected to be suffering from ACS owing to compression of the pudendal nerve and the posterior cutaneous nerve of the thigh by the sacrospinous ligament. Interventions The procedure was performed using the following 9 steps while referencing the laparoscopic neuronavigation technique [6] : step 1, opening the peritoneum along the external iliac artery; step 2, exposure of the external iliac artery; step 3, development of the lumbosacral space; step 4, identification of the lumbosacral trunk; step 5, identification of the superior gluteal nerve; step 6, identification of the sciatic nerve; step 7, identification of the inferior gluteal nerve; step 8, identification of the pudendal nerve; and step 9, transection of the sacrospinous ligament. The surgery was completed successfully without any complications, and the postoperative course was uneventful. We considered that there was no relationship between the ACS and endometriosis. The patient reported that her pain decreased gradually at postoperative month 1 and month 3, and finally the neuralgia was completely resolved at month 6. Neuropelveologic evaluation still continues every 6 months. Conclusion Robot-assisted transection of the sacrospinous ligament is a feasible, safe technique for selected patients with ACS. Exploration of the pelvic nerves should be performed for further diagnosis and therapy before prematurely labeling the patient as refractory to the treatment [7] .

The article describes the technology for detecting and studying late phenomenon in stimulating electroneuromyography in order to objectively assess the state of innervation. The standard study of the motor response (M-response), Pudendal nerve terminal motor latency testing (PNTML), using the St. Mark's electrode from the external sphincter and pelvic floor muscles provides information only about efferent innervation at the distal part of the n. pudendus. At the same time, there are sparse reports in the literature on the study of the state of the mixed-fiber pudendal nerve along its entire length from its exit from the intervertebral foramen to the distal part using the St. Mark's electrode, the method is not clearly described, which, accordingly, causes the lack of application of the technique in clinical practice. The authors of this article cite the methodology for studying the late phenomenon in the form of a mixed feedback-reflex in stimulating electroneuromyography, describing the need to consistently use both methods of its registration.

Objective To develop an ultrasound-guided interfascial plane technique for injection of the pudendal nerve near its sacral origin in cats. Study design Prospective, randomized, anatomical study. Animals A group of 12 feline cadavers. Methods Gross and ultrasound anatomy of the ischiorectal fossa, the pudendal nerve relationship with parasacral structures, and the interfascial plane were described. Computed tomography was employed to describe a cranial transgluteal approach to the pudendal nerve. Bilateral ultrasound-guided injections were performed in eight cadavers using low [(LV) 0.1 mL kg–1] or high volume [(HV) 0.2 mL kg–1] of ropivacaine–dye solution. Dissections were performed to determine successful staining of the pudendal nerve (>1 cm) and inadvertent staining of the sciatic nerve, and any rectal, urethral or intravascular puncture. Pudendal nerve staining in groups LV and HV were compared using Fisher's exact and Wilcoxon rank-sum test as appropriate (p = 0.05). Results The pudendal nerve and its rectal perineal and sensory branches coursed through the ischiorectal fossa, dorsomedial to the ischiatic spine. The pudendal nerve was not identified ultrasonographically, but the target plane was identified between the sacral transverse process, the ischiatic spine, the pelvic fascia and the rectum and it was filled with dye solution. Both branches of the pudendal nerve were completely stained 75% and 87.5% in groups LV and HV, respectively (p = 1.00). The dorsal aspect of the sciatic nerve was partially stained in 37% of injections in group HV. Rectal or urethral puncture, and intravascular injection were never observed. Conclusions and clinical relevance In cats, ultrasound-guided cranial transgluteal injection successfully stained the pudendal nerve in at least 75% of attempts, regardless of injectate volume. Group HV had a greater probability of sciatic nerve staining.

Aims In patients with pudendal neuralgia, prior studies have shown efficacy in chronic stimulation with Interstim® (Medtronic, Inc.). This feasibility study reports on the initial experience of using a wireless system to power an implanted lead at the pudendal nerve, StimWave®, to treat pudendal neuralgia. Methods Retrospective chart review identified patients with a lead placed at the pudendal nerve for neuralgia and powered wirelessly. Clinical outcomes were assessed at Postoperative visits and phone calls. Administered non-validated follow-up questionnaire evaluated the Global Response Assessment, percentage of pain improvement, satisfaction with device, and initial and current settings of the device (h/day of stimulation). Results Thirteen patients had the StimWave® lead placed at the pudendal nerve, 12 (92%) female and 1 (7.6%) male. Mean age was 50 years (range: 20-58). Failed prior therapies include medical therapy (100%), pelvic floor physical therapy (92%), pudendal nerve blocks (85%), pelvic floor muscle trigger point injections (69%), neuromodulation (30.7%), or surgeries for urogenital pain (23.1%). After the trial period, 10/13 (76.9%) had >50% improvement in pain with 6/13 (46.1%) reporting 100% pain improvement. Nine underwent permanent lead placement. At last postoperative visit (range, 6-83 days), 5/9 patients reported >50% pain improvement. Seven patients reached for phone calls (22-759 days) reported symptoms to be "markedly improved" (n = 2), "moderately improved" (n = 4), or "slightly improved" (n = 1). At follow up, complications included lead migration (n = 2), broken wire (n = 1), or nonfunctioning antenna (n = 2). Conclusion Complex patients with pudendal neuralgia may benefit from pudendal nerve stimulation via StimWave®.

A large population of both males and females is affected by sexual dysfunctions, while presently existing treatments have several drawbacks. Novel electroceutical approaches could be promising alternatives. Genital arousal is known to be controlled by autonomic and somatic activity. Most of the nerve fibers involved in these processes origin from the second to fourth sacral nerve, namely the efferent parasympathetic fibers and the afferent sensory fibers carrying the stimuli responsible of triggering reflex arousal, later forming the pudendal nerve. The latter is a reasonable target for implants since it follows a repeatable course and can be exposed via well-known surgical approaches. We compared existing implantable electrodes, the Interstim quadripolar lead and a multipolar cuff, in terms of thresholds and selectivity, which are the first requirement to deliver effective stimulation without inducing pain, spasms, or other collateral phenomena. We employed a hybrid modeling approach: the target nerve was 3D-modeled on real histological cross-sections. FEM modeling was performed to simulate current injection into the fascicles. The fascicles were then populated with compartmentalized axons and neurophysiological simulations using the MRG model were performed. We estimated whether, and at which injected charge level, each axon fired along its length and computed parameters of interest, resulting in hints to guide the development of a future bioelectronic solution.

Epidural spinal cord stimulation (SCS) has recently been reported as a potential intervention to improve limb and autonomic functions, with lumbar stimulation improving locomotion and thoracic stimulation regulating blood pressure. We asked whether sacral SCS could be used to target the lower urinary tract. Here we show that high-density epidural SCS over the sacral spinal cord and cauda equina of anesthetized cats evokes responses in nerves innervating the bladder and urethra and that these nerves can be activated selectively. Sacral epidural SCS always recruited the pelvic and pudendal nerves and selectively recruited these nerves in all but one animal. Individual branches of the pudendal nerve were always recruited as well. Electrodes that selectively recruited specific peripheral nerves were spatially clustered on the arrays, suggesting anatomically organized sensory pathways. This selective recruitment demonstrates a mechanism to directly modulate bladder and urethral function through known reflex pathways, which could be used to restore bladder and urethral function after injury or disease.

BackgroundCircumcision is a surgical removal process of the preputium. Surgical excision and electric current cause neurodegeneration in the excised tissue-related neural network. This study investigates if circumcision and current surgical methods would cause histopathological changes in the penile tissue innervating pudendal nerve dorsal root ganglia.ResultsVascular congestion occluded the microvessels, and degenerative changes were detected in postexcised penile tissue. Neuronal angulation, cytoplasmic condensation, nuclear shrinkage, and condensed nuclei were observed in the pudendal nerve ganglia. Moreover, the degenerated neuron (DN) densities of the pudendal nerve ganglia were 5 ± 2, 98 ± 22, 1093 ± 185, 236 ± 43 and 151 ± 19 in the control, the surgical circumcision, the monopolar cautery, the bipolar cautery and the thermocautery groups, respectively.ConclusionsAlthough only the pudendal nerve endings are affected secondary to prepusium excision another pudendal axons can be damaged during bleeding control with cautery, the destruction of the neuron that sends this axon initiates a general inflammation in that ganglion. As a result, there may be a somatosensitive innervation defect in extrapenile tissues innervated by this ganglion. High-voltage electric devices should not be used unless obligatory.