Abstract
Purpose When pudendal nerve dysfunction fails to improve after medical and pelvic floor therapy,
a surgical approach may be indicated. “Traditional,” “posterior,” transgluteal nerve
decompression fails in an unacceptably high percentage of patients. Insights into
pudendal neuroanatomy and pathophysiology offer improved microsurgical outcomes.
Methods To evaluate results of a peripheral nerve approach to the pudendal nerve, 55 patients
were prospectively evaluated. This cohort included 25 men and 30 women. Surgical approach
was posterior, transgluteal if symptoms included rectal pain; or “anterior,” inferior
pubic ramus approach if symptoms excluded rectal pain. Surgical approach was “resection,”
if trauma created a neuroma, and “decompression,” if there were no neuroma. Effect
of comorbidities was analyzed.
Results At 14.3 months postoperatively, untreated anxiety/depression correlated with outcome
failure, regardless of surgical approach, p < 0.002. There was no difference in results, men versus women, “anterior” versus
“posterior” approach, or neuroma resection versus neurolysis. Success correlated with
the “learning curve” of the surgeon. Self-rated success was significantly better (p < 0.0001) for patients operated on during the second year of the study than the first
year of the study, and improved again in the final year of the study (p < 0.04), with 86% of the patients in final year achieving an excellent result and
14% achieving a good result.
Conclusion There is hope for surgical relief from pudendal nerve problems by distinguishing
neuroma from compression in the diagnosis, and then choosing a site-specific surgical
approach related to which pudendal nerve branches are involved.
Keywords
pudendal nerve - neurolysis - neuroma
