Pudendal Nerve Decompression Surgery

Pudendal nerve decompression surgery is an option that is usually considered after more conservative therapies such as lifestyle changes, pelvic floor physical therapy, and nerve blocks have not proven to be successful. In the published literature PNE surgery can achieve a success rate of anywhere from 60% to 85% but success does not necessarily mean a cure. Surgery is generally considered successful if there is at least a 50% reduction in pain and symptoms. Occasionally pain and symptoms are permanently worse after surgery therefore the decision should be made carefully. 
There are five basic approaches to pudendal nerve decompression surgery but only four of them have been described in the peer-reviewed literature. The five approaches are the transgluteal approach, the trans-ischiorectal fossa approach, the perineal approach, the laparoscopic approach, and the dorsal nerve approach. 
Transgluteal (TG) approach
The transgluteal approach was first described in the literature by Professor Robert in France and is probably the most widely used method of decompression surgery offering the greatest visualization of the nerve during surgery. The incision is made in the buttocks through the gluteal muscles on one side for unilateral surgery or both sides for bilateral surgery. The sacrotuberous (ligament (ST) is windowed and stripped from muscular attachments and the sacrospinous (SS) ligament is divided releasing any compression at the ischial spine. If the ischial spine is abnormally elongated sometimes it is partially shaved off. Some surgeons transpose the nerve slightly to prevent future stretch on the nerve. The Alcock’s canal is explored with the help of a small instrument or the surgeon’s finger and the nerve is released from any fascia that might be tethering it. Some surgeons use a modified version of the TG approach and avoid cutting the ligaments as much as possible. This results in less visualization of the nerve. One surgeon who performs the TG approach replaces the severed ST ligament with cadaver tissue. 
Advantages of TG approach
Best visualization of the nerve
If the nerve is entangled in the ST ligament there is access to release it from the ligament
Disadvantages of TG approach
Relatively large incision
Possible post-operative pelvic instability from severed ligaments
TG surgery publications
Pudendal Nerve Entrapment by Prof. Robert
TG surgery photo
Trans-ischio-rectal-fossa (TIR) approach
The TIR approach was first described in the literature by Dr. Eric Bautrant in France.
For women a small incision is made in the back of the vagina about half-way up. For men the incision is in the perineal area between the scrotum and anus. In most cases the surgeon severs or partially severs the sacrospinous ligament to release the compression between the ST and SS ligaments. The Alcock’s canal is explored by the surgeon’s finger and the nerve released from any fascia that might be tethering it. 
Advantages of the TIR approach
Smaller incision
Spares the ST ligament
Disadvantages of the TIR approach
Less visualization of the surgical area
No access to the ST ligament if the nerve is entangled in that ligament
TIR surgery publications

Notes on Violet's Conversation with Dr. Andrew Elkwood 

Dr. Elkwood's concern is that physicians may take an approach that is too compartmentalized when diagnosing the cause of pelvic pain rather than considering all of the possible causes.  Pudendal neuralgia may be just one of the factors contributing to the patient's pain.  


Perineal approach
In the perineal approach described by Prof Ahmad Shafik a small vertical incision is made in the perineum between the anus and sit bone on one side for unilateral surgery or both sides for bilateral surgery and the surgeon uses a finger to free up the nerve in the Alcock’s canal. For a modified perineal approach the surgeon also uses the tip of the scissors and finger to open up the fascia between the SS and ST ligaments.
Advantages of perineal approach
Least invasive
Spares all ligaments
Disadvantages of perineal approach
Least visualization for the surgeon
Unless modified, does not deal with entrapments at ischial spine
Difficult or impossible to free nerve from entanglement with ligaments
Perineal surgery publications
Laparoscopic approach
Laparoscopic surgery is a minimally invasive surgery that requires three small incisions. A tube called a laparoscope attached to a video camera is inserted through an incision in the belly button. Two additional incisions are made at the pubic hairline through which tiny instruments and items such as sutures can pass.
During laparoscopic surgery the sacrospinous ligament may be severed allowing visual access of the nerve at the ischial spine and Alcock’s canal. The nerve is freed from scarring, fibrotic tissue, and swollen varicose veins. A solution of heparin may be infused into the area to prevent scar tissue from forming. Manipulation is minimal and usually patients can go home within 24 hours.
Laparoscopic surgery publications
Demonstration of a released left pudendal nerve during laparoscopic surgery with transposition and covering with omental flap to prevent refibrosis and re-entrapment.

Video Courtesy of Dr. Tibet Erdogru
What to Expect Before and After Surgery
Most of the PNE surgeons require that you have a series of nerve blocks prior to deciding to have surgery. If the nerve blocks do not provide permanent relief and you decide to have surgery the most important thing to remember is that the recovery period takes time.
Usually pudendal nerve decompression surgery is performed under general anesthesia and there is a 1 to 4 day hospital stay afterward, depending on the procedure you have. Often you will have a urinary catheter in place temporarily. Some of the surgeons put in temporary drains, marcaine pain pumps, or vaginal packing. If there are no complications you can be up and walking around the day after surgery. If you traveled a long distance for your surgery it will be necessary to stay in a nearby hotel for a few days after surgery until your surgeon determines that it is safe for you to return home.
Many people find soft gel ice packs very helpful during the recovery period. It is a great anti-inflammatory and it also helps to numb a painful nerve. 
It is important not to become constipated after surgery so that you do not put additional strain on the nerve. This can be a challenge if you are taking opioids for pain relief. Please refer to the section on constipation on this website for ideas on how to prevent constipation. 
For patients who have incisions in the vagina or perineal area it is important to keep these very clean to prevent infection. 
Typically sex can be resumed 6 weeks after surgery if there are no complications but you should follow the instructions given by your surgeon.
Most people require pain medications for many months after surgery. Pudendal nerve surgery is not the same as most surgeries because nerves take a long time to heal. You may feel new pains or increased pain temporarily as you recover. Many people experience shock-like pain as the nerve is regenerating, especially around the 3 to 4 month point. Often the recovery takes at least a year and many patients have reported improvements as late as 2-3 years after surgery. Some people return to work several months after surgery although most are not completely pain-free yet and require the use of special stand-up workstations and cushions.   
Often many pelvic muscles are in spasm pre-operatively as well as post-operatively. Many patients find physical therapy from a pelvic PT specialist helpful after surgery to get their muscles back into a relaxed state. Most of the surgeons recommend PT be avoided for at least a month after surgery. Swimming is considered an excellent exercise although the breast stroke or frog kick should be avoided.
As you can see, PNE surgery is not an easy surgery to recover from. Published statistics show that between 60% and 80% of patients have at least a 50% improvement in symptoms although there are some people who have reported a worsening in symptoms.


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