Cutting the Perineal Branch

[jon]

My surgeon says he can cut the perineal branch of my pudendal nerve.

He already cut my genitofemoral nerve. It was trapped in scar tissue from my vasectomy, but cutting it made very little difference in my pain level. When I am resting, the pain is less, but once I start moving around, or get the least bit stressed, the pain becomes really bad again.

I previously had an epididectomy and an orchiectomy, all on the left side. I still have horrible pain in the perineal area and my trigger point is the left underside of the scrotum.

Has anyone here ever heard of cutting this nerve? I am totally stoked to have some hope again, but the surgery is really expensive and I would like to find others who have been helped by cutting this branch of the nerve.

I am going to ask my pain doctor if he can try a pain block before my surgery date.

All opinions are welcomed!

[AliPasha1]

Hi Jon,
Who cut your respective nerves.What is he saying about your symptoms after your first surgery regarding the genitalfemoral nerve.

I am not sure that it is a good idea to cut every nerve in the Pelvis.

Kind Regards,
Ali

[nyt]

Hi Jon,

I looked at some of the published anatomical literature and below I put together direct quotes with references.

”The perineal branch exits from the distal portion of the pudendal canal before splitting into the superficial perineal and deep perineal nerves. The superficial perineal branch supplies sensation to the perineum and posterior aspect of scrotum or labia. The deep perineal branch of the perineal nerve provides motor supply to the bulbocavernosus, ischiocavernosus, superficial and deep transverse perineus, and sphincter urethrae muscles.”[1, 2]

“The pudendal canal syndrome has a similar range of symptoms, but also includes urethral sphincter insufficiency because the external urethral sphincter is innervated by the perineal branch of the pudendal nerve.”[3]

“The pudendal nerve originated from the S2 to S4 foramina, exited the pelvis through the greater sciatic foramen, traversed Alcock's canal, and branched to innervate the external anal sphincter, the external urethral sphincter, the perineal musculature, the clitoris, and the skin.”[4]

1. Ramsden, C.E., et al., Pudendal nerve entrapment as source of intractable perineal pain. Am J Phys Med Rehabil, 2003. 82(6): p. 479-84.
2. Robert, R., et al., Anatomic basis of chronic perineal pain: role of the pudendal nerve. Surg Radiol Anat, 1998. 20(2): p. 93-8.
3. Mahakkanukrauh, P., P. Surin, and P. Vaidhayakarn, Anatomical study of the pudendal nerve adjacent to the sacrospinous ligament. Clin Anat, 2005. 18(3): p. 200-5.
4. Barber, M.D., et al., Innervation of the female levator ani muscles. Am J Obstet Gynecol, 2002. 187(1): p. 64-71.

The major question is which branch of the pudendal nerve is being cut. From my understanding because the superficial branch appears to be involved in sensation the only thing that potentially could happen is to feel numb in that area but those areas also have other nerves that are invovled in sensation. For me, the bigger concern is cutting the deep perineal nerve because from the anatomical literature it has motor function. To me, if you cut that nerve you could potentially end up with some type of incontinence issues because it controls the motor function to the urethra. This is a very important question to ask the surgeon as you don't want to end up with incontinence issues because the inability to be able to control the sphincter. You have references above from peer reviewed journals that you can give to the surgeon with your questions supporting any concerns you are having.

[Lernica]

Well done, NYT!

[jon]

Dr. Dellon cut my genitofemoral nerve. I see him again in a couple weeks to evaluate my condition and then operate, if it is indicated.

This is the first I have heard about the deep perineal nerve affecting the urethra. if I knew for sure it would end my pain, I think I'd be willing to take the chance. Maybe the pain you guys are dealing with is not disabling, but I have been unable to work for 7 months and have a big family and a big mortgage. I want my life back.

My trigger point is on the underside of the scrotum on the left side. Does anyone know if there is a way to tell if the pain is the deep or the superficial perineal branch? Can a needle probe be inserted and electrically stimulated?

The only way I can imagine determining which nerve to cut is to be awake (but sedated) during part of the procedure. If he can get the the superficial nerve and stimulate it, I will know if that is the right nerve.

I have a Hibner appointment in November, but decompression results I have seen are not impressive. I would rather cut a nerve and be pain-free again.

[A's Mommy]

Jon,

I second everything that NYT said. The deeper perineal branch, that comes off the main pudendal trunk at the distal end of the Alcock's canal, DOES INDEED serve motor function in opening and closing the external urethral sphincter. I would make sure that it is a superficial perineal branch, such as in the PBPFCN. I'm sure Dr. Dellon knows the difference, he is a very adept surgeon.

Wishing you the BEST, God bless, and pain free days ahead!

A's Mommy

[nyt]

Jon, we all understand how disabling this pain is because we all live with it and we all hate ever second of it. I have been disabled for 3 years and like you want my life back. It is difficult to balance the potential consequences, both known and unknown, when one is deciding to have surgery.

Have you had an MRI by Dr. Potter? That might be a good thing to look into. She would might be able to determine if there are other nerves such as ilioinguinal involved in your pain and where exactly you are entrapped with the pudendal nerve.

It is so hard when we all want to get well so badly that we must take care to investigate all the possible complications which you are doing by asking questions on this board. All these doctors want to really help us and make us well but they don't know everything either. Continue to question and trust your gut instincts as they will never let you down.

Good luck. Prayers are sent your way.

[nyt]

I saw Dr. Howard today for an appointment and asked him about cutting the perineal branch. He said the internal urethra sphincter is controlled by the sympathetic nervous system and the external urethra sphincter is controlled by the parasympathetic nervous system. He said that if you cut the branch to the external urethra sphincter you could potentially not be able to void and could possibly lose voiding sensation. The concern is NOT incontinence but urinary retention! I asked him what other nerves are involved in the voiding process as it is a rather interesting process which I hadn't looked at in several years otherwise I would have remembered what Dr. Howard told me and he said he knew that the pudendal nerve was the main control for relaxation of external sphincter. I also asked if the contralateral side could compensate for the loss and he did not know. He was also concerned about muscle deinnervation but that would all be dependent on where the nerve was cut. He said Dr. Dellon was going to be at the International Pelvic Pain Society and was looking forward to Dr. Dellon's presentation and to see what Dr. Dellon's thoughts were on cutting the perineal branch.

[jon]

I had Dr. Dellon cut the perineal branch of my pudendal nerve several months ago. I was up and walking the next day with what I figured must just be surgical pain. It wasn't.

Although my primary trigger point had been in my left perineal area, and that spot is just barely tender now, my left testicle pain (pre-and post orchiectomy) persists.

I've had no real new urinary issues. My urologist found prostate cancer when trying to find the source of my pain, so I have had a prostatectomy. There is minimal numbness in perineal area. Dr. Dellon said that is because I still have my posterior femoral cutaneous nerve and inferior cluneal nerves.

I flew out the day after my surgery and experienced unbelieveable swelling in my penis due to the pressure change in the plane. Scary, but it went away after a while. My main complaint is that I have had major penile shrinkage. Not sure if that is from the surgery, but it's certainly new.

Right before I left to have the surgery, I went in for a nerve block with my pain doc. I had intended to have him block the left posterior cutaneous femoral nerve, thinking that if it DIDN'T help, I'd be confident the pudendal nerve was the problem. I'd had the pudendal nerve blocked once before, but he used so much of the numbing agent that my hwole left leg went numb. At that time, the thinking was that my problem was pelvic floor dysfunction. That meant that I didn't pay all that much attention to the pain I was feeling and was focused on rushing to see my PT and see if I felt and different internally to her, which I really did not. At the time of the second block the doctor said if it was him he would numb the pudendal nerve to prove the surgery was likely going to help. So I did that and my pain was gone. GONE! For the first time in three years! I even ran into a McDonalds just to sit on their hard plastic chairs to see what it felt like to not be in pain! Of course, that relief only lasted for a couple of hours.

Long story shortened - I am glad I had the $15,000 (out-of-pocket) surgery.When I have really bad days, I remember what bad days used to be like. The knife in the perineum pain is less, but I still have that damned constant ache and the sharp pain that feels like it is going into my soul.

A few weeks ago, I had my first ever bout of sciatica. The sciatic pain was really bad for a few days, but as it lessened I noticed the left side of my left foot and left heel had gone numb (S1), and has stayed numb. I know from a 2009 Lumbar MRI that I have a bulging (toward the spine) spinal disc at the L5-S1 location. I repeated the MRI and it showed the L5-S1 nerve is causing "mild left neural foraminal narrowing". My next two higher discs now have small bulges as well.

It was very interesting to read the part of the post by nyt that said: “The pudendal nerve originated from the S2 to S4 foramina, exited the pelvis through the greater sciatic foramen, traversed Alcock's canal, and branched to innervate the external anal sphincter, the external urethral sphincter, the perineal musculature, the clitoris, and the skin.”, I thought the pudendal nerve originated as L5-S1???

My pain doc is of the opinion that since the nerve block he did (where I was pain free) was away from the spine, that the source of pain was PROBABLY further away from the spine than the injection point. He said he has always wondered if enough of the numbing agent was able to seep back toward the spine.

I went to DiagnosisPro.com, a very interesting website that provides differential diagnosis techniques for single or multiple symptoms. I came up with two potential causes for BOTH sciatica and unilateral testicle pain: (1) Piriformis Syndrome, and (2) Ischial Tunnel Syndrome.

Both are diagnosed by EMG using something called the FAIR Test - Delay of H-reflexes in flexion. adduction and internal rotation.

Apparently, 15% of all people have their sciatic nerve pass through the piriformis muscle. (I've already tried botox in my left piriformis muscle but got no relief.)

Ischial Tunnel Syndrome involves entrapment of the sciatic nerve as it passes by the ischium. "The pudendal nerve may be separately involved". Reference http://www.sciatica.org.

I am going to see an osteopathic doctor about this next week.

I started a new topic regarding the FAIR test.

http://www.pudendalhope.info/forum/view ... =36&t=3605

[Violet M]

Hi Jon,

Just checking in and wondering how your appt. went with the ostepathic doc.

It's interesting that Dr. Dellon would cut the perineal nerve. I had always heard that you would likely just have phantom pain afterward and that the nerve could regrow abnormally. Did Dr. Dellon address any of those issues before he cut the nerve?

Violet