The
Pudendal Nerve
www. pudendal .com
Groupement
Européen de Périnéologie (GEP)
Last Update: December 24th, 2007.
In Memoriam
It is with a profound sense of sadness that we are giving you
knowledge of the
untimely death of our Honour President:
Ahmed Shafik, MD., PhD.
Professor of Surgery and Experimental Research
Cairo, Egypt.
A lot of his anatomical and physiological research on pudendal neuropathy
and levator ani muscles are keystones in Perineology.
We have lost a great scientist and a kind man.
Thank you Professor Shafik
Is it a website for me ?
You have (or your patient has)
pain while
sitting, during intercourse, after ejaculation or in your anus without
reason.
You have incontinence
for stool, gas or
urines.
You have vulvodynia, persistant sexual arousal,
or impotence.
Your problems began after biking, a fall on the
coccyx, a delivery, a surgery in the area, a pelvic trauma.
Maybe you have a "pudendal
neuropathy".
(other names: "pudendal canal syndrome"
or "pudendal nerve entrapment").
The aim of this website is to inform patients
and physicians about this frequent but usually unknown disease.
Contents
Pudendal
neuralgia, pudendal neuropathy and pudendal canal syndrome (PCS)
Compression or stretching (if there is
an abnormal perineal descent) of the pudendal nerve in the Alcock's canal and/or in the "clamp"
between the sacro-spinal and the sacro-tuberous ligaments can
induce the so called "pudendal canal syndrome" (PCS) or "pudendal neuropathy"
or "pudendal nerve entrapment" (PNE) described by
Professor Ahmed
Shafik in 1991.
The "pudendal canal
syndrome" includes:
- perineodynia (pain)
- hypo or hypersensibility of the perineum
- anal
incontinence
- urinary incontinence
- impotence
- probably also: cystalgia, frequency, sexual arousal
syndrome, painful ejaculation...
Pudendal neuralgia (only
one part of the pudendal canal syndrome) has been
described as a very severe pain on one side of the perineum typically increased during
sitting and reduced on a toilet seat.
But the pain (perineodynia) produced by pudendal neuropathy can be different:
- proctalgia
: repetitive acute anal pain of short duration
- bilateral pain
- light pain or itching on one side of the perineum without visible skin disease
(at the beginning)
- vulvodynia
- dyspareunia
Causes:
- bicycle (the most classical
one)
- fall on the coccyx
- constipation with dyschesia (induces perineal descent)
- delivery
- pelvic trauma
- traction on the pelvis during orthopedic
surgery
- sacro-spinal fixation
Diagnosis:
- Typical history: pudendal
neuropathy must be searched in each perineological examination
- Clinical examination:
-
three
clinical signs: asymetry of sensibility
positive "skin rolling test"
pain at the level of the pudendal nerve
-
perineal descent (more
than 2 cm with a
Perineocaliper) increases the risk of PCS
- EMG exploration
- Warm detection
threshold
- Exclusion of other diagnosis
Different treatments are available:
- self-care with a
"perineal suspension pad"
- avoiding activities which aggravate the pain (cycling, hip
flexion...)
- drugs (amitriptyline, Neurontin, Lyrica)
- infiltrations with corticoids and anaesthetic (under finger,
electrostimulation, CT-scan
or ultrasound control)
- physiotherapy
- surgery
- neuromodulation
Pain (perineodynia) in this area is not always a
pudendal neuralgia. Some other causes can explain the pain or increase the
pudendal neuralgia:
- coccygodynia
- piriformis
syndrome
-
interstitial
cystitis
-
myofascial trigger points
- connective tissue restrictions and adverse neural tension
-
sacro-iliac joint dysfunction
- puborectalis
overload
- radiculopathy
(disco or vertebro-radicular conflict in L4-L5 and/or L5-S1.
The
pudendal nerve anatomy
The anatomy
described in this figure is the result of the confrontation between the litterature and dissections done
by members of the Groupement
Européen de Périnéologie
Videos of dissections
are presented on www.Perineology.TV
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Legend:
1. Sacro-spinal ligament
2. Sacro-tuberous ligament
3. Alcock's canal with the
pudendal nerve
4. Nerve of the clitoris (not in the Alcock's canal)
5. Perineal branch of the pudendal nerve
6. Inferior rectal nerve
7. Arcus tendineus fascia pelvis
8. Obturator muscle
9. Piriformis muscle
S2, S3 and S4: sacral roots forming the pudendal nerve
|
The rectal nerve is separated from the pudendal nerve between
the ligaments in 50 %
of the cases and is going through the sacro-spinal ligament in 15 % of the
cases (Mahakkanukrauh
et coll.).
When it is separated form the pudendal nerve,
the rectal nerve passed through the posterior fibers of the sacro-spinal
ligament at a mean distance of 19 mm from the ischial spine. The pudendal nerve
passed posterior to the sacro-spinal ligament at a mean distance of 6 mm in 80
% of the cases and under the ischial spine in the remaining 20 % (Grigorescu,
IUGA meeting Athens 2006).
The levator ani nerve originates from S3 and S4. It runs on
the levator plate from 3 to 20 mm medial to the ischial spine
(Wallner et coll.). It is partly responsible of the innervation of
the levator plate. The integrity of this muscle is necessary to avoid perineal
descent and its sides effects.
|
 |
Legend:
Right side of the pelvis:
1. Levator ani nerve: it runs on
the levator plate 3 to 20 mm medial to the ischial spine
2. Ischial spine
3. Sacro-spinal ligament
4. Levator plate
5. Pudendal nerve: the needle shows the beginning of its course
under the sacro-spinal ligament (6 mm from the ischial spine
in the average) |
The pudendal nerve, the rectal nerve and the levator ani nerve
could be theoretically damaged during certain surgical procedures like
sacro-spinal fixation or section of the sacro-spinal ligament without visual or
finger control of the nerves.
What is the best
surgical approach to
treat pudendal neuropathy ?
This question is until now
difficult to answer. The results on pain seem to be similar between the
differents approaches but no randomized controlled study is available. Up to now there are
3 differents approaches:
- the transperineal
approach described by Shafik: the incision is 4 cm long between the
anus and the ischial bone. Initially this procedure only opens the
Alcock's canal (not the "clamp" between the ligaments). More recently, it has
been demonstrated that the
opening of the fascia linking the sacro-spinal and
the sacro-tuberous ligament is possible by this approach and is sufficient to
open the "clamp" between the ligaments.
- the transgluteal
approach described by Robert: the incision is 10 cm long and
located in the buttock.
- the transvaginal
approach described by Bautrant: in the women the nerve is
approached vaginally. In the men, the incision is in
front of the anus. The dissection is conducted in front of the rectum and then
moves laterally. The levator plate must be retracted or cut to access the Alcock's
canal.
Comparison of the 3
procedures
|
Approaches |
Trans-perineal |
Trans-gluteal |
"Trans-ischiorectal" (*) |
| Incision size |
small |
large |
small or intra-vaginal |
| Incision images |
 |
 |
 |
| Nerve under control during
dissection |
finger |
visual |
no |
| Access to the pudendal
canal |
+++ |
+ |
+ (if section or
retraction of the levator plate) |
| Access to the sacro-spinal
ligament |
++ |
+++ |
++ |
| Opening of the "clamp"
between the 2 ligaments with or without section of the sacro-spinal
ligament |
without |
with |
with (partial) |
| Incision of the gluteal
muscle |
no |
yes |
no |
| Retraction or section of the levator
plate to access the Alcock's canal |
no |
no |
yes |
| Effect on anal and urinary
incontinence |
yes |
yes |
yes |
| Shortcomings |
Blind procedure =>
difficult to learn and to teach. |
The ligament section could induce:
- in the long term some rhumatological troubles in
the pelvis (overload on the other side or on the sacro-iliac
joints).
|
* The ligament section
could induce: - in the long term some rhumatological troubles in
the pelvis (overload on the other side or on the sacro-iliac
joints)
- lesion of the levator ani nerve or of
the rectal nerve
* Risk to damage the levator plate to
access the Alcock's canal.
|
(*) Wrong name in the women because if the surgeon operates
through the vagina the approach is para-rectal (over the levator plate) and not
going through the ischio-rectal fossa.
The pudendal
nerve: powerpoint presentation or videos
|
Click
on the image to open the powerpoint
presentation |
Titles |
Authors and
references of the meeting |
 |
1. Pudendal nerve anatomy
(2min)
2. Decompression of
the pudendal nerve (2min) |
2 videos
without sound ("realplayer")
User: "cairo", Key:"ultrasound"
|
 |
A new approach to the
physical therapy management of chronic pelvic pain (Pdf file 350
k) |
Patricia Rummer (USA), Cairo,
Egypt, MSPFD, 2007 |
|
|
Post-Operative
Rehabilitation Protocol Following Pudendal Nerve Decompression(Pdf
file 580 k) |
Stephanie Prendergast(USA),
Cairo, Egypt, MSPFD, 2007 |
 |
Les algies périnéales (Pdf
file 623 k) |
Catherine Lukowski M.D (Belgium),
Verviers, Belgium, 2006 |
 |
New approach
for treatment of pudendal nerve entrapment |
Eric
Bautrant M.D. (France): Tripartite meeting (GEP, MSCP and MSPFD),
Sharm El Sheikh, Egypt, 2004 |
|
PNE surgery:
intra-operative EMG
For PDF (680 k): click here
|
Eric de
Bisschop M.D. and Eric Bautrant M.D. (France). Tripartite meeting (GEP, MSCP and MSPFD),
Sharm El Sheikh, Egypt, 2004 |
 |
Pudendal
nerve decompression in the treatment of proctalgia |
Professor Olfat El Sibai
(Egypt): IPFDS Taormina, Italy, 2002 |
 |
Traitement
de la douleur périnéale et de l'incontinence par la décompression
du nerf pudendal (in French) |
Jacques Beco
M.D.(Belgium) and Jack Mouchel (France): GEP, Spa, Belgium, 1998 |
Relevant
meetings on the subject
Forthcoming
meetings:
| Link |
Title |
Date |
City |
Country |
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If
you have informations about meetings where the issue of pudendal neuropathy will
be discussed, don't hesitate to contact
us.
Abstracts
from the past meetings:
| Link |
Title |
Date |
City |
Country |
 |
31st meeting of the International
Uorgynecological association. Workshop 8: To
diagnose and to treat pudendal neuropathy: a new challenge in
Perineology
Read the abstract |
September 6-9, 2006 |
Athens |
Greece |
 |
7ème congrès de Gynécologie, Obstétrique et Périnéologie
Diagnostiquer et traiter la neuropathie pudendale, un
nouveau défi pour le périnéologue.
L'agenda Gynécologie n°45, octobre2006 (pdf, 230 ko)
De
Agenda Gynaecologie nr46, october 2006 (pdf, 206 ko) |
May 25-28, 2006 |
Vittel |
France |
|
Tripartite
meeting (GEP, MSCP, MSPFD)
Abstract
from the GEP's speakers (pdf, 129 ko)
|
March 25-27, 2004 |
Sharm El Sheikh |
Egypt |
|
Périnéologie: Comprendre
le syndrome d'Alcock (incontinence urinaire, incontinence anale et douleur) et son traitement
L'Agenda
Gynécologie n°32, juillet 2003 (pdf, 132 ko) De
Agenda Gynaecologie nr 32, juli 2003 (pdf, 416 ko) |
May 15, 2003 |
Verviers |
Belgium |
|
1st Congress of the
Mediterranean Society of Pelvic Floor Disorders
Read the abstracts from:
1. Professor Olfat El Sibai
Pudendal canal decompression in the
treatment of proctalgia
2. Jacques Beco M.D.
Perineology: evaluation of pudendal
nerve decompression in the treatment of the pudendal canal
syndrome. Experience with 75 bilateral decompressions according to
Shafik.
|
October 24-26, 2002 |
Cairo |
Egypt |
Publications
or relevant readings from the GEP's members
Dr J. Beco and Dr
J. Mouchel
1.
Intérêt de la décompression du nerf pudendal pour le chirurgien
périnéologue (pdf, 760 ko)
2.
Traitement de la douleur périnéale et de l'incontinence par la décompression chirurgicale du nerf
pudendal (pdf, 464 ko)
3.
Pudendal nerve decompression in perineology : a case series (BMC Surgery
2004)
4.
Levatorplasty according to Shafik : a basic
procedure in Perineology ? (pdf, 721 ko)
5. Transperineal pudendal
nerve decompression with opening of the fascia linking the sacro-spinal and the
sacro-tuberous ligament. Feasibility study and first results in perineology
(pdf, 220 ko)
6. Décompression complète du nerf
pudendal par voie périnéale. Etude de faisabilité et premiers résultats (pdf,
226 ko)
Dr
G. de Bisschop G. and Dr E. de Bisschop
1. Considérations sur la physiopathologie canalaire du nerf pudendal (pdf, 357
ko)
2.
Le réflexe sacré : son intérêt
en neuropathophysiologie clinique périnéale (pdf 87 ko)
Dr Rajeshree Nundlall
Preliminary study on Doppler
ultrasonography of internal Pudendal Vessels in pudendal neuralgia (pdf, 132 ko)
Dr J.P. Spinosa et al
Les réflexes sacrés étagés dans
l'étude de la névralgie pudendale: validation anatomique
(pdf,702 ko)
De l'importance de l'anatomie
(pdf, 558 ko)
Websites
about pudendal neuralgia
1.
http://www.spuninfo.org
2. http://www.pudendal.info
3. http://www.pudendalnerve.info
4. http://www.tipna.org
5. http://www.pudendo.it
(in italian)
6.
http://pageperso.aol.fr/nerfpudendal/index.htm
(in french, en français;
association de patients)
7.
http://www.pudendalsite.com
(in french, en français, site réalisé par des
patients)
The Perineology webring
1. www.perineology.com
: is the main website giving the definition of this new approach of the female
perineum called Perineology.
2.
www.ultrasonography.org : practical
approach of ultrasound in Perineology. 3.
www.vaginaltape.com :
treatment
of stress urinary incontinence with a small mesh. 4.
www.urgeincontinence.com
: another
approach of urge incontinence. 5.
www.monaccouchement.com :
everything about childbirth for the future mothers (in French).
6. www.perineology.TV
: the videos of our webring are available on streaming (RealPlayer) on behealth.TV
the Belgium Medical web TV.
Contact
us
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If
you have a comment or a question about this subject click
here to send it to the webmaster of www.pudendal.com
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