The Pudendal Nerve

www. pudendal .com

Groupement Européen de Périnéologie (GEP)

Last Update: December 31rd, 2012

 


 

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.


ICS - IUGA meeting Toronto (August 2010)

 to see the webcast, click on this


pelvis3d-bannière

Basic pudendal nerve anatomy is included in this dvd.

To see pudendal nerve stretching during perineal descent on youtube (free sample), click here


Contents

 

1.Pudendal neuralgia, pudendal neuropathy and pudendal canal syndrome (PCS)
 
2. The pudendal nerve anatomy
 
3. What is the best surgical approach to treat pudendal neuropathy ?
 
4. The pudendal nerve: powerpoint presentation or videos
 
5.  Relevant meetings on the subject 
 
6.  Publications or relevant readings from the GEP's members
 
7. Websites about  pudendal neuralgia
 
8. The Perineology webring 
 

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
- cystalgia

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"  or a U-shapped cushion
-  avoiding activities which aggravate the pain (cycling, hip flexion...)
-  drugs (amitriptyline, Neurontin, Lyrica)
-  diet (vitamine D if necessary; take anti-oxydants and omega 3, reduce dairy produce...)
-  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:

- vitamine D deficiency

- Tarlov's cyst
- coccygodynia
- piriformis syndrome 
- interstitial cystitis
- myofascial trigger points
- connective tissue restrictions and adverse neural tension
- sacro-iliac joint dysfunction

- descending perineum syndrome

- 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

The pudendal nerve anatomy

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

Right side of a female pelvis: levator ani nerve

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. If necessary it is possible to cut the sacro-spinal ligament (Shafik 2007). This cut can be done under "pudendoscopy" (see the video)

- 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

 Trans-perineal

Trans-gluteal

Trans-ischiorectal

Nerve under control during dissection yes: finger yes: visual no
Access to the Alcock's canal +++ + +  (if section or retraction of the levator plate)
Opening of the "clamp" between the 2 ligaments with or without section of the sacro-spinal ligament with or without with with (partial)
Opening of the "clamp" between the 2 ligaments  with or without section of the sacro-tuberous ligament without with (some surgeon suture this ligament or use a graft to restore it)(**) without
Incision of the gluteal muscle no yes no
Retraction or section of the levator plate to access the Alcock's canal no no yes
Side effects If section of the sacro-spinal ligament risk of 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).  This risk is increased if the 2 ligaments are cut and not restored. (**)

 

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 because these nerves are not under control

Risk to damage levator plate to access the Alcock's canal because it is necessary to retract or cut this muscle to access canal

(*) Wrong name in the women because if the surgeon operates through the vagina the approach is para-rectal (over the levator plate) and is not going through the ischio-rectal fossa.

(**) Dr Antolak makes an incision in the axis of the sacro-tuberous ligament to reach the Ischio-rectal fossa. This incision is closed at the end of the procedure. Dr Hibner cut the sacro-tuberous ligament but  use a graft to restore it while closing the incision. The risk to induce sacro-iliac joint instability by these two modifications of the Robert's technique seems to be reduced. 

 


 

  The pudendal nerve: powerpoint presentation or videos

 

Click on the image to open the powerpoint presentation

Titles

Authors and references of the meeting

AARMOR Vichy 2012

Facing a pain or a functional trouble of the perineum, how can we make the differential diagnosis between pudendal neuropathy, arachnoiditis or symtomatic Tarlov’s cyst ?

Jacques Beco (Belgium), AARMOR, 2012

 

AARMOR Vichy 2012 Tarlov cyst: different outcomes in open and endoscopic exclusion (Pdf 2445 k)
Juan Jose Mezzadri (Argentina), AARMOR, 2012
Pudendal nerve perineural injections(Pdf 1700 k) Stanley Antolak(USA), ICS, 2011
Pudendal nerve decompression surgery: transgluteal technique
(Pdf 2190 k)
Stanley Antolak(USA), ICS, 2011
Pudendal neuropathy: diagnosis (Pdf 1480 k) Stanley Antolak(USA), ICS, 2011
Relevant anatomy of pudendal nerve and etiological factors of pudendal neuropathies (Pdf 800 k) Jacques Beco (Belgium), ICS, 2011
"Pudendoscopy" and its use during transperineal pudendal nerve decompression (Pdf 88 k)
See also: http://www.youtube.com/watch?v=cXrRFo7ffYE
Jacques Beco(Belgium), ICS, 2011
Workshop12: ICS/IUGA meeting Toronto 2010 Workshop 12: Pudendal Neuropathy and its Pivotal Role in Pelvic Floor Dysfunction and Pain
 
ICS-IUGA Meeting, Toronto (Canada) 2010
Chronic pain after Longo procedure (Pdf 700 k) Bruno Roche et coll. (Switzerland)
Convergence PP, 2009
Complex regional pain syndrome is a disease of the central nervous system (Pdf 404 k) Wilfrid Jänig (Germany)Convergence PP, 2009
Phoenix modification of transgluteal pudendal neurolysis (Pdf 2830 k) Michael Hibner (USA)Convergence PP, 2009
Outcomes of redo pudendal neurolysis (Pdf 933 k) Michael Hibner (USA)Convergence PP, 2009
Ultrasound guided procedures for pelvic pain (Pdf 617 k) Philip Peng (Canada),
ALS, 2009
Pudendal block (Pdf 601 k) Philip Peng (Canada),
Als,
2009
Urologic symptoms and Interstitial Cystitis in Pudendal Neuropathy
(Pdf 605 k)
Stanley Antolak (USA)
Als, 2009
Ilioinguinal neuropathy
(Pdf 1170 k)
Mark Conway (USA)
Als, 2009
AAVIS2008-meeting How can we win the war against pudendal neuropathy(Pdf file 933 k) Jacques Beco M.D. (Belgium), AAVIS 2008
Pudendal canal syndrome: overview  PPT 899 k Pudendal canal syndrome. Overview. Ahmed Shafik M.D. and Olfat El Sibai M.D. (Egypt), MSPFD, 2008.
Electroneurographic studies PDF 1310 k Electroneuromyographic studies in the diagnosis of pudendal entrapment syndrome (Pdf file 1310 k) Naglaa Gadallah M.D. (Egypt), MSPFD, 2008.
PND in overactive bladder  PDF 309 k Pudendal nerve decompression in the treatment of overactive bladder (Pdf file 309 k) Jacques Beco M.D. (Belgium), MSPFD, 2008
Physical therapy PDF 350 k A new approach to the physical therapy management of chronic pelvic pain (Pdf file 350 k) Patricia Rummer (USA), Cairo, Egypt, MSPFD, 2007
Post-op rehabilitation  580 k Post-Operative Rehabilitation Protocol Following Pudendal Nerve Decompression(Pdf file 580 k) Stephanie Prendergast(USA), Cairo, Egypt, MSPFD, 2007
Les algies périnéales. Pdf format Les algies périnéales (Pdf file 623 k) Catherine Lukowski M.D (Belgium), Verviers, Belgium, 2006
PPT about pudendal nerve decompression New approach for treatment of pudendal nerve entrapment  Eric Bautrant M.D. (France): Tripartite meeting (GEP, MSCP and MSPFD), Sharm El Sheikh, Egypt, 2004
PPT about pudendal nerve decompression 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
PPT about pudendal nerve decompression Pudendal nerve decompression in the treatment of proctalgia Professor Olfat El Sibai (Egypt): IPFDS Taormina, Italy, 2002
PPT about pudendal nerve decompression 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

 

       

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
Logo Mediterranean Pelvic Floor Dysfunction Society 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)

7. Interest of retro-anal levator plate myorrhaphy in selected cases of descending perineum syndrome with positive anti-sagging test

8. Concerns about the use of colour doppler in the diagnosis of pudendal nerve entrapment (pdf 127 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

1.Les réflexes sacrés étagés dans l'étude de la névralgie pudendale: validation anatomique
(pdf,702 ko)

2. De l'importance de l'anatomie (pdf, 558 ko)

3. Concerns about the use of colour doppler in the diagnosis of pudendal nerve entrapment (pdf 127 ko)


 

Websites about  pudendal neuralgia

In English:

1. http://www.spuninfo.org

2. http://pudendalhope.org

3. http://www.tipna.org

4. http://www.pudendalhelp.com

5. http://www.pnfdn.org

In Italiano:

5. http://www.pudendo.it  

En Français:

6. http://www.pudendalsite.com

7. http://www.afap-np.com

 


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

 

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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