American Society for Peripheral Nerve

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Injury to the Perineal Branch of the Pudendal Nerve in Women: Outcomes from Surgical Resection of the Perineal Branches and Implantation of Proximal End into the Obturator Internus Muscle
Eric L. Wan, BS; Andrew T Goldstein, MD; A. Lee Dellon, MD, PhD
Johns Hopkins University, Baltimore, MD

Background: The traditional transgluteal approach for the surgical treatment of "pudendal neuralgia" has been disappointing for those patients with "anterior" pudendal nerve symptoms, such a pain in the labia, vestibule, and perineum. In this study, we describe outcomes from a new surgical approach to resect the perineal branches of the pudendal nerve (PBPN).

Materials & Methods: An IRB-approved prospective study enrolled 16 consecutive female patients from 2012 through 2015 who did not have rectal symptoms. Each woman had a successful, diagnostic, pudendal nerve block. The surgical procedure was resection of the PBPN and implantation of the nerve into the obturator internus muscle through a para-labial incision. Mean age at surgery was 49.5 years (SD = 11.6 years). Mechanism of injury was episiotomy in 31%, athletic injury in 25%, vestibulectomy in 31%, and falls in 13%. Four women (25%) had urethral symptoms. Outcomes were the Female Sexual Function Index (FSFI), the Vulvar Pain Functional Questionnaire (VQ), and the Numeric Pain Rating Scale (NPRS). 14 patients completed these questionnaires, reporting on their condition before surgery and currently.

Results: The mean post-operative length of follow-up was 15 months (range: 6 to 43 months). Post-operative significant bruising was the only complication, occurring in 10% of the patients. The overall FSFI significantly improved after surgery (p < 0.05). The specific domains that showed significant improvement were those for arousal, lubrication, orgasm, satisfaction, and pain (p < 0.05). The VQ also significantly improved after surgery (p < 0.001) in 13 of 14 (93%) patients. The NPRS score decreased, on average, from an 8 to a 3 out of 10 (p < 0.0001). Each of the 4 women with urethral symptoms had relief of these symptoms post-operatively.

Conclusions: Resection of the perineal branch of the pudendal nerve with implantation of the nerve into the obturator internus muscle significantly improved the sexual function, vulva function, and pain of women who sustained injury to the perineal branches of the pudendal nerve.

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