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Pudendal Canal Syndrome Overview

Pudendal Canal Syndrome Overview. Ahmed Shafik & Olfat El Sibai , MD , PhD Professors and Chairmen Department of Surgery & Experimental Research Faculty of Medicine, Cairo & Menoufia Universities Shafik’s Foundation for Science. Surgical anatomy of PN: (Shafik ,1995) S2 → upper cord

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Pudendal Canal Syndrome Overview

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  1. Pudendal Canal SyndromeOverview Ahmed Shafik & Olfat El Sibai, MD, PhD Professors and Chairmen Department of Surgery & Experimental Research Faculty of Medicine, Cairo& Menoufia Universities Shafik’s Foundation for Science

  2. Surgical anatomy of PN: (Shafik ,1995) • S2 → upper cord • S3 PN above SPL → lower cord • S4 pass behind SPL medial to ischial spine → pass between SPL + STL→ PC → branches: *IRN * Perineal n * Dorsal n of penis (clitoris)

  3. Presentation: 1- Proctalgia (Shafik, 1991& El-Sibai, 1996) 2- FI (Shafik, 1994) 3- FI in complete R prolapse (Shafik, 1994) 4- USI (Shafik, 1994) 5- ED (Shafik, & El-Sibai, 1995) 6- Scrotalgia (Shafik, 1993) 7- Prostatodynia (Shafik, 1998) 8- Vulvudynia (Shafik, 1997) 9- Interstitial cystitils (Shafik, 2008) 10- Ischemic proctitilis (Shafik, 1996) Pudendal canal syndrome: (Shafik,1991) PN compression in PC

  4. Mechanism of PCS On ↑↑straining at defecation or delivery → ↑ intra-abd.pr. → brunt on LA & anoccygeal raphe → LA sublaxation & sagging → pull on IRN → pull on PN → neuropraxia or axontmesis → PN entrapment neuropathy in PC by edemae & ischemia → motor & sensory manfestation of PCS

  5. Proctalgia: (Shafik, 1991 & El-Sibai 1996) - Abrupt, sharp pain in anal or perianal regions - Few to 30 mts - Intermittent, by day or night - Unrelated to defecation - Aggravated by sitting - 2-3 times / wk - Increasing frequency - Perineal numibness & tingling

  6. - Common in multiparous & difficult deliveries - ±assoc. with FI to soft stools or flatus - D/E: ▪ tenderness on pressing on PN ▪ peri-anal & peri-vulval hypo. or anesthesia ▪ absent anal reflex

  7. FI: (Shafik 1994) • - Females with multiple deliveries • - FI to stools and flatus • - alone or with SUI or in CRP • - ↓ anal pr. • - P. neuropathy by PCS→ IRN neurpthy.

  8. FI in CRP: (Shafik, 1994) • In CRP →↓ EMG activity of LA • Levator dysfunction ± primary cause of CRP • Sublaxated & sagged LA → pull on PN → • Continues LA activity → PN stretch & tramatization → neuropraxia or axontmesis → PN entrapment → IRN neuropathy → FI • PNTML prolonged

  9. USI: (Shafik,1994) • ↓ EMG activity of EUS & prolonged both latency of straining-urethral reflex & PNTML • ET is neurogenic→PCS Evidences : - Weak EUS - Prolonged latency of straining- urethr. reflex • Prolonged PNTML • Concomitant idiopath. FI • ↑ USI incidence with multiparous

  10. Erectile Dysfunction:(Shafik,1994, El-Sibai,1995) ▪ Excluded psycogenic, vasculogenic, hormonal & metabolic (dibetis M) ▪ ± Assoc. with penile pain • Absent nocturnal tumescence • Penile, perineal & scrotal hypo. or anesthesia • EMG: ↓ EUS, EAS & LA • ↑ PNTML

  11. Chronic constipation & ↑↑straining at defecation→↑intra-abd. pr.→ overstretch of LA → LA sublaxation & sagging→ pull on PN & artery →entrapment→dorsal N. of penis neuropathy→ ED

  12. Vulvudynia: (Shafik,1997) • Vulvur burning & introital dyspareunia of idiopathic cause with failed various trt. • Multiparous, assoc. with USI • Pain every 2-3ds. induced by coitus • Not related to defecation or urination • Crisis 2-4hs. • PN block diagnostic • Gyne.exam.→bilat. vulvar erythema & tenderness on pressing on PN • Valvar & perineal hyposthesia or anesthesia

  13. Beco et al, 2004 : • 74 female pts. with perineodynia (vulvudynia,perineal pain & proctalgia), FI & USI • PCD : - Significant improvement of symptoms & signs - ↓ PNTML - ↑ EMG activity of LA & EAS

  14. Scrotalgia:( Shafik,1993) • Scrotal pain alone or ± assoc. penile pain or ED • No testicular pathology (varicocele or infection) • P.H. of chronic constipation & ↑↑ straining at defecation • D/E: -tenderness on pressing on PN -hypo. or anesthesia of perineal area • ↓ EMG of LA &EAS & ↓ PNTML

  15. Prostatodynia: (Shafik,1998) • Pain in perineam & scrotum or anal canal • Continuous with exacerbation or intermittent • Dull aching ,not related to urination or defecation • Assoc. with frequency, urgency & dysuria • Prostatic secretion → no bacteria

  16. No improvement with antibiotic • P.H. chronic constipation & ↑↑ straining • Perineal hyposthesia & weak anal reflex • EMG ↓ activity of LA & EUS, normal EAS • PNTML ↑ • PN block → diagnostic & therapeutic test

  17. IRN → supplies EAS,LA & m.m. of ↓1/2 of AC & perinanal skin Perineal N.→ EUS Mechanism: Constipation & straining → LA sublaxation & sagging → pull on PN → stretch distal part of PN at winding around SPligmt.→ neuropraxia & axontmesis *Subsequant N.compression → PN ischemia→N. damage *P.neuropathy involves perineal N & to a lesser extent IRN

  18. Interstitial Cystitis : (Shafik 2008) - Pain suprapubic,pubic,vaginal & genital - Exacerbated by intercourse or ejaculation - Exam. → suprapubic & vag. wall tenderness - Common in ♀ & IC most common cause of pelvic pain in gyne. - Remission & relapse

  19. - UB innervated by pelvic hypogastric/lumbar splanchnic innerv. Lumbosacral afferent in pelvic & PN sense & regulate continence & micturition - PN commonly compressed by PC or by sacral ligmts. clamp - PN entrapment → P neuritis → PCS - Painful micturition & dysparuma are symptoms of genital & perineal n. involvement of PN.

  20. Pudendal Artery SyndromePresenting as Ischemic ProctitisReport of 3 cases (Shafik,DigSurg 1996): • Not in literature • Anal pain,bleeding &P.H. of stainodynia+PCS • D/E→AC tender,edematous & ulcerated • R &C →free • Biopsy: mucosa lost,submuc.edem.& RC infiltration • D :selective pudendal arteriography → obliterated distal part(PC),not visualized IRA

  21. Et :→ L sublaxation & sagging →pull on artery & nerve in→arteritis & neuropathy • TRT: PCD →release PN & IPA • PO : - symptoms disappear - healing of AC - IPA remains obliterated but improvement is due to release of collateral vess. From compression

  22. Diagnosis: ▪ C/E: ● P.H. of straining ● PCS symptoms ● D/E: -tenderness on pressing on PN -perianal or perineal hypo.or anesthesia ▪ ↓ AC pr. ▪ ↓ anal reflex ▪ ↓ EMG of LA & EAS or EUS ▪ ↑ PNTML

  23. Pudendal nerve decompression: Technique : Anterior approach. ▪ Lithotomy position • Vertical para-anal incision 2cm from A orifice ▪ Ischio-rectal fossa entered ▪ IRN identified across IRF,N hooked by finger & traced to PN in PC ▪ PC fasciotomy ▪ Same procedure on the other side

  24. PND :Posterior app roach(Shafik,1992) • Technique : • Pt. in jack knife position • Vertical para-sacral skin incision • Glut. max. exposed & divided • Triangle identified • PN & vess. are over sacrospinous lig. passing from GSF to LSF • PC fasciotomy & PN releasad • Glut. Max. repaired • Op. repeated on the other side

  25. ● Indication: recurrent PCS ● PO follow up monthly for 6 mth.,every 3 mth. for 14-18 mth.by→ PNTML, EMG & manometry ● PO complications : minimal.

  26. Role of Sacral LigamentClampPudendal Neuropathy (PCS):Result Of Clamp Release(Shfik,2007) • This study showed the cause of PND failure in P neuropathy in the 21 pts. not improved after PCD • Clinical & investigative results improved after SLC release in 80.9% • PN sensory & motor affection improved & points that PN was involved SpL clamp in 80.9%

  27. Failure to improve SL division release PN from compression in SLC • after PCD & improved after SLC release in 17 pts. denotes that PN was affected by SLC • PN compression could be in both SLC & PC

  28. In our study PCS, of 206 cases it occurred in only 21 pts. (10.2%) • This assumed to be due to : (a)- anatomical anomaly of Sp. L & St. L, so narrowing the space between them. (b)- The sharp edge of SPL traumatize PN while passing over it.

  29. Technique of sacral ligament clamp release: • PCD→ anterior approach • Vertical para-anal incision • IRF entered • IRN identified & followed laterally to PN in PC • Verify previous operation (PN free) • Ischial spine & SPL. identified • PN dorsal to SPL. & between SPL. &STL.& enter PC

  30. ■ SPL- overlaying coccygeous m.→ divided at ischial spine by tenotomy knife & releasing PN free ■ Wound loosely closed ■ Op. repeated on other side

  31. Improvement of 80.9% of cases after sacral ligament clamp release, denotes that PN is traumatized not only in PC but also in SLC The cause of non improvement of 19.1% of cases after SLC release is due to advanced irreversible PN damage. Non improvement : - faulty diagnosis - irreversible PN damage Further studies needed

  32. Conclusion ● PCD is effective & successful procedure in treating motor & sensory manifestation of PCS; perineodynia (proctalgia, perineal pain & vulvudynia), FI, USI, ED & ischemic proctitis. ● The anterior approach is easier less time consuming. The posterior approach is indicated in recurrent cases ● PN compressed by: 1- PC commonly 2-Sacral ligments. Clamp

  33. Thank You and Thanks to Ahmed Shafik

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