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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 l.jpg

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


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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)


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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


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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


Proctalgia shafik 1991 el sibai 1996 l.jpg
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


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- 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


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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.


Fi in crp shafik 1994 l.jpg
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


Usi shafik 1994 l.jpg
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


Erectile dysfunction shafik 1994 el sibai 1995 l.jpg
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


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Vulvudynia shafik 1997 l.jpg
Vulvudynia: defecation→↑intra-abd. pr.→ overstretch of LA → LA sublaxation & sagging→ pull on PN & artery →entrapment→(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


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Beco et al, 2004 : defecation→↑intra-abd. pr.→ overstretch of LA → LA sublaxation & sagging→ pull on PN & artery →entrapment→

  • 74 female pts. with perineodynia

    (vulvudynia,perineal pain & proctalgia),

    FI & USI

  • PCD : - Significant improvement of

    symptoms & signs

    - ↓ PNTML

    - ↑ EMG activity of LA & EAS


Scrotalgia shafik 1993 l.jpg
Scrotalgia:( Shafik,1993) defecation→↑intra-abd. pr.→ overstretch of LA → LA sublaxation & sagging→ pull on PN & artery →entrapment→

  • 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


Prostatodynia shafik 1998 l.jpg
Prostatodynia: defecation→↑intra-abd. pr.→ overstretch of LA → LA sublaxation & sagging→ pull on PN & artery →entrapment→(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


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  • No improvement with antibiotic defecation→↑intra-abd. pr.→ overstretch of LA → LA sublaxation & sagging→ pull on PN & artery →entrapment→

  • P.H. chronic constipation & ↑↑ straining

  • Perineal hyposthesia & weak anal reflex

  • EMG ↓ activity of LA & EUS, normal EAS

  • PNTML ↑

  • PN block → diagnostic & therapeutic test


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IRN → supplies EAS,LA & m.m. of ↓1/2 defecation→↑intra-abd. pr.→ overstretch of LA → LA sublaxation & sagging→ pull on PN & artery →entrapment→

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


Interstitial cystitis shafik 2008 l.jpg
Interstitial Cystitis : (Shafik 2008) defecation→↑intra-abd. pr.→ overstretch of LA → LA sublaxation & sagging→ pull on PN & artery →entrapment→

- 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


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- UB innervated by pelvic hypogastric/lumbar defecation→↑intra-abd. pr.→ overstretch of LA → LA sublaxation & sagging→ pull on PN & artery →entrapment→

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.


Pudendal artery syndrome presenting as ischemic proctitis report of 3 cases shafik digsurg 1996 l.jpg
Pudendal Artery Syndrome defecation→↑intra-abd. pr.→ overstretch of LA → LA sublaxation & sagging→ pull on PN & artery →entrapment→Presenting 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


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Diagnosis l.jpg
Diagnosis: in→arteritis & neuropathy

▪ 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


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Pudendal nerve decompression: in→arteritis & neuropathy

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


Pnd posterior app roach shafik 1992 l.jpg
PND :Posterior app roach in→arteritis & neuropathy(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


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● Indication: recurrent PCS in→arteritis & neuropathy

● PO follow up monthly for 6 mth.,every 3 mth. for 14-18 mth.by→ PNTML, EMG & manometry

● PO complications : minimal.


Role of sacral ligament clamp pudendal neuropathy pcs result of clamp release shfik 2007 l.jpg
Role of Sacral Ligament in→arteritis & neuropathyClampPudendal 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%


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Technique of sacral ligament clamp release: (10.2%)

  • 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


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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


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Conclusion 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.

● 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


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Thank You and Thanks to Ahmed Shafik 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.


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