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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

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

slide2
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)

slide10
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

mechanism of pcs
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
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

slide15
- 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

fi shafik 1994
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
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
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
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
slide20
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
vulvudynia shafik 1997
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
slide22
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

scrotalgia shafik 1993
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
prostatodynia shafik 1998
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
slide25
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
slide26
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

interstitial cystitis shafik 2008
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

slide28
- 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.

pudendal artery syndrome presenting as ischemic proctitis report of 3 cases shafik digsurg 1996
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
slide30
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

diagnosis
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

pudendal nerve decompression
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

pnd posterior app roach shafik 1992
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
slide37
● Indication: recurrent PCS

● 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
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%
slide41
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
slide44
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.

technique of sacral ligament clamp release
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
slide46
■ SPL- overlaying coccygeous m.→ divided at ischial spine by tenotomy knife & releasing PN free

■ Wound loosely closed

■ Op. repeated on other side

slide47
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

conclusion
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

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