Pelvic pain of pudendal nerve origin: surgical outcomes and learning curve lessons.

PURPOSE: When pudendal nerve dysfunction fails to improve after medical and pelvic floor therapy, a surgical approach may be indicated. "Traditional," "posterior," transgluteal nerve decompression fails in an unacceptably high percentage of patients. Insights into pudendal neuroanatomy and pathophysiology offer improved microsurgical outcomes.

METHODS: To evaluate results of a peripheral nerve approach to the pudendal nerve, 55 patients were prospectively evaluated. This cohort included 25 men and 30 women. Surgical approach was posterior, transgluteal if symptoms included rectal pain; or "anterior," inferior pubic ramus approach if symptoms excluded rectal pain. Surgical approach was "resection," if trauma created a neuroma, and "decompression," if there were no neuroma. Effect of comorbidities was analyzed.

RESULTS: At 14.3 months postoperatively, untreated anxiety/depression correlated with outcome failure, regardless of surgical approach, p < 0.002. There was no difference in results, men versus women, "anterior" versus "posterior" approach, or neuroma resection versus neurolysis. Success correlated with the "learning curve" of the surgeon. Self-rated success was significantly better (p < 0.0001) for patients operated on during the second year of the study than the first year of the study, and improved again in the final year of the study (p < 0.04), with 86% of the patients in final year achieving an excellent result and 14% achieving a good result.

CONCLUSION: There is hope for surgical relief from pudendal nerve problems by distinguishing neuroma from compression in the diagnosis, and then choosing a site-specific surgical approach related to which pudendal nerve branches are involved.