Brian P. Jacob, David C. Chen, Bruce Ramshaw, Shirin Towfigh (eds.) - The SAGES Manual of Groin Pain-Springer International Publishing (2016)

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M. Hibner and C. Coyne
Once the nerve is identified, scar tissue is carefully removed from
around the nerve.
When the pudendal nerve is cleared of scar tissue, the sacrospinous
ligament is transected and the nerve is transposed anteriorly, thus
decreasing the pressure off the nerve and allowing it to run a more direct,
straight course anteriorly. Once the nerve is transposed, it can be wrapped
in a nerve wrap product of the surgeon’s choice, further decreasing the
reoccurrence of scar tissue build up. The sacrotuberous ligament is subsequently
repaired and the multilayered surgical wound is closed.
In our practice, approximately 75 % of patients have at least 20 %
improvement in pain after this operation (ranging from 100 % improvement
to 20 % improvement). This is similar to reports by Robert et al.,
among others [ 20 ]. Patients usually report improvement within 4 months
of the operation, and maximum improvement can be expected in 18–24
months postoperatively .
Transischiorectal Pudendal Neurolysis Transischiorectal pudendal
neuro lysis is preformed transvaginally in women and through a perineal
incision in men. One advantage of this procedure is that it does not
require transection of the sacrotuberous ligament, and therefore may
decrease the risk of instability of the sacroiliac joint postoperatively. The
biggest drawback seems to be the limited visualization and poor access
to the nerve itself. Particularly in male patients, a perineal incision is
painful and is difficult to heal. In a French study, 83 % of patients had
resolution of their pain after this procedure. Controversially, this high
rate of success has not been confirmed by other studies.
Transperineal Pudendal Neurolysis Transperineal pudendal neurolysis
is a procedure developed specifically for patients with entrapment
of the terminal branches of the pudendal nerve. Thus, first the patients
experiencing pain from the main trunk of the pudendal nerve, found
between the sacrotuberous and sacrospinous ligaments, must be excluded
[ 21 ]. This procedure is most widely applied to patients who experience
isolated clitoral/penile or perineal pain. It is performed with the patient
placed in the lithotomy position and the incision made just lateral to the
labia majora in women or lateral to the scrotum in men .
Endoscopic Transperitoneal Pudendal Neurolysis The pudendal
nerve can be approached through the abdominal cavity during a
laparotomy, laparoscopy, or robotic- assisted laparoscopy [ 22 ]. With
this approach, the trunk of the nerve found between the sacrospinous
and sacrotuberous ligaments can be accessed. Visualizing the nerve
distal to this area would require extensive transection of the levator ani