Effectiveness of Pudendal Nerve Blocks on Postoperative Pain Control and Reduction in Opioid Usage after Gender-affirming Vaginoplasty

Abstract

ABSTRACT Introduction Postoperative pain control in gender-affirming penile-inversion vaginoplasty (PIV) significantly affects patient experience and satisfaction. With the rise of opioid misuse and over-prescription, non-narcotic adjuncts for post-surgical analgesia are greatly needed. Currently, there is limited data on postoperative pain control after genital gender-affirming surgery (gGAS). Objective To evaluate the effects of preoperative pudendal nerve block on post-op patient-reported pain scores and opioid usage. Methods We retrospectively reviewed all trans-female patients undergoing PIV (+ creation of vaginal canal) at a single institution from August 2017 to July 2021. We recorded patient demographics, operative details, surgical-site pain (using a Likert scale 0-10; 0=no pain, 10=severe pain), and analgesic medication usage. Baseline demographics, pain scores and opioid usage were compared between patients who received pudendal nerve block preoperatively (immediately before the surgical procedure) and those who did not. Independent sample t-tests were used for all comparisons. Results Out of 36 consecutive patients (mean age 36.6 years, mean BMI 25.3 kg/m2) that underwent PIV, 25/36 patients did not have pre-op pudendal nerve block, while the most recent 11/36 patients did. Patient characteristics across cohorts were similar, though the 11 patients who had pudendal nerve block had higher rates of depression (54.5% vs. 28.0%, p=0.043) and hypertension (18.2% vs. 4.0%, p=0.041). Surgical-site pain scores on postop day 0 (POD0) were compared: patients who received pudendal nerve block had 35% lower pain scores than those who did not (3.09 vs. 4.74, p<0.001). Surgical-site pain scores on POD5 were 10% lower in those who received pudendal nerve block (4.16 vs. 4.63, p=0.046). Although patients experienced lower subjective pain scores, average total opioid usage was similar between patients who received pudendal block (MME= 224) versus those that did not (MME= 225). Conclusions Our preliminary data suggests that pudendal nerve blocks are safe and effective adjuncts to improve pain control after gender-affirming PIV, thus improving patients’ postoperative experience. This modality should be further investigated and considered for routine usage in vaginoplasty, and other gGAS perioperative pain regimens. Similar opioid usage despite improved pain scores suggests that in-hospital opioid pain regimens should be more closely tailored to patient-reported pain scores. Disclosure No