Pudendal Research Articles

Anatomical neuromuscular variations determined by magnetic resonance imaging in chronic pelvic pain

Background: The diagnosis of neuromuscular pelvic pain is challenging. Despite the increasing use of magnetic resonance imaging (MRI) in the assessment of pudendal neuralgia, there are limited data describing radiological variations of the nerve. Additionally, the utility of MRI in the assessment of pelvic floor tension myalgia is unknown. Aims: To describe the anatomical variations of the pudendal nerve and dimensions of pelvic muscles in patients investigated for neuromuscular pelvic pain using a combined MRI protocol. Materials and methods: A retrospective audit of MRI reports for 136 patients referred to a single radiologist was conducted. Reported data included the appearances of the pudendal nerve and its perineural structures, and the maximal thicknesses of pelvic muscles. Results: Several anatomical variations were identified in the course of the pudendal nerve at or above the ischial spine. Likely/highly likely nerve compression at this level was present in 34.6% of hemipelves. Variations associated with compression included delayed separation of the sacrospinous and sacrotuberous ligaments ( p < 0.0001), close apposition of ligaments ( p < 0.0001), interligamentous bands ( p = 0.033), coccygeal muscle contributions to the sacrospinous ligament ( p = 0.014) and proximal ( p < 0.0001) and thickened falciform ligaments ( p < 0.0001). Variations below the ischial spine were uncommon. Conclusions: This study represents a quantitative and qualitative expansion to the radioanatomical basis of pudendal nerve entrapment on MRI, and highlights the limitations of MRI obtaining reproducible measurements of pelvic muscles. Images from asymptomatic controls and further prospective evaluation of treatment outcomes is required to determine the clinical significance of MRI findings in the assessment of pudendal neuralgia.

The Perineal Post for Hip Arthroscopy Is Dead - Or At Least It Should Be.

Traditionally, distraction of the hip joint during hip arthroscopy has been achieved with the use of a perineal post which acts as a counterforce. However, our knowledge of the potential complications related to the use of a perineal post continues to grow. While pudendal neurapraxia is the most common of these potential complications, the perineal post may also cause skin tears of the perineum, erectile dysfunction and, in rare cases, permanent pudendal nerve injury. In response, several techniques for performing postless hip arthroscopy have been developed in recent years. While some of these techniques are commercially available and some are "do-it-yourself", preliminary evidence has shown minimal risk of groin-related complications with these postless techniques. In addition to reducing complication rates, our research demonstrated significantly better patient-reported outcomes with postless compared to post-assisted hip arthroscopy at a minimum 1-year follow-up. Groin-related complications during hip arthroscopy are confusing and anxiety-producing to patients. Hip arthroscopy is an elective procedure, and patients do not expect to have any groin symptoms after a hip surgery. Because this is a sensitive issue, the potential for groin-related complications is rarely discussed with patients preoperatively. In addition, patients are often confused and reluctant to mention groin-related complications to their surgeon, especially if these symptoms are short-lived. Postless hip arthroscopy is a readily accessible, safe alternative to using a perineal post and should be adopted as the standard of care sooner rather than later.

Comparison of the Analgesic Efficacy of Ultrasound-Guided Transperineal Approach Using Pudendal Nerve Block Versus Caudal Block in Children Undergoing Urological Surgeries: A Randomized Controlled Trial.

Caudal block is an effective regional anesthesia technique for perineal surgeries but is associated with various adverse effects. Recently, pudendal nerve block has emerged as a promising alternative for these procedures. This study assessed the effectiveness of a novel transperineal technique for ultrasound-guided pudendal nerve block and compares it with ultrasound-guided caudal block for perineal surgeries in pediatric patients. The study included 60 American Society of Anesthesiologists (ASA) Physical Status Classification Systemgrade I/II children aged 1-12 years and scheduled for elective perineal operations under general anesthesia. Patients were randomly allocated to two equal groups: Group C (ultrasound-guided caudal block) and Group P (ultrasound-guided pudendal nerve block). The groups were evaluated for time to first rescue analgesia (primary outcome), block performance time, total analgesic consumption, Face, Legs, Activity, Cry, and Consolability (FLACC) scores, time to achieve a Post-Anesthetic Discharge Scoring System (PADSS) score of 9, and any complications. The median interquartile range (IQR) first rescue analgesia time was significantly higher in the pudendal block (17.5 (17-18) hours vs 4.65 (4.5-4.77) hours; p<0.001). The median (IQR) dose of postoperative analgesia (diclofenac) required was similar in the pudendal block group and caudal group (10 (0-10) mg vs 10 (0-20) mg; p=0.290). The median (IQR) FLACC scores at "zero" hour post-surgery were 2 (2-2) and 2 (1-2) in the pudendal and caudal groups, respectively (p=0.052). The median (IQR) PADDS score was significantly higher in the pudendal group (10 (9.25-10) vs 9 (8-9); p<0.001). The time to reach a PADSS score of 9 was significantly longer in the pudendal group (21.4±3 vs 14.9±4.8 hours; p<0.0001). There were no complications in either group. The findings of this study suggest that pudendal nerve blockprovides longer-lasting analgesia, lower pain scores, andfaster readiness for discharge though with a similar analgesic consumption compared to caudal block. These resultsindicate the potential of ultrasound-guided pudendal nerve blocks as a beneficial and safe alternative to caudal block for perineal procedures in children.

US-guided pudendal nerve block as sole anesthetic technique in hemorrhoidectomy: our experience.

US-guided pudendal nerve block as sole anesthetic technique in hemorrhoidectomy: our experience.

An innovative electrical neurostimulation approach to mimic reflexive urination control in spinal cord injury models

Neurogenic lower urinary tract dysfunction (NLUTD) is a frequent consequence of spinal cord injury (SCI), leading to symptoms that significantly impact quality of life. Although many life-saving techniques are available, current treatment strategies for managing NLUTD still exhibit limitations and drawbacks. Here, we introduce a new electrical neuromodulation strategy involving electrical stimulation of the major pelvic ganglion (MPG) to initiate bladder contraction, in conjunction with innovative programmable (IPG) electrical stimulation on the pudendal nerve (PN) to induce external urethral sphincter (EUS) relaxation in freely moving or anesthetized SCI mice. Furthermore, we conducted the void spot assay, and cystometry coupled with EUS electromyography (EMG) recordings to evaluate voiding function, and monitor bladder pressure and EUS activity. Our findings demonstrate that our novel electrical neuromodulation approach effectively triggers coordinated bladder muscle contraction and EUS relaxation, effectively counteracting SCI-induced NLUTD. Additionally, this electrical neuromodulation method enhances voiding efficiency, closely resembling natural reflexive urination in SCI mice. Thus, our study offers a promising electrical neurostimulation approach aimed at restoring physiological coordination and potentially offering personalized treatment for improving voiding efficiency in individuals with SCI-associated NLUTD.

Pelvic Floor Muscle Anatomy and its Contribution to Penile Erection in Olive Baboons.

Despite the number of studies on the contribution of pelvic floor muscles (PFM) to the penile erection process, their significance is still underestimated. The goal of this study was to investigate the role of PFM in the erection process in non-human primates. First, we performed an anatomical study of the penile structures in 12 baboon cadavers. Next, we created chronic electrophysiological models of normal erectile function in 25 olive baboons. We implanted electrodes on the cavernous nerves to control penile blood filling and placed other electrodes on the pudendal nerve to stimulate the ischiocavernosus muscles (ICM) contractions after sufficient blood filling, thus simulating both vascular and muscular phases of penile erection. We controlled the intracavernous pressure (ICP) during nerve stimulations and further performed a mathematical analysis of the collected data. We described the main pro-erectile muscle anatomy and its relationship with penile structures in monkeys. During neurostimulation studies, we showed the key role of ICM in achieving full penile rigidity with suprasystolic ICP up to 120-300 mm Hg. We also developed a math model for calculating the pro-erectile muscle's contraction force with high accuracy. In this study, we demonstrated the crucial role of PFM in the penile erection process using the monkey model, supporting the previous studies' data. We consider these results essential for a better, more complex understanding of the penile erection process and the participating structures in each stage. This is essential for further improving and designing novel erectile dysfunction diagnostics and treatment techniques.

The effect of combined pudendal nerve and spermatic cord block or caudal epidural block on postoperative analgesia after posterior urethroplasty: a randomized trial

BackgroundPostoperative pain management remains a significant challenge for patients undergoing posterior urethroplasty (PU). In a previous study, we proposed a novel technique of combined pudendal nerve (PN) and spermatic cord (SC) block to manage pain after PU. The present trial was conducted to test the hypothesis that this technique is effective for pain control after PU and provides longer-lasting analgesia than caudal epidural block (CB).MethodsSixty patients undergoing PU were randomized into two groups: Group NB received combined PN and SC block, and Group CB received CB. General anesthesia with a laryngeal mask was performed. The primary outcome was the postoperative analgesic duration, and the secondary outcomes included the Numeric Rating Scale (NRS) scores for pain and the number of patients with different motor scores of the lower limb at 3, 6, 12, and 24 h postoperatively.ResultsTwo patients in Group CB were withdrawn due to block failure. The postoperative analgesic duration was statistically longer in Group NB compared with Group CB (mean difference [95% confidence interval], 115.78 min [17.80, 213.75]; P = 0.021). The NRS scores for pain at 12 and 24 h after surgery were statistically lower in Group NB compared with Group CB. Group NB had statistically more patients with motor score 0 at 3 h postoperatively than Group CB.ConclusionsPN combined with SC block is an effective technique for postoperative analgesia in PU. This technique can achieve a longer duration of analgesia and lower pain scores, especially 12 h after surgery, than a CB.Trial registrationThis study was registered in the Chinese Clinical Trial Register (registration no. ChiCTR2100042971, registration date on 2/2/2021).

Cadaver study of ultrasound-guided pudendal nerve block in six horses

Cadaver study of ultrasound-guided pudendal nerve block in six horses

Advancing the predictive accuracy of PNTML in rectal prolapse: An ongoing quest

Fecal incontinence is a common symptom among patients with rectal prolapse. Pudendal nerve terminal motor latency (PNTML) testing can serve as a reference indicator for predicting the outcomes of rectal prolapse surgery, thereby assisting surgeons in formulating more appropriate surgical plans. The direct correlation between preoperative PNTML testing results and postoperative fecal incontinence in patients with rectal prolapse remains a contentious issue, necessitating further clarification. Thus, we analyze the existing publications from both clinical and statistical perspectives to comprehensively evaluate the accuracy of preoperative PNTML testing in rectal prolapse and provide some feasible statistical solutions.

Is Our Limited Understanding of the Effects of Nerve Stimulation Resulting in Poor Outcomes and the Need for Better "Rescue Programming" in SNM and PTNS, and Lost Opportunities for New Sites of Stimulation? ICI-RS 2024.

Sacral neuromodulation (SNM) and percutaneous tibial nerve stimulation (PTNS) are strongly recommended by international guidelines bodies for complex lower urinary tract dysfunctions. However, treatment failure and the need for rescue programming still represent a significant need for long-term follow-up. This review aimed to describe current strategies and future directions in patients undergoing such therapies. This is a consensus report of a Think Tank discussed at the Annual Meeting of the International Consultation on Incontinence - Research Society (ICI-RS), June 6-8, 2024 (Bristol, UK): "Is our limited understanding of the effects of nerve stimulation resulting in poor outcomes and the need for better 'rescue programming' in SNM and PTNS, and lost opportunities for new sites of stimulation?" Rescue programming is important from two different perspectives: to improve patient outcomes and to enhance device longevity (for implantable devices). Standard SNM parameters have remained unchanged since its inception for the treatment of OAB, nonobstructive urinary retention, and voiding dysfunction. SNM rescue programming includes intermittent stimulation (cycling on), increased frequency and changes in pulse width (PW). The effect of PW setting on SNM outcomes remains unclear. Monopolar configurations stimulate more motor nerve fibers at lower stimulation voltage; hence, this could be an option in patients who failed bipolar stimulation in the long term. Unfortunately, there is little evidence for rescue programming for PTNS. However, the development of implantable devices for intermittent stimulation of the tibial nerve may increase long-term adherence to therapy and increase interest in alternative programming. There has been recent promising neurostimulation targeting the pudendal nerve (PNS), especially in BPS/IC. More recently, preliminary data addressed the benefits of high-frequency bilateral pudendal nerve block for DESD and adaptive PNS on both urgency and stress UI in women. The exploration of rescue programming and new stimulation sites remains underutilized, and there are opportunities that could potentially expand the therapeutic applications of nerve stimulation. By broadening the range of target sites, clinicians may be able to tailor treatments according to individual patient needs and underlying conditions, thereby improving overall outcomes. However, further studies are still needed to increase the level of evidence, potentially allowing for an individualized treatment both in patients who are candidates for electrostimulation and in those who have already received surgical implants but seek a better outcome.

The Impact of Pudendal Nerve Injection in Vaginal Surgery: A Secondary Analysis

Importance Evidence regarding the effect of pudendal nerve blockade during vaginal surgery is conflicting. Previous studies compared pudendal nerve blockade to either normal saline placebo injection or no injection, demonstrating small or no difference in pain outcomes. Studies investigating nerve blocks at the time of vaginal surgery have not evaluated the effect of infiltration of the space around the pudendal nerve. Objective The aim of the study was to determine whether intraoperative pudendal nerve injection (bupivacaine or normal saline) will result in improved pain scores and satisfaction compared with patients who receive no pudendal injection. Study Design We performed a secondary analysis of 2 randomized controlled trials investigating postoperative pain after vaginal reconstructive surgery, comparing the outcomes of the following 3 groups: control (no pudendal injection), intervention (bilateral pudendal nerve blockade), and placebo (bilateral normal saline pudendal injections). The primary outcome was postoperative pain scores. Secondary outcomes were opioid use, patient satisfaction, and postoperative complications. Linear mixed effects models were applied to outcomes, and treatment effects with 95% confidence intervals were estimated at each time point from the model. Results One hundred four patients who underwent vaginal surgery were included: 36 pudendal nerve block, 35 normal saline pudendal injection, and 33 no injection. The groups were well-matched. Linear mixed effects models demonstrated no significant differences between treatment groups for postoperative pain severity scores, opioid use, and patient-reported satisfaction at each time point. Conclusions Normal saline injection and no injection seem to have no clinically meaningful difference in effect, and either could reasonably serve as control for pudendal blockade during vaginal surgery.

Comparison of Pudendal Nerve Block and Spinal Anesthesia in Proctological Surgeries: Efficacy, Safety, and Patient Outcomes.

Background and Objectives: The selection of an appropriate anesthesia method is a critical factor in the surgical treatment of proctological diseases, significantly impacting patient outcomes and comfort. Pudendal nerve block (PNB) and spinal anesthesia (SA) are commonly employed in these surgeries, yet the optimal choice between the two remains debated. This study aims to compare the efficacy and safety of PNB and SA in patients undergoing surgical treatment for various proctological conditions, with a focus on postoperative pain management, functional outcomes, and complication rates. Materials and Methods: A prospective observational study was conducted on 590 patients who underwent proctological surgery under either PNB (n = 435) or SA (n = 155). Pain levels were assessed using the Visual Analog Scale (VAS), while functional outcomes were measured using the World Health Organization Disability Assessment Schedule (WHODAS 2.0). Statistical analysis was performed to compare the outcomes between the two groups. Results: Patients in the PNB group reported significantly lower postoperative VAS scores compared to those in the SA group, particularly in hemorrhoidectomy and laser hemorrhoidoplasty procedures. The PNB group also demonstrated superior functional outcomes, with lower postoperative WHODAS 2.0 scores and a reduced incidence of urinary retention compared to the SA group. Furthermore, the duration of surgery and hospital stay were significantly shorter for patients in the PNB group. Conclusions: The findings suggest that PNB may offer advantages over SA in proctological surgeries, particularly in terms of pain management, functional recovery, and reduced complication rates. PNB should be considered a viable alternative to SA, particularly in cases where rapid recovery and minimizing complications are priorities. Exceptions to this include specific proctological surgeries, such as those for malignant tumors in the region, complex anal fistulas, proctological conditions arising from inflammatory bowel diseases, and patients on immunosuppressive therapy. Further research is needed to confirm these results and optimize anesthesia selection in this context.

Innervation pattern and fiber counts of the human dorsal nerve of clitoris

Even tough clitoris plays a critical role in female sexuality, we lack a precise understanding of qualitative and quantitative aspects of the innervation of the human clitoris. To address this issue, we dissected human clitorides from body donors and imaged them after staining with iodine with microCT for a macroscopic analysis. To resolve innervation patterns at the microscopic level we prepared thin sections of clitorides and stained them with trichrome azan to reveal the tissue structure combined with immunocytochemistry against Neurofilament H antibodies to reveal all axons and luxol blue labeling to reveal myelinated axons. We find the clitoral branch of pudendal nerve that innervates the clitoris not as single nerve, but as number of loose bundles. In the crus of the clitoris, about 12 such bundles can be recognized while about 32 bundles are present in the clitoral hemi-body. We counted on avarage 2917 axons in the crus of the clitoris (76% of which are myelinated) and 3137 axons in the hemibody of the clitoris (71% of which are myelinated). While the human clitoris receives only one third of the number of axons that innervate the human penis, an estimate of innervation density (per surface area) revealed that clitoris has approximately 6 times denser innervation compared to the penis. Thus, our study combines histology with microCT analysis provides detailed information on the number, myelination and innervation density of dorsal nerve of clitoris.

ID: 325822 Computational modelling of interpatient differences in neural recruitment during pudendal nerve stimulation

ID: 325822 Computational modelling of interpatient differences in neural recruitment during pudendal nerve stimulation

3 - First in human exploratory study of adaptive pudendal nerve stimulation in women with refractory urge or mixed urinary incontinence: short term results in 11 patients.

3 - First in human exploratory study of adaptive pudendal nerve stimulation in women with refractory urge or mixed urinary incontinence: short term results in 11 patients.

A wireless, battery-free device for electrical neuromodulation of bladder contractions

Lower urinary tract dysfunction (LUTD) is a prevalent condition characterized by symptoms such as urinary frequency, urgency, incontinence, and difficulty in urination, which can significantly impair patient's quality of life and lead to severe physiological complications. Despite the availability of diverse treatment options, including pharmaceutical and behavioral therapies, these approaches are not without challenges. The objective of this study was to enhance treatment options for LUTD by developing a wireless, battery-free device for managing bladder contractions. We designed and validated a compact, fully implantable, battery-free pulse generator using the magnetic induction coupling mechanism of wireless power transmission. Weighing less than 0.2 g and with a volume of less than 0.1 cubic centimeters, this device enables precise stimulation of muscles or neurons at voltages ranging from 0 to 10 V. Wireless technology allows real-time adjustment of key stimulation parameters such as voltage, duration, frequency, pulse width, and pulse interval. Our findings demonstrate that the device effectively controlled bladder contractions in mice when used to stimulate the Major Pelvic Ganglion (MPG). Additionally, the device successfully managed micturition in mice with bilateral transection of the pudendal nerve. In conclusion, the development of this innovative wireless pulse generator provides a safer and more cost-effective alternative to conventional battery-powered neurostimulators for bladder control, addressing the limitations of such devices. We anticipate that this novel technology will play a pivotal role in the future of electrical stimulation therapies for voiding dysfunctions.

Cadaveric Insights into Pudendal Nerve Variations for Sacrospinous Ligament Fixation: A Case Series.

The proximity of the pudendal nerve to the sacrospinous ligaments (SSLs) can lead to serious complications during sacrospinous ligament fixation (SSLF). This case series is aimed at providing an overview of the anatomy of the pudendal nerve, including insights from cadaver dissections and discussions on rare variations observed during these dissections. Dissections were conducted on five female cadavers using a posterior gluteal approach on both sides. The course, morphometric features and variations in the branches of the pudendal nerve were assessed at the level of the SSL and within the pudendal canal. The number of pudendal trunks cranial to the SSL ranged from one to three, with double trunks being the most common (70%). In 2 out of 10 (20%) sides inferior rectal nerves (IRNs) pierced through the SSL. In Case 1, IRNs pierced the SSL bilaterally before entering the pudendal canal and exiting at distances of 23.81mm and 41.18mm from the ischial spine on the right and left sides respectively. In Case 2, nerves with a width of 2.12mm and 2.49mm pierced the SSL and joined the IRN, piercing the SSL at 13.38mm and 12.55 medial to the ischial spine and 16.80mm and 19.32mm lateral to the sacrum, on the left and right sides respectively. In 60% of cases, the IRN entered the pudendal canal, exiting at a median distance of 21.25mm from the ischial spine. We identified significant variations in the number of trunks and branching patterns of the pudendal nerve around the SSL and the course of the IRN caudal to the SSL. We documented IRNs or nerves joining the IRNs piercing the SSL. Identifying these variations is crucial for surgeons to minimize the risk of pudendal nerve injury during SSLF.

Surgical Treatment of Proximal Hamstring Avulsion Injuries Compared With Nonsurgical Treatment: A Matched Comparative Study With a Mean Follow-up of >4 Years From the Proximal Hamstring Avulsion Surgery Cohort Study

Background: Surgical outcomes for proximal hamstring avulsion injury (PHAI) are well documented, yet comparative analyses with nonsurgical approaches remain scarce. Purpose: To compare the functional outcomes between surgical and nonsurgical interventions for PHAI. Study Design: Cohort study; Level of evidence, 3. Methods: This comparative study, conducted at a sports surgery center between January 2012 and July 2021, focused on patients with primary PHAI. The study was a retrospective analysis of prospectively collected data. Group selection involved utilizing propensity score matching to compare an arm of patients who were surgically treated (indications included patients with complete injury, patients with partial injury with >2 cm of retraction, and patients for whom 6 months of nonsurgical treatment failed) with another arm of patients who refused surgery. The primary outcome was evaluated using the Parisian Hamstring Avulsion Score (PHAS). The secondary outcomes included the Tegner Activity Scale (TAS) score; University of California, Los Angeles (UCLA) score; rate and quality of return to sport (RTS); and patient satisfaction. Results: The study included 32 patients (mean age, 55.8 years [SD, 8.4 years]) in the nonsurgical treatment arm and 95 patients in the surgical treatment arm (mean age, 53.4 years [SD, 7.7 years]) (P > .05). The interval from injury to treatment was 5.7 months (SD, 9.6 months) for the surgical group and 12.7 months (SD, 25.9 months) for the nonsurgical group (P > .05). At the final follow-up (nonsurgical group: mean, 56.5 months [SD, 28.2 months]; surgical group: mean, 50.7 months [SD, 33.1 months]), the PHAS was significantly higher in the surgical group (mean, 86.3 [SD, 13.7]) compared with the nonsurgical group (mean, 69.8 [SD, 15.1]) (P < .0001). Higher activity scores were also observed in the surgical group for the TAS and UCLA scores (P = .0224 and P = .0026, respectively). A higher percentage of the surgical group (68.4%) returned to sports compared with the nonsurgical group (46.9%) (P = .0354), with a greater proportion in the surgical group returning at the same or higher level (67.7% vs 26.7%) (P = .0069). Additionally, a higher satisfaction level was reported by patients in the surgical group (89.5%) in contrast to the nonsurgical group (25%) (P < .0001). Three patients in the surgical group experienced complications (2 reruptures and 1 hyperesthesia at the pudendal nerve territories). Odds ratios (ORs) indicated that patients in the surgical group were significantly more likely to achieve or exceed median scores for the PHAS (OR, 6.79; P < .001), TAS score (OR, 2.29; P = .045), and UCLA score (OR, 3.63; P = .003), as well as to RTS at any level (OR, 2.46; P = .031) or at the preinjury level or higher (OR, 6.04; P < .001). Conclusion: This study demonstrated that surgical treatment of PHAI significantly enhances long-term functional scores, including the PHAS, TAS score, UCLA score, satisfaction, and RTS, at a mean follow-up of >4 years compared with nonsurgical treatment. Registration: NCT02906865 (ClinicalTrials.gov identifier)

Impact of Urethral Sphincter Electrophysiology on Botulinum Toxin A Treatment in Women with Non-Neurogenic Dysfunctional Voiding.

Dysfunctional voiding (DV) is an abnormal urethral sphincter activity during voiding in neurologically normal individuals. Urethral sphincter botulinum toxin A (BoNT-A) injection has been used to treat DV, but the results have not been completely satisfactory. This study investigated the neurological characteristics of women with DV using the lower urinary tract electrophysiology (EP) study and the therapeutic efficacy of BoNT-A injection. In total, 48 women with DV and 16 women with normal voiding were included. Videourodynamic studies were conducted to diagnose DV before BoNT-A injection. EP studies, including urethral sphincter electromyography, bulbocavernosus reflex, and pudendal nerve conduction velocity, were conducted. Polyphasic motor unit action potentials suggestive of reinnervation were detected in 58.3% of patients with DV and 18.8% of controls (p = 0.001). Significant improvement in the corrected maximum flow rate (cQmax) was observed in patients with reinnervation at 1 and 3 months after BoNT-A injections into the urethral sphincter. Urethral sphincter denervation or reinnervation activity was commonly noted in 62.5% of women with DV. Repeated BoNT-A injections into the urethral sphincter provided effective treatment in 47.9% of patients, with mild improvement in cQmax observed in patients with urethral sphincter reinnervation. However, the improvement was not superior to those without reinnervation.

Applied anatomy study and preliminary clinical application of hyper selective neurectomy of triceps branches combined with partial neurotomy of S 2 nerve root to relieve spastic equinus foot

To observe the possibility of hyper selective neurectomy (HSN) of triceps branches combined with partial neurotomy of S 2 nerve root for relieving spastic equinus foot. Anatomical studies were performed on 12 adult cadaveric specimens. The S 2 nerve root and its branches were exposed through the posterior approach. Located the site where S 2 joined the sciatic nerve and measured the distance to the median line and the vertical distance to the posterior superior iliac spine plane, and the S 2 nerve root here was confirmed to have given off branches of the pelvic splanchnic nerve, the pudendal nerve, and the posterior femoral cutaneous nerve. Between February 2023 and November 2023, 4 patients with spastic equinus foot were treated with HSN of muscle branches of soleus, gastrocnemius medial head and lateral head, and cut the branch where S 2 joined the sciatic nerve. There were 3 males and 1 female, the age ranged from 5 to 46 years, with a median of 26 years. The causes included traumatic brain injury in 2 cases, cerebral hemorrhage in 1 case, and cerebral palsy in 1 case. The disease duration ranged from 15 to 84 months, with a median of 40 months. The triceps muscle tone measured by modified Ashworth scale (MAC) before operation was grade 3 in 2 cases and grade 4 in 2 cases. The muscle strength measured by Daniels-Worthingham manual muscle test (MMT) was grade 2 in 1 case, grade 3 in 1 case, and 2 cases could not be accurately measured due to grade 4 muscle tone. The Holden walking function grading was used to evaluate lower limb function and all 4 patients were grade 2. After operation, triceps muscle tone, muscle strength, and lower limb function were evaluated by the above grading. The distance between the location where S 2 joined the sciatic nerve and median line was (5.71±0.53) cm and the vertical distance between the location and posterior superior iliac spine plane was (6.66±0.86) cm. Before joining the sciatic nerve, the S 2 nerve root had given off branches of the pelvic splanchnic nerve, the pudendal nerve, and the posterior femoral cutaneous nerve. All the 4 patients successfully completed the operation, and the follow-up time was 4-13 months, with a median of 7.5 months. At last follow-up, the muscle tone of the patients decreased by 2-3 grades when compared with that before operation, and the muscle strength did not decrease when compared with that before operation. Holden walking function grading improved by 1-2 grades, and there was no postoperative hypoesthesia in the lower limbs. HSN of triceps branches combined with partial neurotomy of S 2 nerve root can relieve spastic equinus foot without damaging other sacral plexus nerves.