Pudendal Block Research Articles

CT-guided nerve block for pudendal neuralgia: diagnostic and therapeutic implications.

The objective of our study was to help clarify the role of CT-guided pudendal nerve blocks in the problematic and poorly understood entity of pudendal neuralgia (PN). Over a 1-year period, 52 CT-guided pudendal nerve blocks were performed in 31 patients (28 women, three men; age range, 22-80 years) who suffered from chronic pelvic pain with a presumed diagnosis of PN. A combination of anesthetic and steroid was injected into the pudendal (Alcock) canal. Pre- and postprocedural pain scores (0-10) were tallied and assessed by Student t tests. A p value < 0.05 was indicative of a significant difference. All procedures were successful technically, which was defined as contrast material filling the pudendal canal on CT and subsequent infusion of anesthetic and steroid. Pre- and postprocedural pain scores ranged from 2 to 10 (mean score, 6.13) and 0-10 (mean score, 2.14), respectively; the difference was statistically significant for each nerve block session (first session, p < 0.001; second session, p < 0.001; third session, p = 0.049). Of the 31 patients, two had long-term relief with pudendal nerve blocks alone. Fourteen had subsequent surgery based on initial improvement with block(s), and all 14 patients improved with surgical nerve release. Two patients had no diagnostic response and the diagnosis of PN was excluded. The gynecologic service followed the remaining 13 patients clinically. CT-guided pudendal nerve blocks appear to be valuable diagnostically for PN and uncommonly therapeutically. On the basis of these preliminary results, we have developed an algorithm for the role of the procedure for PN.

On The Etiology of the Electric Activity of the External Anal and Urethral Sphincters

ABSTRACTIn a previous study, the external anal sphincter (EAS) in dogs, known to consist of skeletal muscle fibers, was proved to contain bundles of smooth muscle fibers in between as well. Objective: Cause of electric activity in the external anal and urethral sphincters is not known; the current study investigated this point. Material and Methods: Slices from external anal and urethral sphincters of 21 cadavers (12 male, 9 female). Eighth were fully and mat wide neonates, 13 were adults, were stained with hematoxylin and eosin, Masson's trichrome and succinic dehydrogenase, and examined microscopically. Eighteen healthy volunteers, electromyography activity of their external anal and urethral sphincters was recorded at rest, on coughing, after pudendal nerve block and after drotaverine administration, (a smooth muscle relaxant). Anal and urethral pressures were also measured. Results: Microscopic studies have shown that both external anal and urethral sphincters were formed of bundles of smooth muscle fibers present in between the skeletal muscle fibers. Bilateral pudendal nerve block did not abolish the external anal or the urethral sphincters electromyography activity at rest, or on coughing, and did not cause significant anal or urethral pressure changes (p > .05). Drotaverine administration lead to disappearance of the electromyography activity and significant decline of the anal and urethral pressures (p < .05). The results were reproducible when the tests were repeated in the same subject. Conclusion: Histologic examination revealed the presence of smooth muscle fibers, between the skeletal fibers of the external anal and urethral sphincters. Evidence suggests that the smooth muscle fibers are the source of the electric activity of the sphincters and might explain some physiologic phenomena such as the external anal contraction on rectal distension or on coughing.

Comparison between Anesthetic Approaches with Pudendal Nerve Block on Postoperative Pain Profile after Anorectal Surgery : Our Experience at King Hussein Medical Center

Objective: To compare between different anesthetic methods with pudendal nerve block on postoperative pain quality after various anal surgical interventions. Methods: Our prospective, randomized study included 114 patients, of both sexes, aged 20-55 years, classed I physical status by the American Society of Anesthesiologists (ASA) and assigned for multiple types of anorectal surgical procedures at King Hussein Hospital, King Hussein Medical Center, Amman-Jordan, during the period May-December 2012. Subjects were divided randomly into 4 groups. Group I patients (GI, n=28) received subarachnoid block without pudendal nerve block, group II patients (GII, n=29) received spinal block with pudendal block, group III patients (GIII, n=28) received general anesthesia without pudendal block and group IV patients (GIV, n=29) received general anesthesia with pudendal block. Evaluation of postoperative pain profile during the first postoperative 48 hours included pain rating scale (verbal McGill pain questionnaire with no, mild, moderate and severe pain analgesic requirements and duration of analgesia. P-value < 0.05 was considered as statistically significant. Results: Severe pain incidence was 14.3% in group I and 3.4% in group II (P<0.05) in the first postoperative 48 hours. Severe pain was 17.9% in group III and 6.9% in group IV (P<0.05) in the first postoperative 48 hours. Mean duration of postoperative analgesia was 2.5 hours in group I and was 25.4 hours in group II(P<0.05).Mean duration of postoperative analgesia was 0.5 hours in group III and was 19.5 hours in group IV(P<0.05). Conclusion: Postoperative pain relief after anorectal surgery can be prolonged if pudendal nerve block was added to general anesthesia or subarachnoid block.

Educational Exhibit Abstract No. 445 - Feasibility of utilizing CT- guided theraputic pudendal nerve block in treating pudendal neuralgia

Detail the indications, benefits, and procedural details of a therapeutic pudendal nerve block. Trauma, compression, or entrapment of the pudendal nerve along its course can produce chronic pelvic and perineal pain. Presenting symptoms can mimic a variety of dermatological, urological, and gynecological conditions making the initial diagnosis challenging. A variety of non-diagnostic tests are typically performed and ineffective treatments are attempted with no relief of patient’s symptoms. Even after a diagnosis is established, conservative treatment with physiotherapy and pharmacotherapy might fail to relief symptoms. Studies have found CT-guided pudendal nerve block to be a quick, safe, and effective procedure to diagnose and treat pudendal neuralgia. A local anesthetic injected adjacent to the nerve can provide immediate relief and subsequent treatments with steroid and or botox can be performed for maintenance therapy. Using CT-guided needle placement, a 26 gauge spinal needle is guided towards the pudendal bundle either between the sacrospinous and sacrotuberious ligaments or in the pudendal canal (Alcock’s canal). The needle tip is positioned adjacent to the pudendal nerve and a long acting local anesthetic, such as bupivacaine is administered. If patient’s symptoms resolve immediately, the procedure is found to be diagnostic for pudendal neuralgia and repeated one week apart for two more times. When the procedure is repeated, a corticosteroid, such as triamcinolone or methylprednisolone, is often administered concurrently for its anti-inflammatory effects. CT-guided pudendal nerve block is a safe and effective treatment for patient's with pudendal neuralgia. The procedure can be performed relatively quick for both diagnostic and therapeutic goals.

Chirurgie hémorroïdaire : évolution vers une prise en charge en ambulatoire

Despite recommendations and encouragements, day-case hemorrhoidal surgery is incompletely developed. The incidence of postoperative pain, urinary retention and the risk of bleeding vary according to the surgical procedure but they are considered as the main impediments to ambulatory management. Consequently, besides the use of good clinical practice concerning ambulatory surgery, hemorrhoidal surgery requires an effective control of postoperative pain based on the use of pudendal block, an adaptation of the anesthetic technique and a careful postoperative follow-up.

Dyspareunia Treated By Bilateral Pudendal Nerve Block

In this report, we present a patient with refractory superficial dyspareunia of unclear etiology, who was successfully managed with a bilateral pudendal nerve block. Initial workup failed to identify an obvious source for the pain and first-line therapy for postmenopausal superficial dyspareunia was not effective. A bilateral pudendal nerve block alleviated the problem to three years followup. In this report, we review the current dyspareunia literature and propose a diagnostic algorithm.

Pudendal Nerve Stimulation and Block by a Wireless-Controlled Implantable Stimulator in Cats

The study aims to determine the functionality of a wireless-controlled implantable stimulator designed for stimulation and block of the pudendal nerve. In five cats under α-chloralose anesthesia, the stimulator was implanted underneath the skin on the left side in the lower back along the sacral spine. Two tripolar cuff electrodes were implanted bilaterally on the pudendal nerves in addition to one bipolar cuff electrode that was implanted on the left side central to the tripolar cuff electrode. The stimulator provided high-frequency (5-20 kHz) biphasic stimulation waveforms to the two tripolar electrodes and low-frequency (1-100 Hz) rectangular pulses to the bipolar electrode. Bladder and urethral pressures were measured to determine the effects of pudendal nerve stimulation (PNS) or block. The maximal (70-100 cmH2O) urethral pressure generated by 20-Hz PNS applied via the bipolar electrode was completely eliminated by the pudendal nerve block induced by the high-frequency stimulation (6-15 kHz, 6-10 V) applied via the two tripolar electrodes. In a partially filled bladder, 20-30 Hz PNS (2-8 V, 0.2 ms) but not 5 Hz stimulation applied via the bipolar electrode elicited a large sustained bladder contraction (45.9 ± 13.4 to 52.0 ± 22 cmH2O). During cystometry, the 5 Hz PNS significantly (p < 0.05) increased bladder capacity to 176.5 ± 27.1% of control capacity. The wireless-controlled implantable stimulator successfully generated the required waveforms for stimulation and block of pudendal nerve, which will be useful for restoring bladder functions after spinal cord injury.

The Effectiveness of Pudendal Nerve Block Versus Caudal Block Anesthesia for Hypospadias in Children

Caudal block (CB) has some disadvantages, one of which is its short duration of action after a single injection. For hypospadias repair, pudendal nerve block (PNB) might be a suitable alternative since it has been successfully used for analgesia for circumcision. We evaluated PNB compared with CB as measured by total analgesic consumption 24 hours postoperatively. In this prospective, double-blinded study, patients were randomized into 2 groups, either receiving CB or nerve stimulator-guided PNB. In the PNB group, patients were injected with 0.3 mL/kg 0.25% bupivacaine and 1 µg/kg clonidine. In the CB group, patients were injected with 1 mL/kg 0.25% bupivacaine and 1 µg/kg clonidine. Analgesic consumption was assessed during the first 24 hours postoperatively. The "objective pain scale" developed by Hannalah and Broadman was used to assess postoperative pain. Eighty patients participated in the study, 40 in each group. The mean age in the PNB group was 3.1 (1.1) years and in the CB group was 3.2 (1.1) years. The mean weights in the PNB and CB groups were 15.3 (2.8) kg and 15.3 (2.2) kg, respectively. The percentage of patients who received analgesics during the first 24 hours were significantly higher in the CB (70%) compared with the PNB group (20%, P < 0.0001). The average amount of analgesics consumed per patient within 24 hours postoperatively was higher in the CB group (paracetamol P < 0.0001, Tramal P =0.003). Patients who received PNB had reduced analgesic consumption and pain within the first 24 hours postoperatively compared with CB.

Pudendal Entrapment Neuropathy: A Rare Complication of Pelvic Radiation Therapy

Pudendal nerve entrapment (PNE) is an uncommon cause of chronic pain. Pudendal nerve entrapment typically occurs when the pudendal nerve is fused to nearby anatomical structures or trapped between the sacrotuberous and sacrospinalis ligaments. Pudendal nerve entrapment can be caused by excessive bicycling, pregnancy, anatomic abnormalities, scarring due to surgery, or as a sequela of radiation therapy. Radiation-induced peripheral neuropathy is usually chronic, progressive, and often irreversible. Radiation-induced pudendal neuropathy is much less common than the more familiar brachial plexopathy secondary to radiation treatment for breast cancer. The prevalence of PNE, however, is increasing due to improved long-term cancer survival. Diagnosis of pudendal neuralgia is essentially clinical; no specific clinical signs or complementary tests are reliably confirmatory. A detailed pain history with correlative clinical examination is paramount for accurate diagnosis. Performance of a pudendal nerve block can serve as both a diagnostic and therapeutic tool. Utilization of various imaging studies, as well as the performance of an electrophysiological study with pudendal nerve motor latency testing, may yield valuable evidence in support of a pudendal neuralgia diagnosis. We present the case of a 59-year-old man with stage IV prostate cancer, referred to the pain clinic for chronic perineal and right sided pelvic pain. His pain began insidiously, approximately 2 months after undergoing radiation treatment and chemotherapy 3 years prior. He was ultimately diagnosed as having a right sided pudendal entrapment neuropathy. His pain was refractory to all conventional treatment modalities; therefore we decided to pursue neuromodulation via a dorsal column spinal cord stimulator implant. Below, we describe the decision making process for the diagnosis and treatment of his pudendal neuropathy. Key words: Pudendal nerve entrapment, neuralgia, neuromodulation, spinal cord stimulation.

Ultrasound-guided pudendal nerve block in cats undergoing perineal urethrostomy: a prospective, randomised, investigator-blind, placebo-controlled clinical trial.

The objective of this study was to evaluate the clinical usefulness, in terms of analgesic efficacy and safety, of ultrasound-guided pudendal nerve block performed with bupivacaine in cats undergoing perineal urethrostomy. Eighteen client-owned male cats scheduled for perineal urethrostomy were enrolled in the study and assigned to one of two treatment groups. The pudendal nerve block was performed under general anaesthesia, as described elsewhere, with 0.3 ml/kg of either saline (group C) or 0.5% bupivacaine (group B) - the total injection volume being split equally between the two sites of injection (left and right). Intra-operatively, assessment of nociception was based on the rescue analgesics requirement, as well as on the evaluation of changes in physiological parameters in comparison with the baseline values. Postoperative pain assessment was performed using three different pain scales at recovery and then 1, 2 and 3 h after recovery. Cats in group B showed lower heart rates and required fewer analgesics during surgery than group C. Postoperatively, group B had lower pain scores and needed less rescue buprenorphine than group C. Iatrogenic block-related complications were not observed. In conclusion, the ultrasound-guided pudendal nerve block can be considered clinically useful in feline medicine as it provides reliable analgesia in cats undergoing perineal urethrostomy.

Analgesia for forceps delivery.

A forceps delivery may be indicated when a fetus fails to progress to delivery, or when delivery needs to be expedited in the second stage of labour. Effective analgesia is required to ensure that the woman is comfortable throughout the delivery, to allow the obstetrician to safely perform the procedure. It is currently unclear what the most effective and safe agent or method is to provide pain relief during forceps delivery. To assess the effectiveness and safety of different analgesic agents and methods available for forceps delivery for women and their babies. We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 July 2013), reviewed published guidelines and searched the reference lists of review articles. Randomised controlled trials comparing an analgesic agent or method used for forceps delivery with placebo/no treatment or an alternative agent or method. Two review authors independently assessed study eligibility, extracted data and assessed the risk of bias of included studies. We included four trials involving 388 women that were judged to be at an unclear to high risk of bias overall. A variety of different agents for providing analgesia were assessed in the trials, and a number of different methods to measure pain relief were used, and thus results could not be combined in meta-analysis. Three trials compared diazepam with an alternative agent (ketamine; vinydan-ether; "other" anaesthesic agent) for the provision of general anaesthesia, and one trial compared spinal analgesia to pudendal nerve block (in both groups lignocaine was administered).With regard to the primary outcomes, women receiving diazepam for forceps delivery in one small trial were more likely to judge their pain relief as effective compared with women receiving vinydan-ether (risk ratio (RR) 1.13; 95% confidence interval (CI) 1.02 to 1.25; 101 women). In a further small trial, no significant difference was seen in the number of women judging their pain relief as effective when diazepam was compared with ketamine (RR 1.42; 95% CI 0.98 to 2.07; 26 women). In the trial that compared spinal analgesia to pudendal nerve block, women receiving spinal analgesia were significantly more likely to regard their analgesia as adequate (RR 3.36; 95% CI 2.46 to 4.60; 183 women) and were less likely to report severe pain during forceps delivery (RR 0.02; 95% CI 0.00 to 0.27; 183 women). No trials reported on the review's other two primary outcomes of serious maternal adverse effects or complications, and neonatal mortality or serious morbidity.In terms of secondary outcomes, women receiving diazepam compared with vinydan-ether, were significantly less likely to experience vomiting (RR 0.04; 95% CI 0.00 to 0.62; 101 women). No significant differences were seen for the few neonatal outcomes that were reported across any of the comparisons (including Agpar score of less than seven at five minutes and acidosis as defined by cord blood arterial pH less than 7.2). There is insufficient evidence to support any particular analgesic agent or method as most effective in providing pain relief for forceps delivery. Neonatal outcomes have largely not been evaluated.

Development and Clinical Application of Pudendal Nerve Block Using A Peripheral Nerve Locator for Reproductive Surgery in Horses

AimsTo develop, describe and evaluate clinical applicability of pudendal nerve block using a peripheral nerve locator.MethodsIn a pilot study, 6 ponies were used to determine the correlation between nerves serving the perineal region (namely pudendal, caudorectal and perineal nerves) and the muscle contractions observed when an electrolocation technique was used. After appropriate electrolocation a small volume of lidocaine/methylene blue solution was injected under general anaesthesia. The dye location relative to the specified nerves was examined after humane euthanasia followed by dissection of the relevant region. In a second experiment, 7 Thoroughbred horses were used to evaluate the appropriate volume of lidocaine solution for the nerve block. Lidocaine/methylene blue solution was injected after positive electrolocation immediately (5–40 min) after euthanasia. A stained segment of 2 cm or more of the nerve was deemed to be sufficient and was evaluated after dissection. Finally, evaluation of a bilateral pudendal nerve block was used to provide anaesthesia and analgesia in 10 clinical cases involving both mares and geldings.ResultsAnal twitch alone was associated with injection of the caudal rectal nerve, whereas combined twitch of the anus and perineum was required for reliable location and injection of the pudendal nerve. Injection was more accurate in standing rather than laterally recumbent horses. A volume of 10–20 ml bilaterally, reliably provided at least 60 min of clinical analgesia for perineal surgery. Procedures satisfactorily completed included; urethral extension and perineal body repair in mares and penile examination, removal of penile tumours and penile amputation in male patients.Conclusions and practical significancePudendal nerve block is a practical and effective alternative to epidural analgesia for selected standing surgical procedures of the reproductive tract in male and female horses.Ethical animal researchThe Cornell University Institutional Animal Care and Use Committee approved the project and informed client consent was obtained. Sources of funding: None. Competing interests: None.

A critique of current practice of transvaginal pudendal nerve blocks: A prospective audit of understanding and clinical practice

Pudendal nerve blocks are a pre-requisite to forceps delivery without regional anaesthesia. Their efficacy is dependent on introducing local anaesthetic in close proximity to the pudendal nerve and allowing sufficient time for its onset of action. An audit of 57 obstetricians evaluated their clinical technique against standards using both a questionnaire and adapted model pelvis. The majority of participants were unable to describe correctly the point of infiltration and were unaware of the lag time required to effect adequate analgesia. We identify a deficiency in training and describe a method by which training can be facilitated and assessed.

Research in the pudendal nerve block anesthesia timing during second stage of labor

Objective To discuss the influence of pudendal nerve block anesthesia on pain degree and labor course when presentation at different positions during the second stage of labor,in order to find the better anesthesia timing and method to reduce pain,shorten labor,increase maternal comfort to a maximum extent and provide the best service for the maternal.Methods 200 cases of primiparas with fullterm and single-birth were selected and numbered randomly,patients with odd numbers were set to the observation group,patients with even numbers were set to the control group,100 cases in each group.In the observation group,when the presentation reached S+1,1％ lidocaine was used to perform pudendal nerve block anesthesia.In the control group,the pudendal nerve block anesthesia was performed before perineal incision.Results The pain intensity,time of the second labor stage,perineum damage degree between the two groups were statistically different.The observation group with Ⅱ-grade level,Ⅲ-grade level pain were 32 cases less than that of the control group.The perineum incision later crack number in the observation group was 24 cases less than that of the control group.The number of delivery within 1 hour in the second labor process in the observation group was 21 cases more than that in the control group.Conclusions Implementation of bilateral pudendal nerve block anesthesia in the second stage of labor when the presentation reaches S+1 can alleviate childbirth pain,shorten the second stage of labor,reduce the degree of perineal trauma. Key words: The second stage of labor; Bilateral pudendal nerve block anesthesia; Anesthesia timing; Pain; Perineal trauma

Development of an ultrasound-guided technique for pudendal nerve block in cat cadavers.

The objective of this prospective experimental cadaveric study was to develop an ultrasound-guided technique to perform an anaesthetic pudendal nerve block in male cats. Fifteen fresh cadavers were used for this trial. A detailed anatomical dissection was performed on one cat in order to scrutinise the pudendal nerve and its ramifications. In a second step, the cadavers of six cats were used to test three different ultrasonographic approaches to the pudendal nerve: the deep dorso-lateral, the superficial dorso-lateral and the median transperineal. Although none of the approaches allowed direct ultrasonographical identification of the pudendal nerve branches, the deep dorso-lateral was found to be the most advantageous one in terms of practicability and ability to identify useful and reliable landmarks. Based on these findings, the deep dorso-lateral approach was selected as technique of choice for tracer injections (0.1 ml 1% methylene blue injected bilaterally) in six cat cadavers distinct from those used for the ultrasonographical study. Anatomical dissection revealed a homogeneous spread of the tracer around the pudendal nerve sensory branches in all six cadavers. Finally, computed tomography was performed in two additional cadavers after injection of 0.3 ml/kg (0.15 ml/kg per each injection sites, left and right) contrast medium through the deep dorso-lateral approach in order to obtain a model of volume distribution applicable to local anaesthetics. Our findings in cat cadavers indicate that ultrasound-guided pudendal nerve block is feasible and could be proposed to provide peri-operative analgesia in clinical patients undergoing perineal urethrostomy.

Insufficient pain relief in vacuum extraction deliveries: a population‐based study

To investigate the pain relief used in association with vacuum extraction assisted deliveries and to identify risk factors for not receiving pain relief during the procedure. Retrospective birth register study. Nationwide study in Sweden. The study population consisted of all women (n=62568) with a singleton pregnancy who gave birth in gestational weeks 37(+0) to 41(+6) between 1999 and 2008 and were delivered by vacuum extraction. Register study with data from the Swedish Medical Birth Register. Epidural blockade, spinal blockade, pudendal nerve blockade, infiltration of the perineum, no pain relief. In all, 32.4% primiparas and 51.4% multiparas who had a vacuum-assisted delivery had this without potent pain relief such as epidural blockade, spinal blockade or pudendal nerve block. When infiltration was added as a method for pain relief, 18% were still delivered without pain relief. Multiparas were more likely than primiparas to be delivered without potent pain relief, odds ratio (OR) 2.29 95% confidence interval (CI) (2.20-2.38). Compared with women delivered by vacuum extraction due to prolonged labor, those with signs of fetal distress were more likely to be delivered without potent pain relief (OR) 1.74, 95% (CI) (1.68-1.81). A considerable number of women are delivered by vacuum extraction without pain relief. The high proportion might reflect that clinical staff do not always consider pain relief to be of high priority in vacuum extraction deliveries or that they fear impaired pushing forces.

Relief of Urinary Urgency, Hesitancy, and Male Pelvic Pain with Pulse Radiofrequency Ablation of the Pudendal Nerve: A Case Presentation

Background and Aims. This report demonstrates the utility of a pudendal nerve block by pulsed radiofrequency ablation (RFA) for the treatment of male pelvic pain and urinary urgency and hesitancy. Methods. The patient is an 86-year-old gentleman with a 30-year history of urinary hesitancy and urgency. The patient also had pain in the area of the perineum but considered it a secondary issue. The patient was seen by a number of specialists, tried various medications, and underwent a variety of procedures to no avail. Therefore, the patient underwent a pulsed RFA of the pudendal nerve. Results. The patient underwent a pulsed RFA of the pudendal nerve; the patient reported marked improvement in his pelvic pain as well as a drastic reduction in his urinary urgency and hesitancy. Conclusion. Urinary urgency and hesitancy and male pelvic pain are some of the most common symptoms affecting men. Pudendal nerve block by pulsed RFA is an effective treatment of pelvic pain. It may also hold some therapeutic value in the treatment of urinary urgency and hesitancy as our case demonstrated. Further studies are needed to help clarify both the anatomy of the pelvis as well as if pudendal blocks are effective in treating more than pelvic pain.

CT Guided Pudendal Nerve Block

Purpose: Retrospective review of CT-guided pudendal nerve blockade for chronic pelvic pain caused by pudendal neuralgia. Materials & Methods: The study included 23 patients (average age, 40.6 yr; range, 25 - 71 yr) diagnosed with pudendal neuralgia. Diagnostic criteria were: pain in the anatomic distribution of the pudendal nerve, pain worsening with sitting, pain relieved by lying down, and no sensory loss on examination. Alternative etiologies were considered and, if present, patients were excluded from the study. Patients underwent 1 - 4 CT-guided pudendal nerve blocks, using 22-gauge spinal needles placed with intermittent CT guidance. The needles were directed to the expected path of the pudendal nerve, either immediately caudal to the ischial spine or in Adcock’s canal. Nerve blocks were performed with 1 cc depot methylprednisolone (40 mg/cc), Bupivacaine 0.25% (3 cc) and Lidocaine 2% (2 cc). Procedure times were recorded. Patients were examined for perineal and vulva anesthesia 1 h after the blocks were performed. Patients’ records were reviewed for procedural success and complications. Results: Procedure time was 17.1 min (range, 11 - 26). Twenty-one blocks were performed at the ischial spine, and 2 were performed at the pudendal canal. Twenty-two (95.6%) of 23 patients reported perineal analgesia after the injection was performed, for a procedural success rate of 96%. One patient developed bilateral leg weakness which resolved in 6. Conclusion: Pudendal nerve block can be performed with CT guidance in a safe and effective manner. Further evaluation of the long-term effectiveness of the procedure with a prospective study is warranted.

Surgical treatment of nervus pudendus

An objective of our work was to clarify variations in pudendal nerve formation, as well as their possible impact on the clinical picture.Bilateral pudendal nerve course and formation was studied on 20 adult cadavers. Anterior approach was used in 15 of them, both posterior and anterior approaches were used in five of them. The prefixed type plexus formation was observed in eight cases (40 %). In these cases S1, S2 roots contributed to the formation of the pudendal nerve. In the postfixed type particularly the S3 root was dominant in two cases (66.7 %), and less the S4 root in one case (23.3 %) from three cases. Mostly the S2 root participated in its formation in 17 cases (85 %). The pudendal nerve branches run below the sacrospinous ligament on the level of the sacrospinous and sacrotuberous ligaments. The changes of the nerve and the branching therof were most evident from the anterior access below the sacrospinous ligament and in front of the sacrotuberous ligament. The inferior rectal nerve penetrating the sacrospinous ligament was seen in one case, it has risen from the pudendal nerve before entering the pudendal canal in four cases. The dorsal nerve of the penis has risen from the S1 root in two cases (10 %). We observed its branching before entering the pudendal canal in 15 cases (75 %). It has divided in the pudendal canal in other cases. This description may be useful particularly for the pudendal nerve block and the nerve saving surgeries directed on the relevant region (Fig. 8, Ref. 24).

Pudendal nerve block in HDR-brachytherapy patients: do we really need general or regional anesthesia?

In male patients, the pudendal block was applied only in rare cases as a therapy of neuralgia of the pudendal nerve. We compared pudendal nerve block (NPB) and combined spinal-epidural anesthesia (CSE) in order to perform a pain-free high-dose-rate (HDR) brachytherapy in a former pilot study in 2010. Regarding this background, in the present study, we only performed the bilateral perineal infiltration of the pudendal nerve. In 25 patients (71.8±4.18years) suffering from a high-risk prostate carcinoma, we performed the HDR-brachytherapy with the NPB. The perioperative compatibility, the subjective feeling (German school marks principle 1-6), subjective pain (VAS 1-10) and the early postoperative course (mobility, complications) were examined. All patients preferred the NPB. There was no change of anesthesia form necessary. The expense time of NPB was 10.68±2.34min. The hollow needles (mean 24, range 13-27) for the HDR-brachytherapy remained on average 79.92±12.41min. During and postoperative, pain feeling was between 1.4±1.08 and 1.08±1.00. A transurethral 22 French Foley catheter was left in place for 6h. All patients felt the bladder catheter as annoying, but they considered postoperative mobility as more important as complete lack of pain. The subjective feeling was described as 2.28±0.74. Any side effects or complications did not appear. Bilateral NPB is a safe and effective analgesic option in HDR-brachytherapy and can replace CSE. It offers the advantage of almost no impaired mobility of the patient and can be performed by the urologist himself. Using transrectal ultrasound guidance, the method can be learned quickly.