Pudendal Nerve Injury Research Articles

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.

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.

Robot-Assisted Exploration of the Alcock Canal: A Novel Surgical Technique

ObjectiveTo demonstrate a safe and reproducible surgical approach to the Alcock canal with a full decompression of the pudendal nerve. SettingPudendal neuralgia, a condition causing debilitating pelvic pain, is traditionally managed through a trans-gluteal incision.1-2 This surgical approach offers limited visualization and ability for nerve decompression.3 With the current technique, a full exposure and decompression of the pudendal nerve was achieved. ParticipantsA 44-year-old para 2 with symptoms of left pudendal neuralgia. InterventionsA 44-year-old para 2 presented with burning vaginal pain radiating to the left groin that was aggravated with sitting. She underwent a robotic-assisted left sacrospinous ligament transection and fasciotomy of the obturator internus muscle for suspected pudendal neuralgia. The surgery was performed with three robotic ports using the daVinci® Xi robotic system. ConclusionWith the enhanced access to the pudendal nerve provided by the novel surgical technique demonstrated in this study, a more comprehensive nerve decompression can be performed. This technique was successfully applied to a patient with pudendal neuralgia. There were no immediate intra-operative or post-operative complications. In short-term follow-up, the patient had significant relief of preoperative symptoms. While all surgical procedures for pudendal neuralgia have a risk of pudendal nerve and vessel injury,4 the presented technique has the potential to limit these risks by providing an enhanced view of the relevant anatomy. Future adaptation and refinement of this technique may contribute to the advancement of the surgical management of pudendal neuralgia.

Contribution of pudendal nerve injury to stress urinary incontinence in a male rat model

Urinary incontinence is a common complication following radical prostatectomy, as the surgery disturbs critical anatomical structures. This study explored how pudendal nerve (PN) injury affects urinary continence in male rats. In an acute study, leak point pressure (LPP) and external urethral sphincter electromyography (EMG) were performed on six male rats with an intact urethra, the urethra exposed (UE), the PN exposed (NE), and after PN transection (PNT). In a chronic study, LPP and EMG were tested in 67 rats 4 days, 3 weeks, or 6 weeks after sham PN injury, PN crush (PNC), or PNT. Urethras were assessed histologically. Acute PNT caused a significant decrease in LPP and EMG amplitude and firing rate compared to other groups. PNC resulted in a significant reduction in LPP and EMG firing rate 4 days, 3 weeks, and 6 weeks later. EMG amplitude was also significantly reduced 4 days and 6 weeks after PNC. Neuromuscular junctions were less organized and less innervated after PNC or PNT at all timepoints compared to sham injured animals. Collagen infiltration was significantly increased after PNC and PNT compared to sham at all timepoints. This rat model could facilitate preclinical testing of neuroregenerative therapies for post-prostatectomy incontinence.

A High Incidence of Perineal Post-Related Complications After Hip Arthroscopy Is Self-Reported by Patients in Anonymous Online Forums

PurposeTo evaluate online, self-reported pudendal nerve or perineal injuries related to the use of a perineal post during hip arthroscopy. MethodsPublic posts on Reddit and the Health Organization for Pudendal Education were searched to identify anonymous individuals reporting symptoms of pudendal nerve or perineal injury following hip arthroscopy. Included posts were by any individual with a self-reported history of hip arthroscopy who developed symptoms of pudendal nerve injury or damage to the perineal soft tissues. Demographic information and details about a person’s symptoms and concerns were collected from each post. Descriptive statistics was used to analyze the data. ResultsTwenty-three online posts reported on a perineal post-related complication following hip arthroscopy. Gender information was available in 16 (70%) posts (8 male, 8 female). Twenty-two posts reported a sensory injury, and four posts reported a motor injury with sexual consequences (sexual dysfunction, dyspareunia, impotence). Symptom duration was available in 15 (65%) posts (8 temporary, 7 permanent). Permanent symptoms included paresthesia of the perineum or genitals (7) and sexual complaints (5). Two posts stated they were counseled preoperatively about the possibility of this injury. Zero patients reported that a postless hip arthroscopy alternative was an option made available to them before surgery. ConclusionA high incidence of permanent pudendal nerve, perineal skin, and genitourinary/sexual complications are self-reported and discussed online by patients who have undergone post-assisted hip arthroscopy. These patients report being uninformed and undereducated about the possibility of sustaining a post-related complication. No patient reported being informed of postless hip arthroscopy pre-operatively. Clinical RelevanceIdentifying and evaluating self-reported patient information in online medical forums can provide important information about patient experiences and outcomes. Level of EvidenceLevel IV Cross-Sectional/Observational.

Postless Hip Arthroscopy: A Technical Note on Obtaining Distraction

Hip arthroscopy techniques continue to evolve. Historically, a post has been used as an aid to establish adequate hip joint distraction. However, this technique is associated with potentially devastating postoperative pudendal nerve injury and other urologic and gynecologic complications. In this article, we present our technique for postless hip arthroscopy.

A computed tomography (CT) based morphometric study of superior pubic ramus anatomy among Arabs to determine safe intramedullary pubic rami screw insertion.

To assess the morphometric variables of the superior pubic ramus in an Arab/ Middle Eastern population to establish a safe pubic screw fixation technique. Cross-sectional retrospective analysis of computed tomography (CT) pelvic images. Morphometric data were extracted including; on pubic ramus length, insertion angles, potential danger zones and ramus diameters. The correlation between pubic rami diameter and patient demographics was also analyzed. A total of 231 participants were included (45% female). The mean pubic ramus length was 104mm in females and 127mm in males. The narrowest canal diameters at the para-symphyseal area were; 7.35mm (males) and 4.75mm (females). The mediolateral insertion angle was 49.4° in females and 41.8° in males. The cephalic-caudal angle was 49.9° in males and 42.1° in females. The mean distance from the lateral ilium entry point to the joint articular surface was 23.5mm in males and 19.9mm in females. The symphysis pubis to tubercle exit point was higher in females than males (24.2mm vs 16.6mm, respectively). There was a significant positive correlation between age and pubic ramus diameters in all age groups. The results from this study suggest that percutaneous pubic rami screw fixation using the standard 6.5 or 7.3mm cannulated screw system may potentially be unsafe in female Arab patients. This subset of patients may require alternative non-cannulated screws (3.5-4.5mm) or plate options. Further, female patients may have a higher risk of acetabular joint penetration, while males have a potentially higher risk of pudendal nerve injury.

Traction-related complications in hip arthroscopy for 26 years. A systematic review.

The primary aim of the study is to determine the rate of traction-related complications in hip arthroscopy (HA) including perineal compression and distraction injuries, and the secondary objective is to report the incidence of complications in HA found on the studies selected by a systematic review. Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were used for data extraction from the PubMed and Cochrane databases obtained in February 2022. Reviewers extracted the title, author, date of publication, number of hips treated and number of complications describing the affected area, nerve and soft tissue injury related to traction. Studies on postless HA and HA combined with other procedures were excluded. Twenty-six years of HA literature was found in the search that included 35 studies and 8126 hips (89% Level IV) that reported the complications found during the procedure and described complications related to traction. A total of 623 hips (7.7%) had some sort of complications during HA, and complications related to traction were in 227 hips (36%). Injuries caused specifically by the perineal compression were in 144 hips (23%) that included the pudendal nerve and soft tissue injury of the groin area. Complications caused by the distraction were in 83 hips (13%) that included sciatic and peroneal nerve injury, numbness or pain of ankle and foot. HA complications occurred in 7.7% of hips treated, which is found in this systematic review. One-third of the complications are related to traction, 23% are caused by perineal compression and 13% are caused by distraction.

Brain-Derived Neurotrophic Factor Is Indispensable to Continence Recovery after a Dual Nerve and Muscle Childbirth Injury Model.

In women, stress urinary incontinence (SUI), leakage of urine from increased abdominal pressure, is correlated with pudendal nerve (PN) injury during childbirth. Expression of brain-derived neurotrophic factor (BDNF) is dysregulated in a dual nerve and muscle injury model of childbirth. We aimed to use tyrosine kinase B (TrkB), the receptor of BDNF, to bind free BDNF and inhibit spontaneous regeneration in a rat model of SUI. We hypothesized that BDNF is essential for functional recovery from the dual nerve and muscle injuries that can lead to SUI. Female Sprague-Dawley rats underwent PN crush (PNC) and vaginal distension (VD) and were implanted with osmotic pumps containing saline (Injury) or TrkB (Injury + TrkB). Sham Injury rats received sham PNC + VD. Six weeks after injury, animals underwent leak-point-pressure (LPP) testing with simultaneous external urethral sphincter (EUS) electromyography recording. The urethra was dissected for histology and immunofluorescence. LPP after injury and TrkB was significantly decreased compared to Injury rats. TrkB treatment inhibited reinnervation of neuromuscular junctions in the EUS and promoted atrophy of the EUS. These results demonstrate that BDNF is essential to neuroregeneration and reinnervation of the EUS. Treatments aimed at increasing BDNF periurethrally could promote neuroregeneration to treat SUI.

Current Trends in the Use of Postless Hip Arthroscopy: A Survey of the International Society for Hip Arthroscopy Membership.

Previous studies have demonstrated the risks of pudendal nerve and/or soft tissue complications due to the use of a perineal post during hip arthroscopy. Recently, various postless hip arthroscopy techniques have been described in the literature. To assess the current international trends in the use of postless hip arthroscopy among hip preservation specialists. Cross-sectional study. An anonymous 11-item survey was sent by email to all members of the International Society for Hip Arthroscopy (ISHA) in January 2022. Surgeons were asked various questions regarding their current use of post-assisted or postless hip arthroscopy, if they had changed their setup technique during their career and the reason for that change, and their perceived rate of pudendal nerve and/or perineal soft tissue injuries using their current technique. Descriptive statistics were used to report the results of each question. The Student t test was used to compare the number of years in practice between post-assisted and postless users. Fisher exact tests were performed to compare categorical rates of pudendal nerve and soft tissue complications between post-assisted and postless users. A total of 126 surveys were completed from 431 ISHA members (29.2%). Sixty-one percent of the surgeons currently use a perineal post, while 33% use a postless technique. Seventy-five percent of the perineal post users and 98% of the postless users self-reported a rate of pudendal nerve and/or soft tissue injury of <1% (P = .015). Among 41 respondents who indicated changing their technique at some point, 59% reported doing so because of pudendal nerve and/or soft tissue complications. Among surgeons who switched from a perineal post to a postless setup, 71% indicated they have noticed a decrease in the rate of pudendal nerve and/or soft tissue complications. Although use of a perineal post is still a more common setup technique among hip arthroscopists, approximately one-third of surgeons use a postless technique. Surgeons who have switched to a postless technique often did so because of perineal complications, with the majority noticing a subjective decrease in these complications with the use of postless hip arthroscopy.

Anococcygeal Nerve and Sitting Pain: Differential Diagnosis and Treatment Results.

The plastic surgeon is often asked to reconstruct the sacral area related to pilonidal cysts or a tumor, or after other surgery, such as coccygectomy. When sitting pain is not due to the pudendal or posterior femoral cutaneous nerve injury, the anococcygeal nerve (ACN) must be considered. Clinically, its anatomy is not well known. Rather than consider coccygectomy when the traditional nonoperative treatment of coccydynia fails, resection of the ACN might be considered. A review of traditional anatomy textbooks was used to establish classical thoughts about the ACN. A retrospective cohort of patients with sitting pain related to the coccyx was examined, and those operated on, by resecting the ACN, were examined for clinicopathologic correlations. When the ACN is described in anatomy textbooks, it is with varying distributions of innervated skin territory and nerve root composition. Most include an origin from sacral 5 and coccygeal 1 ventral roots. Most agree that the ACN forms on the ventral side of the sacrum/coccyx, alongside the coccygeus muscle, to emerge laterally and travel dorsally to innervate skin over the coccyx and lower sacrum. A review of 13 patients with sitting pain due to the ACN, from 2015 to 2019, demonstrated a mean age of 54.6 years. Eleven were female. The etiologies of ACN injury were falls (9), exercise (3), and complication from surgery (1). Six of the 9 patients who had surgery were able to be followed up with a mean length of 36.3 months (range, 11-63 months). Overall, 3 had an excellent result, 2 had a good result, and 1 was not improved. The one with a failed result showed improvement with coccygectomy. The ACN must be included in the differential diagnosis of sitting pain. It is most often injured by a fall. The ACN can be evaluated with a diagnostic nerve block, can be identified at surgery, and can be resected, and its proximal end can be implanted into the coccygeus muscle. This surgery may prove an alternative to coccygectomy.

Protective effect and potential mechanism of Schwann cell‐derived exosomes on mechanical damage of rat dorsal root ganglion cells

Pudendal nerve (PN) injury was one of the most important pathogenesis of stress urinary incontinence (SUI). Schwann cell (SC)-derived exosomes could promote axonal regeneration. Wnt protein could significantly promote axonal regeneration and participate in the regulation of proliferation and differentiation of neural stem cells. Therefore, we sought to determine whether SCs-derived exosomes might also protect against damaged dorsal root ganglion cells (DRGs) through the Wnt/β-catenin pathway. The DRGs injury model was fabricated using a four-point bending system. The exosomes were separated from the SCs supernatant. XAV939, which was a small molecule inhibitor, was used to inhibit the Wnt/β-catenin pathway. Next, Cell Counting Kit-8 (CCK8) kit was used to detect cell activity. We evaluated the proliferative activity of DRG cells using the cell cycle and apoptosis detection kit. We assessed the cell apoptotic rates through the Annexin V/PE double staining. Finally, we detect the expression of downstream proteins of Wnt/β-catenin pathway in DRG cells using western blotting. SC-derived exosomes had protective effects on DRGs after mechanical damage, which could promote cell proliferation, transition of the cell cycle to the G2 phase, and inhibit cell apoptosis. Exogenous administration of XAV939 suppressed the promoting effect of SCs -derived exosomes on DRG cells and the expression of downstream proteins of Wnt/β-catenin pathway in DRG cells was also suppressed. These results suggested that SC-derived exosomes have a repairing effect on DRG cells injury caused by cyclic mechanical stretching (CMS) and the Wnt/β-catenin pathway is potentially involved in the process.

Pudendal Nerve Injuries in Sports and Exercise: A Case Series of Pudendal Neuropathies From Squats

Background: Pudendal neuropathy is an underrecognized cause of pelvic pain that can be difficult to diagnose and treat. Cycling has been the traditional etiology associated with exercise-induced pudendal neuropathy, but with changing aesthetic and societal norms emphasizing a strong physique, there has been increasing anecdotal evidence of squat-based exercises causing the condition. Study Design: Case series. A retrospective medical record review was performed to look at all patients with pudendal nerve injuries who presented to a physical medicine and rehabilitation pelvic floor rehabilitation clinic over a 1-year period. Case Description: There were 15 cases of pudendal neuropathy thought to be due to squat-based exercises. Here, we present 4 of these patients (1 male and 3 females) who had good follow-up and compliance with treatment recommendations, along with their respective outcomes. Outcomes: This is the first case series to present a number of patients with pelvic pain due to pudendal neuropathies presumably derived from squat-related exercise. All 4 of these patients had good outcomes utilizing a multidisciplinary approach to management. Discussion: It is important for both physicians and physical therapists to learn to recognize pudendal neuropathy as a cause of pelvic pain and to counsel patients effectively to help them avoid pudendal nerve injury during exercise.

Therapeutic new targets for stress urinary incontinence in the central nervous system

Stress urinary incontinence (SUI) is a common and bothersome problem among middle-aged women. However, there are few useful drugs for SUI. Urethral hypermobility and intrinsic sphincter deficiency are two main causes of SUI. Various animal models of SUI, such as vaginal distention, pudendal nerve injury, or ovariectomy, have been developed to study the pathophysiology of SUI. In addition, we have previously reported that cerebral infarction rats also induce SUI. Leak point pressure measurements are the most commonly used methods to evaluate the urethral dysfunction in SUI animal models. Originally, we have developed microtransducer-tipped catheter measurements of urethral activity during sneezing. Previous or our basic research has clarified potential strategies for pharmacotherapy of SUI in the central nervous system. Therapeutic targets include adrenergic and serotonergic (5-HT) receptors in the spinal cord, which stimulate pudendal nerve innervating the external urethral sphincter and/or sympathetic nerve innervating urethral smooth muscle. Activation of α1-adrenoceptors, 5-HT2C, or 5-HT7 receptors enhances the reflex at the spinal cord level whereas pre- or postsynaptic α2-adrenoceptors and/or 5-HT1A receptors inhibit the reflex. We have recently reported that stimulation of the spinal μ-opioid receptors by tramadol also enhances the reflex. Thus, we review the recent advances in basic SUI research and potential targets for pharmacotherapy of SUI in the central nervous system.

130 Evaluation of Bothersome/Distressing Penile Numbness with Orgasmic Dysfunction: Role of Neuro-Genital Testing to Localize the Site of Neurologic Pathology

Penile numbness is an unusual, troubling symptom that may cause delayed/muted orgasm. The afferent neurologic pathway (S2, 3, 4) to the brain passes along dorsal/pudendal nerves, in the cauda equina along sacral spinal nerve roots, and along the spinal cord to the brain. Penile numbness causing orgasm dysfunction can be caused by different pathologies and locations within this pathway. Reduced genital sensation/orgasm dysfunction may follow end organ injuries such as dorsal nerve damage during penile implant surgery especially with the infra-pubic approach; pudendal nerve injury such as during a straddle/fall onto the perineum or pudendal neuropathy from diabetes; radiculopathy of sacral afferent roots within the cauda equina such as from lumbar disc disease; spinal cord pathology such as spinal cord injury or multiple sclerosis; or lesions in the brain such as aneurysms as examples. The purpose of this retrospective chart review was to utilize objective assessments to determine the location of pathology in neurologic pathways of penile sensation from penis to brain so as to better manage patients.

Neuromonitoring Changes During Hip Arthroscopy in the Pediatric Population

Objectives:The objectives of this study were to determine the prevalence, pattern, and predisposing factors for sciatic, femoral, obturator, and pudendal nerve injury during hip arthroscopy in the pediatric population.Methods:We retrospectively reviewed charts of all pediatric patients who underwent hip arthroscopy with neuromonitoring from 2013 until May 2018. Neuromonitoring included when traction was applied and removed, and somatosensory evoked potentials (SSEP) in the peroneal and posterior tibial nerves and electromyography (EMG) signal for the obturator, femoral, and peroneal and posterior tibial branch of the sciatic nerves. Each report was reviewed for total traction time, EMG changes, SSEP changes more than 50% after traction application, and the time for SSEPs to return to baseline. Demographic data and postoperative notes were reviewed for any signs of clinical nerve injury and if/when recovery occurred. We determined the rate of SSEP and EMG changes, time from traction onset to SSEP and EMG changes, time after traction released until SSEP returns to baseline, and rate of neuropraxia and any potential risk factors.Results:We identified 78 patients who underwent hip arthroscopy (16±2 years of age; 54 females). Reasons for hip arthroscopy included femoral acetabular impingement (37%), hip dysplasia with labral tear (27%), slipped capital femoral epiphysis (23%), labral tear (5%), snapping hip (3%), diagnostic scope (3%), Perthes with labral tear (1%), and trauma (1%). Average traction time was 64±30 min. SSEPs decreases of less than 50% occurred in 76% of patients in the peroneal nerve, and 69% of patients in the posterior tibial nerve. In the contralateral limb, there was a 50% drop in SSEPs in the peroneal nerve in 13% of patients and in the posterior tibial nerve in 8% of patients. For the peroneal nerve, this drop in signal occurred 23±11 min after traction was applied and returned intraoperatively at a rate of 74% 29±23 min after traction removal. For the posterior tibial nerve, this drop in signal occurred 22±12 min after traction was applied and returned intraoperatively at a rate of 83% 24±15 min. after traction removal. EMG activity was observed after traction application in 10% of patients in the obturator nerve at 36±34 min., 9% of patients in the femoral nerve at 22 ± 15 min., 14% of patients in the peroneal nerve at 19±27 min, and 5% of patients in the posterior tibial nerve at 42±42 min. The rate of pudendal nerve neuropraxia was 0%. The rate of clinical neuropraxia postoperatively was 18%. Those who sustained a neuropraxia had on average a 54 min. longer surgery (p=0.005) and a trend towards a 14 min. longer traction time (p=0.096). Diagnosis had no statistical effect on the rate of clinical diagnosis.Conclusion:Hip arthroscopy is increasingly utilized to treat several unique diagnoses in the pediatric population. As such, it is important to understand the potential risks of treating different diagnosis in this population. The important findings of this study are that neuromonitoring changes occur in more than 70% of patients and 18% will have some decreased sensation in either their peroneal nerve or posterior tibial nerve that resolves within 1-2 days after surgery. There is also a low risk of neuropraxia if there are no neuromonitoring changes during surgery. Diagnosis (Hip dysplasia/SCFE/FAI) did not change incidence of neuropraxia. Longer surgery and traction time appear to be the only risk factors for neuropraxia in hip arthroscopy in pediatric patients.

Electrical stimulation enhances neuronal cell activity mediated by Schwann cell derived exosomes

Electrical stimulation (ES) therapy has good effects in patients with nervous system injury-related diseases. ES promotes nerve cell regeneration and stimulates Schwann cells to express neurotrophic factors. The incidence of stress urinary incontinence (SUI) among elderly people is increasing. Some studies suggest that damage to the pudendal nerve is closely related to the pathogenesis of SUI. It has also been found that pelvic ES can reduce SUI symptoms in a rat model of SUI caused by pudendal nerve injury. Clinically, pelvic floor electrical stimulation is effective in patients with mild to moderate SUI. These studies indicate that ES may ameliorate damage to the pudendal nerve and thus achieve the goal of SUI treatment, although the mechanism of action of this treatment remains unclear. Therefore, the purpose of the present study was to clarify the relationships among ES, neural cells and Schwann cells at the cellular level. We applied ES to nerve cells at 100 mV/mm or 200 mV/mm for 0, 0.5, 1, or 2 h to investigate changes in nerve cell activity. We then co-cultured the nerve cells with Schwann cells to explore the influence of single-culture and co-culture conditions on the nerve cells. Compared to non-ES, ES of the nerve cells increased their activity. Compared to those in single culture, co-cultured nerve cells exhibited an additional increase in activity. We also found that Schwann cell derived exosomes could promote the activity of nerve cells, with glutamate and calcium ions playing a potential role in this process. These results suggest that the mutual regulation of neural cells and Schwann cells plays an important role in the process by which ES ameliorates neurological function, which may provide a basis for subsequent studies.

Pudendal nerve injury impairs anorectal function and health related quality of life measures ≥2 years after 3D conformal radiotherapy for prostate cancer

Purpose: To compare GI symptoms, measures of generic and disease specific health related quality of life (HRQoL), anorectal and pudendal nerve function and anal sphincter morphology between (i) patients ≥2 years after 3D conformal radiotherapy (3D-CRT)±high dose rate (HDR) brachytherapy for carcinoma of the prostate and aged matched patients before radiotherapy and (ii) symptomatic and asymptomatic patients ≥2 years after 3D-CRT ± HDR brachytherapy.Material and methods: Methodology included: (i) modified LENT-SOMA scales for GI symptoms, (ii) EORTC QLQ-C30 and EORTC QLQ-PR25 questionnaires for generic and disease specific HRQoL, (iii) anorectal manometry and terminal motor latency for anorectal and pudendal nerve function and (iv) endorectal ultrasound for anal sphincter morphology. GI symptoms, parameters of HRQoL, anorectal and pudendal nerve function and anal sphincter morphology were compared using Mann–Whitney’s U, unpaired t and χ2 tests.Results: Impairment of HRQoL bowel symptoms in the patients ≥2 years after 3D-CRT ± HDR brachytherapy was associated with worse anorectal motor and sensory function, internal and external anal sphincter morphology and 5× greater prevalence of pudendal nerve dysfunction compared with age matched patients before radiotherapy. Symptomatic patients had worse (i) HRQoL measures including global quality of life and bowel and urinary symptom scores, (ii) rectal bleeding, fecal urgency and incontinence scores and (iii) a 2× higher prevalence of pudendal nerve dysfunction compared with asymptomatic patients.Rectal and anal (i) V 40 Gy >65%, (ii) Dmax >60 Gy, (iii) pudendal nerve Dmax >60 Gy and (iv) Anal V 60 Gy >40% were associated with a greater prevalence of pudendal nerve dysfunction.Conclusions: 3D-CRT ± HDR brachytherapy for prostate carcinoma, impairs late functional measures including HRQoL, anorectal and pudendal nerve function. Rectal, anal and pudendal nerve radiation dose constraints are proposed for reducing the prevalence of pudendal nerve dysfunction.

Pudendal nerve injury is a relatively common but transient complication of hip arthroscopy.

Hip arthroscopy is emerging as the standard of care for conditions involving the hip, and has a unique set of complications. The purpose of this review was to identify (1) the crude rate of pudendal nerve injury following hip arthroscopy and (2) the specific factors leading to pudendal nerve injury. MEDLINE, EMBASE, and PubMed were searched from database inception to October 2016. Patient demographics, indications, surgical technique, complication rates, treatment approaches, and rehabilitation strategies were extracted. Twenty-four studies (n = 3405) were included, withthe majority (66%) of studies being level IV evidence. The mean age was 33.9 ± 9.7years (range 12-78) and 48.2% were males. Average follow-up was 30.2 ± 19.1months. 62 patients were reported to have sustained pudendal nerve injury (1.8%) post-operatively, and all resolved within 6 weeks to 3 months. Of the seven studies that reported using a perineal post, 20 patients were diagnosed with pudendal nerve injury (4.3%), in contrast to two studies (189 patients) reporting only 0.5% pudendal nerve injury without the use of perineal post. Two studies commented on time of traction during surgical intervention with mean times of 98 and 68min with complication rates of 10% and 6.6%, respectively. Pudendal nerve injury is not uncommon following hip arthroscopy, with a reported rate found in this review of 1.8%. Potential risk factors may include the use of a perineal post and long traction times. All reported cases resolved within 3 months. Patients should be informed of complications related to pudendal nerve injury, which include sexual and urinary dysfunction. Level IV, systematic review of level I-IV studies.

Pulsed Radiofrequency Ablation of Pudendal Nerve for Treatment of a Case of Refractory Pelvic Pain

Pudendal neuralgia (PN) is a result of pudendal nerve entrapment or injury, also called “Alcock syndrome.” Pain that develops is often chronic, and at times debilitating. If conservative measures fail, invasive treatment modalities can be considered. The goal of this case report is to add to a small body of literature that a pulsed radiofrequency (PRF) ablation can be effectively used to treat PN and to show that high resolution MR neurography imaging can be used to detect pudendal neuropathy. Case Presentation: We present a case of a 51-year-old woman with 5 years of worsening right groin and vulva pain. Various medication trials only lead to limited improvement in pain. The first diagnostic right pudendal nerve block was done using 3 mL of 0.25% bupivacaine with 6mg of betamethasone using a transgluteal technique and a target of the right ischial spine; this procedure resulted in ~8 hours of &gt; 50% pain relief. The patient was then referred for MR neurography of the lumbosacral plexus. This study revealed increased signal of the right pudendal nerve at the ischial spine and in the pudendal canal, findings consistent with the clinical picture of PN. Six weeks after the initial block, the patient underwent a second right transgluteal pudendal nerve block, utilizing 3 mL of 0.25% bupivacaine with 40 mg of triamcinolone acetonide; this procedure resulted in ~8 hours of 100% pain relief. Satisfied with these results the patient decided to undergo pudendal nerve PRF ablation for possible long-term relief. For this therapeutic procedure, a right transgluteal approach was again utilized. PRF ablation was performed for 240 seconds at 42° Celsius. Following this ablation the patient reported at least 6 weeks of significant (&gt; 50%) pain relief. Discussion and Conclusion: In this paper we presented a case of successful treatment of PN with PRF ablation and detection of pudendal neuropathy on MR neurography. We believe that transgluteal PRF ablation for PN might be an effective, minimally invasive option for those patients that have failed conservative management. MR neurography employed in this case is not only helpful in confirming the diagnosis of PN but could also be useful in ruling out other causes of pelvic pain, such as genitofemoral neuropathy, endometriosis, adenomyosis, or pelvic mass lesion. To conclude, transgluteal PRF ablation can serve as a viable treatment option for mitigating symptoms of pudendal neuropathy and MR neurography is useful in confirming a clinically suspected diagnosis of PN. Key words: Pelvic pain, pudendal neuralgia, MR neurography, pulsed radiofrequency ablation, transgluteal technique, Alcock canal syndrome