SP06. Pudendal Nerve Entrapment: Efficacy of Surgical Decompression in Alleviating Pain Symptoms

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PURPOSE: Pudendal neuralgia is a debilitating chronic pain condition resulting from compression or irritation of the pudendal nerve, generally manifesting as pain with sitting, as well as pain in pudendal nerve distribution areas (peri-anal, perineal, labioscrotal, and penile/clitoral areas). Misdiagnosis and treatment delays are common because it is often under-recognized. Surgical decompression is a safe and viable therapeutic option, though there is considerable variation in decompression techniques. This study presents our experience with surgical decompression at Alcock’s canal or beneath the piriformis muscle at the sciatic outlet. METHODS: An IRB-approved retrospective analysis was conducted on patients with pudendal neuralgia treated between 2022 and 2024. Neurolysis was performed at Alcock’s Canal or the sciatic outlet based on clinical presentation and work-up, including presence of Tinel sign, and anesthetic block response. Primary outcomes included symptomatic changes at 3, 6, and 12 months postoperatively. Secondary outcomes included changes in compound muscle action potential (CMAP) pre- and post-decompression. RESULTS: Fifty-one patients (n=35 males, n=16 females) underwent 68 operations (n=65 unilateral, n=3 bilateral). The median (Q1-Q3) age at surgery was 54.0 years (33.0-63.9). Symptom distribution was equal (26 bilateral, 26 unilateral), with at least 50% reporting perineal, perianal, and scrotal/labial pain. The median duration of symptoms was 2.5 years (1.5 - 4.0), and the median time from consultation to decompression was 190 days (102-470). Neurolysis was performed at Alcock’s canal in 60.3% (n=41) and both Alcock’s Canal and the sciatic outlet in 39.7% (n=27). Intraoperatively, neurolysis significantly decreased the lowest recorded CMAP waveform (pre-neurolysis median 2.5mA to 0.5mA post-neurolysis, Z= -4.71, p <.001). Six patients were lost to follow-up. Subjective reports indicated no/minimal improvement in 6.45% (n=4), moderate improvement in 43.5% (n=27), and significant improvement in 50.0% (n=31) from patients pre-operative symptoms. At the 12-month follow-up, 71.5% of the 21 available patients reported significant improvement. CONCLUSION: Surgical decompression may offer a viable tool for treating this devastating condition. Successful outcomes are likely predicated on excellent patient selection, including positive response to a preoperative anesthetic block, and an examination consistent with entrapment at either of these locations. CMAP changes should be interpreted with caution, but immediate improvements may indicate the true site of electric compression. Further research is ongoing to elucidate the various compression points of the pudendal nerve, and reliably intervening to afford patients a cure.

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