Dellon A Lee, Coady Deborah, Harris Dena
Department of Plastic Surgery, Peripheral Nerve Surgery, Johns Hopkins University, Baltimore, Maryland.
Department of Gynecology and Obstetrics, New York University Langone Medical Center, New York City, New York.
J Reconstr Microsurg. 2015 May;31(4):283-90. doi: 10.1055/s-0034-1396896. Epub 2015 Jan 28.
When pudendal nerve dysfunction fails to improve after medical and pelvic floor therapy, a surgical approach may be indicated. "Traditional," "posterior," transgluteal nerve decompression fails in an unacceptably high percentage of patients. Insights into pudendal neuroanatomy and pathophysiology offer improved microsurgical outcomes.
To evaluate results of a peripheral nerve approach to the pudendal nerve, 55 patients were prospectively evaluated. This cohort included 25 men and 30 women. Surgical approach was posterior, transgluteal if symptoms included rectal pain; or "anterior," inferior pubic ramus approach if symptoms excluded rectal pain. Surgical approach was "resection," if trauma created a neuroma, and "decompression," if there were no neuroma. Effect of comorbidities was analyzed.
At 14.3 months postoperatively, untreated anxiety/depression correlated with outcome failure, regardless of surgical approach, p < 0.002. There was no difference in results, men versus women, "anterior" versus "posterior" approach, or neuroma resection versus neurolysis. Success correlated with the "learning curve" of the surgeon. Self-rated success was significantly better (p < 0.0001) for patients operated on during the second year of the study than the first year of the study, and improved again in the final year of the study (p < 0.04), with 86% of the patients in final year achieving an excellent result and 14% achieving a good result.
There is hope for surgical relief from pudendal nerve problems by distinguishing neuroma from compression in the diagnosis, and then choosing a site-specific surgical approach related to which pudendal nerve branches are involved.
当阴部神经功能障碍在药物治疗和盆底治疗后未能改善时，可能需要采取手术方法。“传统的”“后路”经臀神经减压术在相当高比例的患者中失败。对阴部神经解剖学和病理生理学的深入了解可改善显微手术效果。
为评估阴部神经周围神经手术方法的结果，对55例患者进行了前瞻性评估。该队列包括25名男性和30名女性。如果症状包括直肠疼痛，手术方法为后路经臀；如果症状不包括直肠疼痛，则为“前路”耻骨下支入路。如果外伤形成神经瘤，则手术方法为“切除术”；如果没有神经瘤，则为“减压术”。分析了合并症的影响。
术后14.3个月，无论手术方法如何，未治疗的焦虑/抑郁与治疗失败相关，p < 0.002。男性与女性、“前路”与“后路”入路、神经瘤切除术与神经松解术的结果没有差异。成功与外科医生的“学习曲线”相关。在研究的第二年接受手术的患者自我评定的成功率明显高于第一年（p < 0.0001），在研究的最后一年再次提高（p < 0.04），最后一年86%的患者取得了优异的结果，14%的患者取得了良好的结果。
通过在诊断中区分神经瘤与压迫，然后根据受累的阴部神经分支选择特定部位的手术方法，阴部神经问题有望通过手术得到缓解。
