Center for Urologic and Pelvic Pain, St. Paul, Minnesota, USA.
Neurourol Urodyn. 2024 Nov;43(8):1883-1894. doi: 10.1002/nau.25555. Epub 2024 Jul 20.
(1) To use intraoperative photographs to visualize and explain pudendal nerve compressions and anatomical variations of compression sites in patients with chronic pelvic pain. (2) To emphasize the diagnostic importance of sensory examination with a safety pin at the six pudendal nerve branches in all patients with chronic pelvic pain; the dorsal nerves (penis or clitoris; the perineal nerves; and the inferior rectal nerves).
Between 2003 and 2014, "definite" pudendal neuropathy was diagnosed by examination and with two neurophysiologic tests. Neurolysis, via a transgluteal approach, was recommended only after 14 weeks of conservative care failed to adequately improve symptoms and validated symptom scores. Photographs of surgical findings were culled for their educational impact. An illustration of each photo clarifies the surgical anatomy.
The transgluteal incision permits access to pudendal anatomy and compression sites from the subpiriformis area through the interligamentary space and the pudendal canal (Alcock canal). Compressions were acquired or congenital and severity varied significantly. Pinprick sensory testing diagnoses pudendal neuropathy in 92% of both genders. Mid-nerve compression occurred commonly between the sacrotuberous and sacrospinous ligaments less frequently in the Alcock canal, but also at aberrant pathways, for example, between layers of the sacrotuberous ligament; a separate inferior rectal nerve passing through the sacrospinous ligament; at an anomalous lateral pathway posterior to the ischial spine. The results of international surgeons are discussed.
Decompression surgery was recommended in approximately 35% of patients in this practice, when pudendal neuropathy (pudendal syndrome), did not respond to two conservative levels of treatment: (1) nerve protection and medications and, (2) a series of three pudendal nerve perineural injections given at 4-week intervals. Significant nerve compression is consistently observed. Pathophysiology includes axonopathy from ischemia and demyelination. Neuropathy is readily diagnosed using a pinprick sensory examination of six pudendal nerve branches. Monitoring with the National Institutes of Health Chronic Prostatitis Symptom Index records cures >13 years.
（1）利用术中照片可视化并解释慢性盆腔痛患者阴部神经受压和受压部位的解剖学变异。（2）强调在所有慢性盆腔痛患者中使用安全别针对 6 条阴部神经分支进行感觉检查的诊断重要性；阴部神经的背侧神经分支（阴茎或阴蒂；会阴神经；和直肠下神经分支）。
在 2003 年至 2014 年间，通过检查和两项神经生理测试诊断为“明确”阴部神经病变。仅在保守治疗 14 周后症状仍未得到充分改善且验证症状评分后，建议进行经臀切开术的神经松解术。选择有教育意义的手术发现照片。每张照片的插图都阐明了手术解剖结构。
经臀切口可从梨状肌区域通过耻骨联合间隙和阴部管（阴部管）进入阴部解剖结构和受压部位。压迫是获得性或先天性的，严重程度差异很大。针刺感觉测试在两性中均可诊断出 92%的阴部神经病变。中部神经压迫常见于骶结节和骶棘韧带之间，在阴部管中较少见，但也存在异常途径，例如，在骶结节韧带的各层之间；一条单独的直肠下神经穿过骶棘韧带；在坐骨棘后异常的外侧途径。讨论了国际外科医生的结果。
在本实践中，当阴部神经病变（阴部综合征）对两种保守治疗水平（1）神经保护和药物治疗，以及（2）每隔 4 周进行 3 次阴部神经周围注射治疗没有反应时，建议对约 35%的患者进行减压手术。始终观察到明显的神经压迫。病理生理学包括缺血和脱髓鞘引起的轴突病。使用针刺感觉检查 6 条阴部神经分支可轻松诊断神经病变。使用美国国立卫生研究院慢性前列腺炎症状指数（National Institutes of Health Chronic Prostatitis Symptom Index）进行监测可记录超过 13 年的治愈情况。
