Pudendal Canal Syndrome
Overview
Ahmed Shafik & Olfat El Sibai ,MD ,PhD
Professors and Chairmen Department of
Surgery & Experimental Research
Faculty of Medicine, Cairo & Menoufia Universities
Shafik’s Foundation for Science
Surgical anatomy of PN: (Shafik ,1995)
 S2 → upper cord
 S3
lower cord
 S4
PN above SPL →
pass behind SPL medial to ischial spine → pass
between SPL + STL→ PC → branches:
*IRN
* Perineal n
* Dorsal n of penis
(clitoris)
Pudendal canal syndrome: (Shafik,1991)
PN compression in PC
Presentation:
1- Proctalgia
(Shafik, 1991& El-Sibai, 1996)
2- FI
(Shafik, 1994)
3- FI in complete R prolapse (Shafik, 1994)
4- USI
(Shafik, 1994)
5- ED
(Shafik, & El-Sibai, 1995)
6- Scrotalgia
(Shafik, 1993)
7- Prostatodynia
(Shafik, 1998)
8- Vulvudynia
(Shafik, 1997)
9- Interstitial cystitils
(Shafik, 2008)
10- Ischemic proctitilis
(Shafik, 1996)
Mechanism of PCS
On ↑↑straining at defecation or delivery →
↑ intra-abd.pr. → brunt on LA & anoccygeal
raphe → LA sublaxation & sagging →
pull on IRN → pull on PN → neuropraxia or
axontmesis → PN entrapment neuropathy
in PC by edemae & ischemia → motor &
sensory manfestation of PCS
Proctalgia: (Shafik, 1991 & El-Sibai 1996)
- Abrupt, sharp pain in anal or perianal regions
- Few to 30 mts
- Intermittent, by day or night
- Unrelated to defecation
- Aggravated by sitting
- 2-3 times / wk
- Increasing frequency
- Perineal numibness & tingling
- Common in multiparous & difficult deliveries
- ±assoc. with FI to soft stools or flatus
- D/E: ▪ tenderness on pressing on PN
▪ peri-anal & peri-vulval hypo. or anesthesia
▪ absent anal reflex
FI: (Shafik
1994)
 - Females with multiple deliveries
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- FI to stools and flatus
- alone or with SUI or in CRP
- ↓ anal pr.
- P. neuropathy by PCS→ IRN neurpthy.
FI in CRP:
1994)
(Shafik,
 In CRP →↓ EMG activity of LA
 Levator dysfunction ± primary cause of CRP
 Sublaxated & sagged LA → pull on PN →
 Continues LA activity → PN stretch &
tramatization → neuropraxia or
axontmesis → PN entrapment → IRN
neuropathy → FI
 PNTML prolonged
USI:
(Shafik,1994)
 ↓ EMG activity of EUS & prolonged both
latency of straining-urethral reflex & PNTML
 ET is neurogenic→PCS
Evidences :
- Weak EUS
- Prolonged latency of straining- urethr. reflex
- Prolonged PNTML
- Concomitant idiopath. FI
- ↑ USI incidence with multiparous
Erectile Dysfunction:
(Shafik,1994, El-Sibai,1995)
▪ Excluded psycogenic, vasculogenic,
hormonal & metabolic (dibetis M)
▪ ± Assoc. with penile pain
 Absent nocturnal tumescence
 Penile, perineal & scrotal hypo. or
anesthesia
 EMG: ↓ EUS, EAS & LA
 ↑ PNTML
 Chronic constipation & ↑↑straining at
defecation→↑intra-abd. pr.→ overstretch
of LA → LA sublaxation & sagging→ pull
on PN & artery →entrapment→ dorsal N.
of penis neuropathy→ ED
Vulvudynia:
(Shafik,1997)
 Vulvur burning & introital dyspareunia of
idiopathic cause with failed various trt.
 Multiparous, assoc. with USI
 Pain every 2-3ds. induced by coitus
 Not related to defecation or urination
 Crisis 2-4hs.
 PN block diagnostic
 Gyne.exam.→bilat. vulvar erythema &
tenderness on pressing on PN
 Valvar & perineal hyposthesia or anesthesia
Beco et al, 2004 :
 74 female pts. with perineodynia
(vulvudynia,perineal pain & proctalgia),
FI & USI
 PCD : - Significant improvement of
symptoms & signs
- ↓ PNTML
- ↑ EMG activity of LA & EAS
Scrotalgia:( Shafik,1993)
 Scrotal pain alone or ± assoc. penile pain or
ED
 No testicular pathology (varicocele or infection)
 P.H. of chronic constipation & ↑↑ straining at
defecation
 D/E: -tenderness on pressing on PN
-hypo. or anesthesia of perineal area
 ↓ EMG of LA &EAS & ↓ PNTML
Prostatodynia: (Shafik,1998)
 Pain in perineam & scrotum or anal
canal
 Continuous with exacerbation or
intermittent
 Dull aching ,not related to urination or
defecation
 Assoc. with frequency, urgency & dysuria
 Prostatic secretion → no bacteria
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No improvement with antibiotic
P.H. chronic constipation & ↑↑ straining
Perineal hyposthesia & weak anal reflex
EMG ↓ activity of LA & EUS, normal EAS
PNTML ↑
PN block → diagnostic & therapeutic test
IRN → supplies EAS,LA & m.m. of ↓1/2
of AC & perinanal skin
Perineal N.→ EUS
Mechanism: Constipation & straining →
LA sublaxation & sagging → pull on PN →
stretch distal part of PN at winding around
SPligmt.→ neuropraxia & axontmesis
*Subsequant N.compression → PN
ischemia→N. damage
*P.neuropathy involves perineal N &
to a lesser extent IRN
Interstitial Cystitis : (Shafik 2008)
- Pain suprapubic,pubic,vaginal & genital
- Exacerbated by intercourse or ejaculation
- Exam. → suprapubic & vag. wall
tenderness
- Common in ♀ & IC most common cause of
pelvic pain in gyne.
- Remission & relapse
- UB innervated by pelvic hypogastric/lumbar
splanchnic innerv. Lumbosacral afferent in
pelvic & PN sense & regulate continence &
micturition
- PN commonly compressed by PC or by
sacral ligmts. clamp
- PN entrapment → P neuritis → PCS
- Painful micturition & dysparuma are
symptoms of genital & perineal n.
involvement of PN.
Pudendal Artery Syndrome
Presenting as Ischemic Proctitis
Report of 3 cases (Shafik,DigSurg 1996):
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Not in literature
Anal pain,bleeding &P.H. of stainodynia+PCS
D/E→AC tender,edematous & ulcerated
R &C →free
Biopsy: mucosa lost,submuc.edem.& RC
infiltration
 D :selective pudendal arteriography →
obliterated distal part(PC),not visualized IRA
 Et :→ L sublaxation & sagging →pull on
artery & nerve in→arteritis & neuropathy
 TRT: PCD →release PN & IPA
 PO : - symptoms disappear
- healing of AC
- IPA remains obliterated but
improvement is due to release of
collateral vess. From compression
Diagnosis:
▪ C/E: ● P.H. of straining
● PCS symptoms
● D/E: -tenderness on pressing on PN
-perianal or perineal hypo.or anesthesia
▪ ↓ AC pr.
▪ ↓ anal reflex
▪ ↓ EMG of LA & EAS or EUS
▪ ↑ PNTML
Pudendal nerve decompression:
Technique : Anterior approach.
▪ Lithotomy position
 Vertical para-anal incision 2cm from A orifice
▪ Ischio-rectal fossa entered
▪ IRN identified across IRF,N hooked by finger &
traced to PN in PC
▪ PC fasciotomy
▪ Same procedure on the other side
PND :Posterior app roach
(Shafik,1992)
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Technique :
Pt. in jack knife position
Vertical para-sacral skin incision
Glut. max. exposed & divided
Triangle identified
PN & vess. are over sacrospinous lig. passing
from GSF to LSF
 PC fasciotomy & PN releasad
 Glut. Max. repaired
 Op. repeated on the other side
● Indication: recurrent PCS
● PO follow up monthly for 6 mth.,every 3
mth. for 14-18 mth.by→ PNTML, EMG &
manometry
● PO complications : minimal.
Role of Sacral Ligament Clamp
Pudendal Neuropathy (PCS):
Result Of Clamp Release
(Shfik,2007)
 This study showed the cause of PND
failure in P neuropathy in the 21 pts. not
improved after PCD
 Clinical & investigative results improved
after SLC release in 80.9%
 PN sensory & motor affection improved &
points that PN was involved SpL clamp in
80.9%
 Failure to improve SL division release PN
from compression in SLC
 after PCD & improved after SLC release
in 17 pts. denotes that PN was affected
by SLC
 PN compression could be in both SLC &
PC
 In our study PCS, of 206 cases it
occurred in only 21 pts. (10.2%)
 This assumed to be due to :
(a)- anatomical anomaly of Sp. L & St.
L, so narrowing the space between them.
(b)- The sharp edge of SPL traumatize
PN while passing over it.
Technique of sacral ligament
clamp release:
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PCD→ anterior approach
Vertical para-anal incision
IRF entered
IRN identified & followed laterally to PN in PC
Verify previous operation (PN free)
Ischial spine & SPL. identified
PN dorsal to SPL. & between SPL. &STL.& enter
PC
■ SPL- overlaying coccygeous m.→
divided at ischial spine by tenotomy
knife & releasing PN free
■ Wound loosely closed
■ Op. repeated on other side

Improvement of 80.9% of cases after
sacral ligament clamp release, denotes
that PN is traumatized not only in PC but
also in SLC
The cause of non improvement of 19.1%
of cases after SLC release is due to
advanced irreversible PN damage.
Non improvement :
- faulty diagnosis
- irreversible PN damage
Further studies needed
Conclusion
● PCD is effective & successful procedure
in treating motor & sensory manifestation
of PCS; perineodynia (proctalgia, perineal
pain & vulvudynia), FI, USI, ED & ischemic
proctitis.
● The anterior approach is easier less time
consuming. The posterior approach is
indicated in recurrent cases
● PN compressed by: 1- PC commonly
2-Sacral ligments. Clamp
Thank You and
Thanks to
Ahmed
Shafik