Post-traumatic double crush pudendal nerve entrapment syndrome after fracture of the pelvis: A case report

Abstract

Pudendal syndrome is primarily characterized by stress urinary incontinence, dysuria, sexual arousal syndrome, painful erections, and anal incontinence. The syndrome occurs when the pudendal nerve or one of its branches is compressed, stretched, or injured. Double crush is the compression of a peripheral nerve at two or more separate areas with various signs and symptoms. We, herein, aimed to introduce the case of a 42-year-old male who underwent the distal release procedure due to the diagnosis of “double crush pudendal syndrome” following a proximal release surgery previously performed elsewhere. The patient’s history revealed a pelvic fracture with urethral injury 27 years ago. Throughout the years, the patient had been evaluated by various medical disciplines and undergone several treatments. In 2017, an orthopedic surgeon performed proximal pudendal nerve release using transgluteal approach, and then rectal pain and defecation complaints relieved. However, in 2019, the patient was referred to our clinic because of the persistence of erection and perineal complaints after the proximal pudendal nerve release. Based on a detailed clinical and laboratory assessment, the diagnosis of double crush neuropathy was established, and distal release of the pudendal nerve using transperineal approach was performed. To determine the efficiency of the surgical treatment, International Index of Erectile Function (IIEF) and Quality of Erection Questionnaire (QAQ) tests were used preoperatively and at the first postoperative year. Furthermore, to assess the perineal pain, erection pain, and pain during intercourse Visual Analog Scale (VAS) was used. The erectile dysfunction improved from the severe degree (9 points) to the mild degree (22 points) postoperatively. The patient’s general and sexual satisfaction scores, and erection quality score improved compared to the preoperative baseline. According to VAS, the perineal pain, erectile pain, and pain during intercourse decreased postoperatively. (from 7 to 2 out of 10, from 8 to 3 out of 10, from 7 to 2 out of 10, respectively). When perineal and sexual complaints are encountered following pelvic trauma, the pudendal nerve-related problems, especially double crush syndrome, should be kept in mind in differential diagnosis. A multidisciplinary approach must be established in order to avoid any delay in diagnosis and treatment. Surgical intervention may provide a significant improvement in clinical and functional status.

Pudendal nerve neurolysis outcomes for urogenital and rectal disorders in patients suffering from pudendal nerve entrapment: A systematic review

“…In some cases, PNE, SUI, and AI may coexist. Ayik et al [ 22 ] reported a case with bilateral PNE following a pelvis fracture 27 years before. Proximal transgluteal PNN relieved rectal pain and resolved AI.…”

“…Finally, 70 full-text papers underwent further screening for appropriateness, leading to the exclusion of 49 additional papers. Finally, 21 papers met the inclusion criteria and were included [ 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 ]. Fig.…”

“…Among the included studies, 7 were retrospective [ 12 14 19 23 24 27 31 ], 8 were prospective [ 11 13 15 16 20 21 25 29 ], and 6 were case reports [ 17 18 22 26 28 30 ]. No randomized trials were identified.…”

“…No randomized trials were identified. The surgical techniques employed varied, with 8 studies utilizing minimally invasive surgery [ 12 15 18 19 20 23 29 30 ], while the remaining ones used transgluteal or transperineal open PNN [ 11 13 14 16 17 21 22 24 25 26 27 28 31 ]. Six studies assessed the specific site of PNE [ 11 12 13 14 15 16 ].…”

“…Six studies assessed the specific site of PNE [ 11 12 13 14 15 16 ]. LUTS was evaluated in 5 studies [ 15 17 18 19 20 ], anal or urinary incontinence in 6 studies [ 13 19 21 22 23 24 ], and sexual dysfunction in 11 studies [ 16 17 19 22 25 26 27 28 29 30 31 ]. Table 1 shows the characteristics of the included papers.…”