De Novo Pudendal Neuropathy After TOT-O Surgery for Stress Urinary Incontinence.

2011·0.07 MB·English

by  Paulson, John D.

S P
CIENTIFIC APER
De Novo Pudendal Neuropathy After TOT-O Surgery
for Stress Urinary Incontinence
John D. Paulson, MD, James Baker, PhD
ABSTRACT INTRODUCTION
Background and Objectives: Five cases of pelvic nerve Since the advent of the tension-free vaginal tape (TVT),
complications after transobturator tape (TOT) inside-out retro pubic sling surgery with TVT for stress urinary in-
surgical procedures for stress urinary incontinence are continence in the female has become the gold standard
presented. for treating stress urinary incontinence by this minimally
invasive technique.1 Follow-up has suggested that long-
Methods: We conducted a chart review of patients with
term results have shown efficacy, safety, and tolerability.
complications referred to our practice.
In the early 2000s, vaginal slings (transobturator tape)
Results:FivepatientswithnervecomplicationsafterTOT [TOT]utilizingatransobturatortechnique(outside-in)be-
inside-out procedures were investigated. Pudendal neu- camemorepopular2andcouldbeperformedquickerand
ropathy and interstitial cystitis were seen in this series of seemedtohavecomparableefficacyandproducedfewer
patients with several patients having myofascial pain in problems with the bladder and the bowel.3-7 De Leval in
the lower abdominal area. 20068introducedatransobturatorminimallyinvasivepro-
cedure for urinary stress incontinence (inside-out) in the
Conclusions:Althoughnotcommonlyreported,compli-
female, which differed from the original TOT approach.
cations from needle placement and from the area of nee-
This method involved placing the tunneling needle from
dle exit in a TOT procedure can exist, and the surgeon
inside the vagina, under the pubic ramus and out the
mustbecarefulwhenplacingtheneedlethroughthearea
obturator fossa. Subsequent studies have noted that its
of the obturator fossa.
safetyprofileiscomparabletothatoftheTOT(outside-in)
Key Words: Pudendal neuropathy, Interstitial cystitis, and that it works as well in relieving incontinence due to
Transobturator tape surgery. stress.5,9-11
There have been reports of groin pain and other minor
complicationsthatusuallysubsidespontaneouslywiththe
TOT-O procedure (inside out) and TOT outside-in. Re-
portsofsexualdysfunctionaftertheseproceduresarevery
limited.9,11-13 No reports have been published of severe
pelvic pain secondary to these procedures. The differen-
tialdiagnosisofpersistentpelvicpaincanincludemuscle
strain, osteitis pubis, inflammation, or nerve entrapment.
This report explores the first reported cases of “De Novo
PudendalNeuropathy”in5individualswhohadaTOT-O
procedure. Stedman’s Medical Dictionary14 defines neu-
ropathy as any disturbance or pathologic changes in the
nervoussystem.Peripheralneuropathyisaproblemwith
the nerves that carry information to and from the brain
Institute for Advanced Endoscopic Training, Rockville, Maryland, USA (Dr
Paulson). and spinal cord. This problem can produce pain, loss of
Department of Anatomy, Howard University School of Medicine, Washington, sensation, and an inability to control muscles.15
DistrictofColumbia,USA(DrBaker).
Addresscorrespondenceto:AddressforCorrespondence:JohnD.Paulson,MD,
15636 Haddonfield Way, Gaithersburg, Maryland 20878, USA. Telephone: (240) CASE REPORT
751-2175,Fax:[phone],E-mail:[email protected]
From July 1, 2008 through June 30, 2009, five patients
DOI:10.4293/108680811X13125733356279
came to the office after surgical procedures for stress
©2011byJSLS,JournaloftheSocietyofLaparoendoscopicSurgeons.Publishedby
theSocietyofLaparoendoscopicSurgeons,Inc. urinary incontinence and were seen for chronic pelvic
326 JSLS(2011)15:326–330
pain after TOT-O procedures that had been previously the symptoms was noted, this was used to help diagnose
performed 6 months to 3 years prior to being seen. No pudendal nerve entrapment.17
pain had been noted prior to the surgical procedure per-
Determining a myofascial neuropathy involves getting a
formedforstressurinaryincontinence.Acompletehistory
history, physical examination, and an anesthetic block to
wastaken.Exclusionofcertaindiagnosesorinclusioninto
the area of distribution of the nerve that relieves the
themultitudeofproblemswasnecessarytoformulatethe
discomfort. This was performed on each of the patients.
diagnosis. A Pain, Urgency and Frequency (PUF) ques-
tionnaire16 was administered to the patients, and abdom-
Therapy involved specific blocks (abdominal myofascial
inalandpelvicexaminationswereperformedtocheckfor
blocks, such as ilioinguinal/iliohypogastric nerve blocks,
any abnormalities including neuropathic and myofascial
pentosan polysulfate sodium, instillations of the bladder
pain.Myofascialpaindistributioninthelowerabdominal
[usinglidocaine,heparin,triamcinolone,andbicarbonate]
area if present was confirmed, as was Carnett’s sign; the
andaddingDMSO[dimethylsulfoxide]afterseveralinstil-
area of distribution of the pudendal nerve was followed
lations), and 3 of 5 patients were given gabapentin.
andpain,whenelicited,wasnoted.Bladdertendernessto
palpation after voiding was recorded.
RESULTS
If a patient had myofascial pain discomfort, blocks were
injectedwithbupivicaineanddecreaseofpainwasnoted. All patients had TOT inside-out procedures. All had no
For the patients who had pain in the pudendal area, an history of pain prior to the surgery for incontinence and
anesthetic response to a pudendal nerve block was care- symptoms as described previously. PUF questionnaires
fully recorded.17 It was determined that “clinical testing revealedprobableinterstitialcystitis(IC)withlevelsrang-
with positive anesthetic response during pudendal nerve ing from 16 to 25 (Table 1). Abdominal myofascial pain
block can be used to diagnose pudendal nerve entrap- syndrome was elicited in 2 patients. Cystoscopy demon-
ment.” Cystoscopy with hydro distention with the patient stratedpositiveglomerulationsin4ofthe5patientstested
under anesthesia was performed on the 5 patients, and (Table 1). All patients responded to blocks with anes-
glomerulationsinall4quadrantsweredocumentedin4of thetic agents administered, and over time, the continua-
the 5 patients. tion of these blocks led to a diminution of discomfort.
Thefirststepwastodeterminethesymptoms.Oftenthere Alleviation of both bladder pain and pudendal pain was
is a spontaneous or evoked burning pain. It is also pos- noted. Sexual dysfunction mostly dyspareunia, was im-
sible to have a deep aching or noxious feeling in the provedbytreatingtheseproblems.Althoughfollow-upof
pelvic area and an exaggerated sensation to a stimulus thetreatmentswerenotperformedforanextendeddura-
that usually does not cause discomfort. Pudendal nerve tion of time, 2 patients became asymptomatic within 5
pain often worsens in the sitting position with relief or months to 6 months, and within a year all had improved.
amelioration by standing, or sitting on a toilet seat. The One patient did not return for follow-up after several
second step was to locate the site of the symptoms on monthsbuthadsignificantimprovement,andletusknow
physical examination. Lastly, the third step involved giv- she was doing well and would call if her pelvic pain
ing an anesthetic block to the pudendal nerve. If relief of became a problem.
Table1.
FivePatientsWithPelvicPain
Patient BladderPainby PudendalPainby DyspareuniaBeforeTreatment MyofascialPain PUF Cystoscopy(cid:1)10
Examination Examination VisualAnalogScale18-20 Abdominal Scores14 Glomerulations
PerQuadrant
1 (cid:2) (cid:2) 8/10 - 23 (cid:2)
2 (cid:3) (cid:2) 9/10 - 19 (cid:2)
3 (cid:2) (cid:2) 10/10 (cid:2) 25 (cid:2)
4 (cid:2) (cid:2) 10/10 (cid:2) 22 (cid:2)
5 (cid:2) (cid:2) 10/10 - 16 (cid:3)
JSLS(2011)15:326–330 327
DeNovoPudendalNeuropathyAfterTOT-OSurgeryforStressUrinaryIncontinence,PaulsonJDetal.
DISCUSSION
Table2.
CriteriaoftheNantesCriteriaforPudendalNeuropathy.
ReportsofthesafetyofboththeTOToutside-inandthe
AdaptedfromLabatetal.25
TOTinside-outhaveshownthatboththeoperationsare
EssentialCriteria
usually safe.3-7,9-11,13,21-23 A study of embalmed hemi
pelvises that looked at the various nerves and their Painisintheterritoryofthepudendalnerve:fromtheanusto
thepenisorclitoris
relationship to the various sling procedures demon-
strated that the distances to the dorsal nerve of the Thepainispredominantlyexperiencedwhilesitting
clitorisaresimilar,butthatthereisamajordifferencein Thepaindoesnotawakenthepatientatnight
that the distance from the needle to the obturator canal Painhasnoobjectivesensoryimpairment
is closer in the inside-out technique. This means that
Painisrelievedbyadiagnosticpudendalnerveblock
theinside-outproceduremaybefraughtwithincreased
ComplementaryDiagnosticCriteria
potential problems of nerve damage.24 The entry point
Therecanbeburning,shooting,stabbingpain,andnumbness
is always more exact than the exit point in these types
of surgical procedures. Occasionallythereisallodyniaorhyperpathia
Therecanberectalorvaginalforeignbodysensation
As the pudendal nerve leaves the ischiorectal fossa and
Therecanbeworseningofpainduringtheday
passesintotheurogenitaltriangle,itgivesofftheperineal
Itispredominantlyunilateralpain
nerve and dorsal nerve of the clitoris. The perineal nerve
penetrates the posterior aspect of the superficial fascia Thediscomfortcanbetriggeredbydefecation
and enters the superficial pouch of the perineum. It di- Therecanbeapresenceoftendernessonpalpationofthe
vides into muscular branches to supply the ischiocavern- ischialspine
osus, bulbospongiosus, and superficial transverse peri- Clinicalneurophysiologyfindingsinnulliparouswomen
neal muscles and continues into the skin as the posterior ExclusionCriteria
labial branches. In addition, branches of the perineal
Ifthereisexclusivitywithcoccygeal,gluteal,pubic,or
nerve enter the deep pouch to supply the sphincter ure- hypogastricpain
thrae and sphincter vaginalis. The dorsal nerve to the
Pruritus
clitorispassesthroughthedeeppouchandcoursesalong
Exclusivelyepisodesofparoxysmalpain
the dorsal aspect of the clitoris.
Ifimagingabnormalitiescanaccountforthepain
Surrounding the vagina and lower uterus are many sym- AssociatedSignsNotExcludingtheDiagnosis
patheticandparasympatheticbranchescoursingfromthe Buttockpainwhilesitting
inferiorhypogastricplexus.Vaginalnervesfromthelower
Referredsciaticpain
part of the inferior hypogastric plexus and uterovaginal
Painreferredtothemedialaspectofthethigh
plexus follow the vaginal arteries to supply the vaginal
Suprapubicpain
walls, the erectile tissue of the vestibular bulbs and clito-
ris,theurethra,andthegreatervestibularglands.Running Urinaryfrequencyand/orpainonafullbladder
withthesefibersaremanygeneralvisceralafferent(GVA) Painoccurringafterejaculation
fibers that follow the sympathetics and parasympathetics Dyspareuniaand/orpainaftersexualintercourse
back to the spinal cord (they run with the pelvic [para-
Erectiledysfunction
sympathetic]andsacral[sympathetic])splanchnics.Pelvic
Associatedwithnormalclinicalneurophysiology
pain fibers from the upper parts of the vagina (GVA) run
with the pelvic splanchnic nerves. If the anterior vagina
wall is being dissected, rarely general visceral efferent
One reported case in the literature has shown that hemor-
(GVE) and GVA fibers may be damaged accounting for
rhage and nerve damage of the needle tunneler in a TOT
why there are very few problems with vaginal surgery
inside-outprocedurecouldbeacauseofbleedingandpain.26
involving the anterior compartment.
Corona et al27 have recently described neuropathy after TOT
surgeryandproposedlaparoscopicneurolysisastherapy.
The Nantes criteria25 were developed for the diagnostic
criteria of pudendal neuropathy; this entity is a clinical Historymustbeextensivelyexploredforallpatientswith
problemthatoftenisdifficulttodiagnose(Table2).All5 chronic pelvic pain. Exclusion of other diagnoses or in-
patients fulfilled the criteria. clusion into the myriad of problems often helps with the
328 JSLS(2011)15:326–330
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pain sensation occurring with a particular stimulation,
9. David-Montefiore E, Frobert JL, Grisard-Anaf M, et al. Peri-
which usually does not cause discomfort, or there can be
operative complications and pain after the suburethral sling
an unpleasant or exaggerated prolonged pain response.
procedureforurinarystressincontinence:aFrenchprospective
Symptomsofpudendalnerveentrapmentareoftenexag-
randomised multicentre study comparing the retropubic and
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