In surgical approaches to the perineum in general and anal region specifically, considering the possible variations of the inferior rectal nerve is important for the surgeon. Normally, the inferior rectal nerve originates as a branch of the pudendal nerve. However, during routine dissection, a variant of the inferior rectal nerve was found where it arose directly from the third sacral nerve ventral ramus (S3). Many cases have described the inferior rectal nerve arising independently from the sacral plexus, most commonly from the fourth sacral nerve root (S4); however, few cases have reported the inferior rectal nerve arising from S3. Herein, we describe a variant of the inferior rectal nerve in which the nerve arises independently from the sacral plexus.
Anal Canal ; Lumbosacral Plexus ; Perineum ; Pudendal Nerve

PURPOSE: The laparoscopic rectopexy has become increasingly popular with verified stability, surgical route selection should be tailored to individual patient characteristics rather than operative risk. The perineal approach is useful in young male patients who need to preserve fertility. This study aimed to compare the characteristics of men and women who underwent Delorme-Thiersch procedures and analyze the postoperative outcomes of the perineal approach by sex. METHODS: We retrospectively reviewed the medical records of 293 patients who underwent Delorme-Thiersch operations in Seoul Song Do Colorectal Hospital between January 2011 and September 2017. Patient clinical characteristics and postoperative complications were analyzed by sex. We analyzed surgical outcomes with preoperative and 3-month postoperative incontinence questionnaires, constipation levels, and anal manometry. RESULTS: In this study, men with rectal prolapse were younger than women with the same condition. American Society of Anesthesiologists physical status classifications were higher in women and women had more L-spine X-ray and pudendal nerve terminal motor latency test abnormalities. Anorectal manometry pressures were higher in men. Men also had longer operation times and hospital stays and more postoperative complications (8 T ring infections, 6 patients with bleeding, 3 with strictures, 2 with severe pain, and 2 with rectal perforations). The recurrence rate was higher among women. CONCLUSION: Men with rectal prolapse were younger, healthier, and had relatively better anorectal function than women. The Delorme-Thiersch operation in men promoted lower recurrence rates and was advantageous in preserving the fertility of young patients, but the incidence of complications was also higher in men. Adequate counseling and preparation for the possibility of complications are needed.
Classification ; Constipation ; Constriction, Pathologic ; Counseling ; Female ; Fertility ; Hemorrhage ; Humans ; Incidence ; Length of Stay ; Male ; Manometry ; Medical Records ; Music ; Postoperative Complications ; Pudendal Nerve ; Rectal Prolapse ; Recurrence ; Retrospective Studies ; Seoul

PURPOSE: Pudendal neuralgia (PN) is a painful and disabling condition, which reduces the quality of life as well. Pudendal nerve infiltrations are essential for the diagnosis and the management of PN. The purpose of this study was to compare the effectiveness of finger-guided transvaginal pudendal nerve infiltration (TV-PNI) technique and the ultrasound-guided transgluteal pudendal nerve infiltration (TG-PNI) technique.METHODS: Forty patients who underwent PNI for the diagnosis of PN were evaluated. Thirty-five of these 40 patients, who were diagnosed as PN, underwent a total of 70 further unilateral PNI. All the patients underwent PNI for twice after the first diagnostic PNI, 1 week apart.RESULTS: In the ultrasound (US)-guided TG-PNI group, the success rate was 68.8% (11 of 16) in both “pain in the sitting position” and “pain in the region from the anus to the clitoris.” The success rate of blocks in the US-guided TG-PNI group was 75% (12 of 16) in terms of pain during/after intercourse. In the finger-guided TV-PNI group, the success rate was 84.2% in both “pain in the sitting position” and “pain in the region from the anus to the clitoris.” The success rate of blocks in the fingerguided TV-PNI group was 89.5% (17 of 19) in terms of pain during/after intercourse. There was no statistically significant difference in the success rate of the 3 assessed conditions between the 2 groups (P>0.05).CONCLUSIONS: The TV-PNI may be an alternative to US-guidance technique as a safe, simple, effective approach in pudendal nerve blocks.
Anal Canal ; Anesthesia, Obstetrical ; Diagnosis ; Humans ; Nerve Block ; Neuralgia ; Pelvic Pain ; Pudendal Nerve ; Pudendal Neuralgia ; Quality of Life ; Ultrasonography ; Ultrasonography, Interventional

BACKGROUND/AIMS: Fecal incontinence (FI) is a prevalent condition among women. While biomechanical motor components have been thoroughly researched, anorectal sensory aspects are less known. We studied the pathophysiology of FI in community-dwelling women, specifically, the conduction through efferent/afferent neural pathways. METHODS: A cross-sectional study was conducted on 175 women with FI and 19 healthy volunteers. The functional/structural study included anorectal manometry/endoanal ultrasound. Neurophysiological studies including pudendal nerve terminal motor latency (PNTML) and sensory-evoked-potentials to anal/rectal stimulation (ASEP/RSEP) were conducted on all healthy volunteers and on 2 subgroups of 42 and 38 patients, respectively. RESULTS: The main conditions associated with FI were childbirth (79.00%) and coloproctological surgery (37.10%). Cleveland score was 11.39 ± 4.09. Anorectal manometry showed external anal sphincter and internal anal sphincter insufficiency in 82.85% and 44.00%, respectively. Sensitivity to rectal distension was impaired in 27.42%. Endoanal ultrasound showed tears in external anal sphincter (60.57%) and internal anal sphincter disruptions (34.80%). Abnormal anorectal sensory conduction was evidenced through ASEP and RSEP in 63.16% and 50.00% of patients, respectively, alongside reduced activation of brain cortex to anorectal stimulation. In contrast, PNTML was delayed in only 33.30%. Stools were loose/very loose in 56.70% of patients. CONCLUSIONS: Pathophysiology of FI in women is mainly associated with mechanical sphincter dysfunctions related to either muscle damage or, to a lesser extent, impaired efferent conduction at pudendal nerves. Impaired conduction through afferent anorectal pathways is also very prevalent in women with FI and may play an important role as a pathophysiological factor and as a potential therapeutic target.
Anal Canal ; Brain ; Cross-Sectional Studies ; Evoked Potentials ; Fecal Incontinence ; Female ; Healthy Volunteers ; Humans ; Manometry ; Neural Pathways ; Parturition ; Pudendal Nerve ; Tears ; Ultrasonography

ObjectiveTo investigate the protective effect of human urine-derived stem cells (USCs) on erectile function and cavernous structure in rats with cavernous nerve injury (CNI).

METHODSSixty adult male SD rats with normal sexual function were randomly divided into four groups of equal number: sham operation, bilateral CNI (BCNI) model control, phosphate buffered saline (PBS), and USC. The BCNI model was established in the latter three groups of rats by clamping the bilateral cavernous nerves. After modeling, the rats in the PBS and USC groups were treated by intracavernous injection of PBS at 200 μl and USCs at 1×106/200 μl PBS respectively for 28 days. Then, the maximum intracavernous pressure (mICP) and the ratio of mICP to mean arterial pressure (mICP/MAP) of the rats were calculated by electrical stimulation of the major pelvic ganglions, the proportion of nNOS- or NF200-positive nerve fibers in the total area of penile dorsal nerves determined by immunohistochemical staining, the levels of endothelial cell marker eNOS, smooth muscle marker α-SMA and collagen I detected by Western blot, and the smooth muscle to collagen ratio and the cell apoptosis rate in the corpus cavernosum measured by Masson staining and TUNEL, respectively.

RESULTSAfter 28 days of treatment, the rats in the USC group, as compared with those in the PBS and BCNI model control groups, showed significant increases in the mICP (［81 ± 9.9］ vs ［31 ± 8.3］ and ［33 ± 4.2］ mmHg, P <0.05), mICP/MAP ratio (0.72 ± 0.05 vs 0.36 ± 0.03 and 0.35 ± 0.04, P <0.05), the proportions of nNOS-positive nerve fibers (［11.31 ± 4.22］% vs ［6.86 ± 3.08］% and ［7.29 ± 4.84］% , P <0.05) and NF200-positive nerve fibers in the total area of penile dorsal nerves (［27.31 ± 3.12］% vs ［17.38 ± 2.87］% and ［19.49 ± 4.92］%, P <0.05), the eNOS/GAPDH ratio (0.52 ± 0.08 vs 0.31 ± 0.06 and 0.33 ± 0.07, P <0.05), and the α-SMA/GAPDH ratio (1.01 ± 0.09 vs 0.36 ± 0.05 and 0.38 ± 0.04, P <0.05), but a remarkable decrease in the collagen I/GAPDH ratio (0.28 ± 0.06 vs 0.68 ± 0.04 and 0.70 ± 0.10, P <0.05). The ratio of smooth muscle to collagen in the corpus cavernosum was significantly higher in the USC than in the PBS and BCNI model control groups (17.91 ± 2.86 vs 7.70 ± 3.12 and 8.21 ± 3.83, P <0.05) while the rate of cell apoptosis markedly lower in the former than in the latter two (3.31 ± 0.83 vs 9.82 ± 0.76, P <0.01; 3.31 ± 0.83 vs 9.75 ± 0.91, P <0.05).

CONCLUSIONSIntracavernous injection of USCs can protect the erectile function of the rat with cavernous nerve injury by protecting the nerves, improving the endothelial function, alleviating fibrosis and inhibiting cell apoptosis in the cavernous tissue.

Actins ; analysis ; Animals ; Arterial Pressure ; Collagen ; analysis ; Disease Models, Animal ; Erectile Dysfunction ; prevention & control ; Male ; Nitric Oxide Synthase Type I ; analysis ; Nitric Oxide Synthase Type III ; analysis ; Penile Erection ; physiology ; Penis ; innervation ; Pudendal Nerve ; Random Allocation ; Rats ; Rats, Sprague-Dawley ; Saline Solution ; administration & dosage ; Stem Cell Transplantation ; methods ; Stem Cells ; Urine ; cytology

The majority of patients with neuropathic incontinence and other pelvic floor conditions associated with straining at stool have damage to the pudendal nerves distal to the ischial spine. Sacral nerve stimulation appears to be a promising innovation and has been widely adopted and currently considered the standard of care for adults with moderate to severe fecal incontinence and following failed sphincter repair. From a decision-to-treat perspective, the short-term efficacy is good (70%–80%), but the long-term efficacy of sacral nerve stimulation is around 50%. Newer electrophysiological tests and improved anal endosonography would more effectively guide clinical decision making.
Adult ; Biofeedback, Psychology ; Clinical Decision-Making ; Electrophysiology ; Endosonography ; Fecal Incontinence* ; Humans ; Pelvic Floor ; Pudendal Nerve ; Spine ; Standard of Care

Objective: To explore the effects of immediate and delayed intracavernous injection of bone marrow mesenchymal stem cells (BM-MSCs) on neurogenic erectile dysfunction (NED) induced by bilateral cavernous nerve injury in Sprague-Dawley (SD) rats. METHODS: BM-MSCs isolated from male SD rats were cultured and identified. Twenty-eight 8-week-old male SD rats were randomly divided into four groups, sham operation, NED model control, BM-MSCs immediate, and BM-MSCs delayed, and NED models were established in the latter three groups by crushing the bilateral cavernous nerves. The rats in the sham operation and model control groups were injected intracavernously with placebo while those in the latter two with BM-MSCs immediately or 2 weeks after modeling. At 12 weeks after operation, the penile function of the rats was assessed according to the penile intracavernous pressure (ICP), mean arterial pressure (MAP), and ICP/MAP ratio obtained from different groups of rats. Then, all the animals were sacrificed and the penile cavernosal tissue collected for histological analysis. RESULTS: At 12 weeks after modeling, both ICP and ICP/MAP were significantly increased in the BM-MSCs immediate and delayed groups as compared with those in the model control (P <0.05), and so were the ratio of smooth muscle to collagen (P <0.05) and the smooth muscle content in the corpus cavernosum (P <0.05), and the number of neurofilament (NF)-positive nerve fibers (P <0.05) and the expression of neuronal nitric oxide synthase (nNOS) in the dorsal nerves of the midshaft penis (P <0.05). CONCLUSIONS Intracavernous injection of BM-MSCs can improve erectile function in rats with bilateral cavernous nerve injury by elevating the smooth muscle-collagen ratio and smooth muscle content in the corpus cavernosum and thus preventing its fibrosis as well as by increasing the number of NF-positive nerve fibers and expression of nNOS in the penile dorsal nerves.
Animals ; Disease Models, Animal ; Erectile Dysfunction ; enzymology ; etiology ; therapy ; Male ; Mesenchymal Stem Cell Transplantation ; methods ; Muscle, Smooth ; Nitric Oxide Synthase Type I ; metabolism ; Penile Erection ; physiology ; Penis ; enzymology ; innervation ; Pudendal Nerve ; Random Allocation ; Rats ; Rats, Sprague-Dawley

Pudendal nerve entrapment syndrome is an unusual cause of chronic pelvic pain. We experienced a case of pudendal neuralgia associated with a ganglion cyst. A 60-year-old male patient with a tingling sensation and burning pain in the right buttock and perineal area visited our outpatient rehabilitation center. Pelvis magnetic resonance imaging showed the presence of multiple ganglion cysts around the right ischial spine and sacrospinous ligament, and the pudendal nerve and vessel bundle were located between the ischial spine and ganglion cyst at the entrance of Alcock's canal. We aspirated the lesions under ultrasound guidance, and consequently his symptoms subsided during a 6-month follow-up. This is the first report of pudendal neuralgia caused by compression from a ganglion cyst around the sacrospinous ligament.
Burns ; Buttocks ; Follow-Up Studies ; Ganglion Cysts* ; Humans ; Ligaments ; Magnetic Resonance Imaging ; Male ; Middle Aged ; Outpatients ; Pelvic Pain ; Pelvis ; Pudendal Nerve* ; Pudendal Neuralgia* ; Rehabilitation Centers ; Sensation ; Spine ; Ultrasonography

PURPOSE: To investigate the inhibitory effect and possible mechanism of intraurethral stimulation on overactive bladder (OAB) induced by acetic acid irritation. METHODS: Cystometry was performed in 13 urethane-anesthetized female rats. Intravesical infusion of 0.5% acetic acid was used to irritate the bladder and induce OAB. Multiple cystometrograms were performed with mirabegron, continuous stimulation, mirabegron plus continuous stimulation, and beta3-adrenoceptor antagonist plus continuous stimulation to determine the mechanism underlying the inhibitory effect by intraurethral stimulation. RESULTS: Infusion of acetic acid significantly decreased bladder capacity. Intraurethral stimulation at 2.5 Hz plus mirabegron significantly increased bladder capacity and decreased the nonvoiding contraction count. The changes were strongly inhibited after the beta3-adrenoceptor antagonist was administered. CONCLUSIONS: Activation of urethral afferent nerves can reverse OAB, which activates C-fiber afferent nerves. This animal study indicates that intraurethral stimulation may interfere with OAB through hypogastric nerve activation and pudendal nerve neuromodulation.
Acetic Acid ; Animals ; Electric Stimulation ; Female* ; Humans ; Pudendal Nerve ; Rats* ; Splanchnic Nerves ; Urinary Bladder ; Urinary Bladder, Overactive*

Pudendal neuralgia is characterized by severe sharp pain along the innervation area of pudendal nerve, which may be worsened when sitting position. Successful pudendal nerve block is crucial to the diagnosis of pudendal neuralgia. Although fluoroscopy-guided pudendal nerve blocks have traditionally been performed, recently ultrasound-guided pudendal nerve blocks were reported. For the long term effect of nerve block, pulsed radiofrequency was performed under fluoroscopic guidance in some reports. We report our successful experiences of three cases using ultrasound-guided pulsed radiofrequency.
Diagnosis ; Humans ; Nerve Block ; Pudendal Nerve* ; Pudendal Neuralgia*