Presacral neurectomy

[mgail]

I have been going to Dr. Nathan Guerette in Richmond, VA. He is a urogynecologist working only on female pelvic disorders. I am very pleased with his help so far. I went through the Interstim trial which was unsuccessful. It may have given me 15-20% decrease in pain if that. The trial insertion was very, very painful (10/10). The main discomfort came with a "vibrating electrical type stimulation in my pelvic area if you turned it up too much. Several weeks ago I underwent Botox intravaginal injections. Since he is a urogynecologist, all of his therapies are done intravaginally because of the ability to get right at the nerve without having the go through the buttocks. The Botox helped somewhat. I am scheduled next week to have a larger 300 mL dose to see if that helps. If it does, of course that would be a Godsend....At my last visit we discussed surgery. At first, after reading about surgery on this website through the buttocks, I was adamantly against having that due to the physical debility involved and not being able to work (I work at home as a medical transcriptionist). He does not do it that way. The surgery he does is a presacral neurectomy. It is done in the hospital laparoscopically under anesthesia and he wants me to say overnight to ensure I have no bleeding. If you go on line and pull up presacral neurectomy, you can see that it is in an area with numerous large critical vessels which he would have to traverse to get to the pudendal nerve. Of course, there are side effects that may happen (urinary incontinence, sexual problems), but if it eliminated my pain I would rather wear Depends and be able to live a life, which is limited right now because of pain. I have also, after going to pain physicians, etc., found that if I take three 300 mg gabapentin at the time I take Tramadol, this has really seemed to help. Of course, like everything else, it does not totally eliminate the pain, but I think it has helped. This is still not a maximum dose for gabapentin. Has anyone had a presacral neurectomy done or know anything about it? Thanks so much.
Gail

[stephanies]

Hi Gail,

I am sorry the Interstim did not work for you. Is Dr. Guerrette planning to access your pudendal nerve through the laparoscopic procedure you describe or do something else for your pain? Has he done this procedure before for relief of PN pain? Has he provided any information on success rates? I have not heard of this procedure for PN pain, but maybe someone with more medical knowledge than I will be able to give you more information.

Sincerely,
Stephanies

[Violet M]

Hi Gail,

I've never heard of this being done for pudendal neuralgia. Have you been diagnosed with PN?

Here is a description of the procedure. http://www.laparoscopyhospital.com/lapa ... ectomy.htm
http://tinyurl.com/mda67mq

According to the University of Maryland Medical Center, the presacral plexus carries signals from the uterus to the brain.
http://umm.edu/programs/womens-center/s ... neurectomy
http://tinyurl.com/lpww5sr

I'm just trying to figure out where the pudendal nerve comes in here. As close as I can tell, presacral neurectomy doesn't involve the pudendal nerve. According to the article, it involves L5/S1. The pudendal comes off of S2,3,4. Have you had a nerve block to the presacral plexus to see if it helps?

If you've been diagnosed with PN, I'm wondering if it would be wise to get a second opinion from a pudendal neuralgia physician before trying something that major.

Best,

Violet

[mgail]

Hey guys....

He says it's the pudendal nerve. I had my first nerve block (through the buttocks) by a pain MD, which gave no relief at all. Dr. Guerette gave me a nerve block intravaginally a few weeks ago which helped on the drive (1 hour) home. Thursday I go back in to get a dose of 300 mL of Botox (the lower dose did not help) to see if that works. I will ask him more specifically when I see him on Thursday about the location of the nerves. I appreciate your help in this....

[Violet M]

Hey Gail,

Just wondering how your Botox injection went. Hope you are feeling better.

Violet

[mgail]

Hey Violet.

Sorry for not responding sooner. I'm not getting E-mail notifications of any replies. (I hopefully have resolved that). I had the Botox a week ago Thursday (300 mL intravaginally in different areas), and not hurting too bad until today which has been a painful day. I've upped my gabapentin to 1200 mg a day which I thought was helping some. So frustrating. The main result of my second botox injection was dribbling in the morning and nearly not making it to the bathroom in time (which is better than not going at all, I must admit). Now I keep a towel on my bedside table. Other than that, no side effects really. I go back week after next for a consult with Dr. Guerette. After studying the anatomy charts, etc., and doing more research, I don't see how he can get to the pudendal nerve through a laparoscopic incision, unless he knows of something I'm not hearing about. I am also going to ask him about radiographic studies since I have had none really except for my lumbar spine. There is no way I can undergo a gluteal resection because of being unable to work (sitting doing medical transcription), so that is out of the question. That is the main reason I was excited when he said no, he did it laparoscopically. What a pain ion the ass (literally) problem....

Gail

[stephanies]

Hi Gail,

I had TG surgery bilaterally and I did not feel the recovery from the surgery itself was extraordinarily difficult. I had surgery in CA on a Tuesday and flew (mostly sitting) home to D.C. on Friday (4 days later). Once home I avoided sitting, much as I had done pre-op. Can you take a few weeks off work for the incisions to heal or work standing up or reclining for a while? I am not advocating that you choose TG surgery since that choice can only be made by you and your doctors, but I wanted to share my experience so you know it can be an option if you decide surgery is the right decision.

Sincerely,
Stephanies

[Violet M]

Gail, there are physicians who perform pudendal nerve decompression surgery using a laparscopic approach but I don't think that is the same as a presacral neurectomy. Presacral literally means above the sacrum and neurectomy means cutting the nerves. It deals with the presacral plexus of nerves. This is not the same as pudendal nerve decompression surgery which releases the pudendal nerve from compression in the peripheral pudendal nerve which is below the sacrum. Just wanted to make sure you knew what type of surgery you were considering before going into it. If your diagnosis is pudendal neuralgia (PN), I'm not sure how presacral neurectomy helps you. Do you have a diagnosis of pudendal neuralgia or is your pelvic pain caused by something else?

If you have pudendal neuralgia but don't want the buttocks incisions you could also consider the approach done by Dr. Bautrant called the TIR approach. Have you already tried physical therapy from a PN knowledgeable PT?

Violet