Health Organization for Pudendal Education

Pudendal nerve decompression surgery using a balloon probe

Eric de Bisschop * - * Rajeshree Nundlall 
* 55 Avenue Goums 
13400 Aubagne 
04 42 16 33 95 

The Purpose of the study is to demonstrate that surgical decompression of the pudendal nerve can be done without cutting the ligaments. 
Since May 2009, 16 patients were selected. These patients had clinical signs of pudendal neuralgia. Electromyographic exploration  based on the sacral reflex and somatosensory evoked potentials cortical pudendal nerve and pudendal vessels exploration via Doppler demonstrated an area of compression at the level of the infra-piriformis in 11 cases and at the ischiorectal fossa in 5 cases. 
Of all these 16 patients, nerve blocks at the infra-piriformis level has been positive over periods ranging from 1-9 months. Patients were known to suffer from this disease for several years. 

Anatomy 
PN is a mixed nerve that takes its origin at the roots S2, S3 and S4, with a possible contribution of S1 (2). The PN then passes under the 
sacrospinous ligament (LSE). The inferior rectal nerve (NRI), first collateral of the pudendal nerve, starts before the entry of the ischiorectal fossa (IRF), does therefore depend on the falciform process (Pfa) or in the Alcock canal (AC). It will innervate the dorsal quadrant of the anal sphincter (AS). The PN becomes the perineal nerve (NPE), continues under the Pfa and the Ca Needless innervate the ventral quadrant of SA (3). 
The levator ani nerve (PBN) traverses the anterior muscle coccygeal. It thus does not pass under the sacrospinous ligament or under the falciform process and thus avoids the CA. It innervates, among other things, the pubococcygeus muscle (MPC). 
Note that the PN has many anatomical variations, it can go above or below the LSE, or can go through it...

Material and Method 
We are using a Foley catheter right CH 12. A spinal needle of 120 mm is introduced at the same distance from the tip into the light. 
The needle is used as a rigid guide. The Incision is made in the para-anal area. We open the ischiorectal fossa with a finger. We Introduce the rigid probe tip with the balloon in the infra-piriformis cavity. We open the infra-piriformis cavity by filling the balloon with 5 ml of saline solution. The balloon deflates and then we withdraw the probe. 
This operation is repeated 3-4 times by shifting laterally the end of the probe. 

Results: 
Of the 16 patients operated and after 1 month, 14 have described the a complete disappearance of pain in the 48 hours following the intervention, 2 patients experience partial improvements. 

Complications: bruising on the buttocks from the 2 patients that experienced a partial improvement. 

Advantages: 
· No ligament section so no risk of sacroiliac instability and no risk of piriformis syndrome 
· No blind resection so no risk of injury  to the pudendal and / or levator ani nerves 
· Rapid clinical improvement 
· Little risk of postoperative fibrosis 
· Possible use of a neurostimulator connected to the spinal needle 

Summary
This new surgical method of pudendal nerve decompression seems to present very encouraging results. 

E. de Bisschop, copyright 2009 E. de Bisschop, copyright 2009 

scaredgal wrote:Does it appear that this new procedures can also decompress distal nerves? (clitoral, Perineal and Inferior rectal?)

Two patients got over 50% improvement in 2 months (one can sit to watch a movie but not all day yet, the other went back to her job doing professional laundry driving to deliver etc one month post surgery). Two patients are not yet cured (under 3 months for one, over a year for another.) The patient waiting over a year already had the TIR in AIX prior to this Ballooon surgery in Martigues. (on the french forums the rule is not to name the docs, but rather their cities... so I'm being french here.)

This dilation type surgery done in variations by Shafik, Khalfallah, and DeBisschopp works only in cases of weak compression of the pudendal canal.
When PNE is related to severe entrapament due to fibrosis, the simple dilatations, whatever the procedure is, are not effective. In such cases, surgical decompression surgery is needed (Transgluteal or trans ischio rectal) in order to properly open the canal and remove the scar tissue.

Before surgery, I need:

Differential staged sacral reflexes, somesthesics evoked potentials and ultrasounds of pudendal vessels.

1. In my surgery, I decompress from the roots to the final terminals, so The decompression is made at the infrapiriformis area, ligamentous clamp, ischiorectal fossea and alcock canal. The trunk and all branches are free after this method. I operated many people who has been operated by Dr Bautrant or Pr Robert, and it's easy for me, with my methos, to take off the scar tissu. Inhuinal nerve, I cannot reach it. To reach it you need an coelioscope and the pain is totally different (abdominal side pain and groin increasing when the muscle of the abdonmen contract). For the cluneal nerve, I reach it by this method (my method).

2.Often, 77%go out of the clinic without pain or very few. Often, when they arrive at home, the pain comes again but less and decrease progressively. Some patient can sit one hour after surgery but I advise to care about the sitting position during 1 month. My resukts are: more than 80% improvment : 77% after 2 days, 84% after 1 month and 89% after 3 month. So you could expecta cure in one month

I operated patients with pain more than 40 years with good results.

About this procedure: small incision (2 cm) between anus and ischiom. Opening the tissu under the skin. Introducing the small balloon until the infrapiriformis area. Pump up this balloon to separate this level. Introducing a finger. Looking for the Pudendal nerve. Then let slide the finger along the nerfve and all branches to take off the tissu which compress the nerve. opening the alcock tunel. Rising the openings. Close the skin