Transvaginal pudendal nerve blocks in patients with pudendal neuralgia: 2-year follow-up results.

PURPOSE: Pudendal neuralgia (PN) is an extremely painful neuropathy of the pudendal nerve resulting in a negative impact on a patient's quality of life. The aim of this study is to evaluate the 2-year outcomes of repetitive doses of the transvaginal pudendal nerve injections (PNI), and to compare the success of the PNI concerning anatomical levels (endopelvic and extrapelvic portion) of the pudendal nerve pathology. METHODS: This retrospective longitudinal cohort study consists of patients with PN diagnosed with the first four essential Nantes criteria. Diagnostic PNI was performed on 67 patients to fulfill the fifth criteria of Nantes. A total of 56 patients who responded to the initial diagnostic PNI underwent therapeutic repeated transvaginal PNIs twice for 3 weeks apart. Mean pain intensity scores were measured using a visual analog scale at the 1st, 3rd, 6th, 12th, and 24th months after the therapeutic blocks were completed. Effectiveness of the PNIs' was defined as ≥ 50% improvement of the initial pain, and relative improvement was defined as 30-50% improvement of the initial pain. Treatment failure was defined as the reduction of the initial pain by less than 30% or the return of the pain to its worst condition. RESULTS: The efficacy of the PNIs significantly declined over time. Pudendal nerve blocks provided a significant decrease in pain scores; however, this decrease lost its strength significantly in the 24th month. The intervention was more effective in entrapments of the pudendal nerve between sacrospinous and sacrotuberous ligaments or below (Level-2) when compared to the injuries in the endopelvic part (Level-1). More than 50% pain reduction continued in five patients with pathology at Level-1 and 24 patients with pathology at Level-2. CONCLUSION: Repeated PNIs could provide a significant decrease in pain scores for both short- and long-term periods. However, the efficacy of the PNIs declined over 2 years. The success of PNIs may be affected by the anatomical level of the nerve injury; therefore, interligamentous pudendal nerve entrapment cases have more benefits than the cases of pudendal nerve entrapment in the endopelvic part. However, it is recommended to perform therapeutic nerve blocks even in patients with suspected endopelvic pudendal nerve pathology before the referral to surgery.

Peripheral nerve involvement in multiple sclerosis: Demonstration by magnetic resonance neurography.

OBJECTIVE: To detect and quantify peripheral nerve lesions in multiple sclerosis (MS) by magnetic resonance neurography (MRN). METHODS: Thirty-six patients diagnosed with MS based on the 2010 McDonald criteria (34 with the relapsing-remitting form, 2 with clinically isolated syndrome) with and without disease-modifying treatment were compared to 35 healthy age-/sex-matched volunteers. All patients underwent detailed neurological and electrophysiological examinations. Three Tesla MRN with large anatomical coverage of both legs and the lumbosacral plexus was performed by using 2-dimensional (2D) fat-saturated, T2-weighted (T2w) and dual echo turbo spin echo sequences as well as a 3D T2-weighted, fat-saturated SPACE sequence. Besides qualitative visual nerve assessment, a T2w signal quantification was performed by calculation of proton spin density and T2 relaxation time. Nerve diameter was measured as a morphometric criterion. RESULTS: T2w hyperintense nerve lesions were detectable in all MS patients, with a mean lesion number at thigh level of 151.5 ± 5.7 versus 19.1 ± 2.4 in controls (p < 0.0001). Nerve proton spin density was higher in MS (tibial/peroneal: 371.8 ± 7.7/368.9 ± 8.2) versus controls (tibial/peroneal: 266.0 ± 11.0/276.8 ± 9.7, p < 0.0001). In contrast, T2 relaxation time was significantly higher in controls (tibial/peroneal: 82.0 ± 2.1/78.3 ± 1.7) versus MS (tibial/peroneal: 64.3 ± 1.0/61.2 ± 0.9, p < 0.0001). Proximal tibial and peroneal nerve caliber was higher in MS (tibial: 52.4 ± 2.1mm2 , peroneal: 25.4 ± 1.3mm2 ) versus controls (tibial: 45.2 ± 1.4mm2 , p < 0.0015; peroneal: 21.3 ± 0.7mm2 , p = 0.0049). INTERPRETATION: Peripheral nerve lesions could be visualized and quantified in MS in vivo by high-resolution MRN. Lesions are defined by an increase of proton spin density and a decrease of T2 relaxation time, indicating changes in the microstructural organization of the extracellular matrix in peripheral nerve tissue in MS. By showing involvement of the peripheral nervous system in MS, this proof-of-concept study may offer new insights into the pathophysiology and treatment of MS. Ann Neurol 2017;82:676-685.

Long-term effects of simulated childbirth injury on function and innervation of the urethra.

AIMS: Pudendal nerve and external urethral sphincter (EUS) injury during vaginal delivery are risk factors for stress urinary incontinence (SUI). Although most patients with short-term postpartum SUI regain continence within 1 year, they have a higher predisposition to develop recurrent SUI years later, suggesting a possible mechanistic relationship. In contrast, animal models generally recover spontaneously and have not been studied much in the long term. The aim of this study was to investigate the long-term effects of simulated childbirth injury in rats. METHODS: Thirty-four Sprague-Dawley female rats underwent sham injury or pudendal nerve crush and vaginal distension (PNC + VD), a simulated childbirth injury. Nine weeks later, leak point pressure (LPP) and EUS electromyography (EMG) were recorded simultaneously. The pudendal nerve was harvested for histological analysis. EUS neuromuscular junctions (NMJs) and their innervation were qualitatively assessed using immunofluorescence. A t-test was used to compare quantitative outcomes between groups, with P < 0.05 indicating a significant difference. RESULTS: There was no significant difference in LPP or EUS EMG amplitude or firing rate between the two groups. Nonetheless after PNC + VD, NMJs in the EUS were diffuse and were innervated by tortuous and multiple axons, demonstrating that reinnervation of the EUS was still in progress. CONCLUSIONS: Although continence function recovered 9 weeks after simulated childbirth injury, innervation of EUS was not complete at this time point, suggestive of persistent neurogenic deficiency which when compounded by the effects of aging may lead to a delayed recurrence of SUI in this animal model with increased age.

[EXPERIMENTAL MODELS OF STRESS URINARY INCONTINENCE].

Despite numerous medical and surgical treatment strategies available, the problem of stress urinary incontinence (SUI) in women is still not completely resolved. Continuing research is underway to modify the sling operations and develop new bulk-enhancing agents, including the use of tissue engineering and cell technologies. To evaluate the safety and effectiveness of new methods at the preclinical stage, adequate and reproducible experimental models of SUI in laboratory animals should be used. This article presents analysis of all SUI models described in the scientific literature and the results of an experimental study comparing two primary ways of modeling, based on bilateral pudendal nerve damage in female rats. The experiment results showed that only bilateral electrocoagulation of proximal part of pudendal nerves by the posterior approach ensured a stable and long-term SUI symptoms in animals in the form of leak point pressure reduction in the urodynamic study and increase of the of the urethral lumen according to histomorphometric analysis. The results suggest that an adequate experimental SUI model is urethral rabdomiosphincter denervation by pudendal nerve electrocoagulation by the posterior surgical approach, when the nerve is damaged in the area of its separation from sciatic nerve. In this case stable and reproducible results are obtainable.

Contribution of pudendal nerve injury to stress urinary incontinence in a male rat model.

Urinary incontinence is a common complication following radical prostatectomy, as the surgery disturbs critical anatomical structures. This study explored how pudendal nerve (PN) injury affects urinary continence in male rats. In an acute study, leak point pressure (LPP) and external urethral sphincter electromyography (EMG) were performed on six male rats with an intact urethra, the urethra exposed (UE), the PN exposed (NE), and after PN transection (PNT). In a chronic study, LPP and EMG were tested in 67 rats 4 days, 3 weeks, or 6 weeks after sham PN injury, PN crush (PNC), or PNT. Urethras were assessed histologically. Acute PNT caused a significant decrease in LPP and EMG amplitude and firing rate compared to other groups. PNC resulted in a significant reduction in LPP and EMG firing rate 4 days, 3 weeks, and 6 weeks later. EMG amplitude was also significantly reduced 4 days and 6 weeks after PNC. Neuromuscular junctions were less organized and less innervated after PNC or PNT at all timepoints compared to sham injured animals. Collagen infiltration was significantly increased after PNC and PNT compared to sham at all timepoints. This rat model could facilitate preclinical testing of neuroregenerative therapies for post-prostatectomy incontinence.

[Non-infectious cystalgias]. / Cystalgies non infectieuses.

The trophicity of women's urogenital tissues depends on the hormone level and on the quality of the vaginal flora. Stresses of these mucous membranes, seemingly minor, give rise to complaints of a perceived perineal discomfort, which is disproportionate to the causes. Population in Occident has access to the best medical care and hygiene conditions ever. Yet, expenditures on treatment of these minor disorders are unwarranted. Cystalgia leads to a large number of consultations to general practitioner, gynaecologist and urologist. The aging of our societies is another reason. While life expectancy was 51 in 19th century, it is now 83. Women will now live a third of their life after menopause'. Complaints due to these hormonal withdrawal symptoms need to be heard as they are leading to specific psychological behaviours, which are disconcerting for the clinician. Patients will strive by all means to obtain treatments which are often inappropriate and which sometimes entails the risk of evolving to a chronicity of the pains.

[Neurophysiologic evaluation of patients with chronic prostatitis (III B chronic pain syndrome)].

The article presents the results of neurophysiological examination of 32 patients with noninflammatory form of abacterial chronic prostatitis/ chronic pelvic pain syndrome (CP/CPPS III B). Intramuscular electromyography was performed, right and left bulbocavernous reflex and cortical somatosensory evoked potentials during stimulation of n. pudendus were evaluated. It is shown that there is a high frequency of abnormal neurophysiological patterns in the absence of clinical neurological disease in patients with CP/CPPS III B. In this case, the pain as the main symptom was not associated with prostate disease. It is suggested that some patients with a diagnosis of CP/CPPS III B have neurological pathology that not manifested at the time of the examination.

[Mechanisms of formation and diagnosis of tunnel pudendal neuropathy]. / Mekhanizmy formirovaniia i diagnostika tunnel'nykh pudendoneiropatii.

The article contains information on the most common causes of lesions of the pudendal nerve - tunneling neuropathy. The author considers a set of the Nantes diagnostic criteria for pudendal neuralgia and presents a brief differential diagnosis of pelvic neuropathies. A case of Tinel's pudandal symptom with interligamentous compressions is described. The causes of the low diagnosability of pudendal neuropathy are analysed.

Electrical stimulation enhances neuronal cell activity mediated by Schwann cell derived exosomes.

Electrical stimulation (ES) therapy has good effects in patients with nervous system injury-related diseases. ES promotes nerve cell regeneration and stimulates Schwann cells to express neurotrophic factors. The incidence of stress urinary incontinence (SUI) among elderly people is increasing. Some studies suggest that damage to the pudendal nerve is closely related to the pathogenesis of SUI. It has also been found that pelvic ES can reduce SUI symptoms in a rat model of SUI caused by pudendal nerve injury. Clinically, pelvic floor electrical stimulation is effective in patients with mild to moderate SUI. These studies indicate that ES may ameliorate damage to the pudendal nerve and thus achieve the goal of SUI treatment, although the mechanism of action of this treatment remains unclear. Therefore, the purpose of the present study was to clarify the relationships among ES, neural cells and Schwann cells at the cellular level. We applied ES to nerve cells at 100 mV/mm or 200 mV/mm for 0, 0.5, 1, or 2 h to investigate changes in nerve cell activity. We then co-cultured the nerve cells with Schwann cells to explore the influence of single-culture and co-culture conditions on the nerve cells. Compared to non-ES, ES of the nerve cells increased their activity. Compared to those in single culture, co-cultured nerve cells exhibited an additional increase in activity. We also found that Schwann cell derived exosomes could promote the activity of nerve cells, with glutamate and calcium ions playing a potential role in this process. These results suggest that the mutual regulation of neural cells and Schwann cells plays an important role in the process by which ES ameliorates neurological function, which may provide a basis for subsequent studies.

nNOS-positive minor-branches of the dorsal penile nerves is associated with erectile function in the bilateral cavernous injury model of rats.

The changes in neuronal nitric oxide synthases (nNOS) in the dorsal penile nerves (DPNs) are consistent with cavernous nerve (CN) injury in rat models. However, the anatomical relationship and morphological changes between the minor branches of the DPNs and the CNs after injury have never been clearly explored. There were forty 12 week old male Sprague-Dawley rats receiving bilateral cavernous nerve injury (BCNI). Erectile function of intracavernous pressure and mean arterial pressure were measured. The histology and ultrastructure with H&E stain, Masson's trichrome stain and immunohistochemical stains were applied on the examination of CNs and DPNs. We demonstrated communicating nerve branches between the DPNs and the CNs in rats. The greatest damage and lowest erectile function were seen in the 14th day and partially recovered in the 28th day after BCNI. The nNOS positive DPN minor branches' number was significantly correlated with erectile function. The sub-analysis of the number of nNOS positive DPN minor branches also matched with the time course of the erectile function after BCNI. We suggest the regeneration of the DPNs minor branches would ameliorate the erectile function in BCNI rats.

Anatomical Variants of the Pudendal Nerve Observed during a Transgluteal Surgical Approach in a Population of Patients with Pudendal Neuralgia.

BACKGROUND: Several studies have described the course and anatomical relations of the pudendal nerve. Several surgical nerve decompression techniques have been described, but only the transgluteal approach has been validated by a prospective randomized clinical trial. The purpose of this study was to describe the course of the nerve and its variants in a population of patients with pudendal neuralgia in order to guide the surgeon in the choice of surgical approach for pudendal nerve decompression. OBJECTIVES: In order to support the choice of the transgluteal approach, used in our institution, we studied the exact topography, anatomical relations, and zones of entrapment of the pudendal nerve in a cohort of operated patients. STUDY DESIGN: Observational study. SETTING: University hospital. METHODS: One hundred patients underwent unilateral or bilateral nerve decompression performed by a single operator via a transgluteal approach. All patients satisfied the Nantes criteria for pudendal neuralgia. The operator meticulously recorded zones of entrapment, anatomical variants of the course of the nerve, and the appearance of the nerve in the operative report. RESULTS: One hundred patients and 145 nerves were operated consecutively. Compression of at least one segment of the pudendal nerve (infrapiriform foramen, ischial spine, and Alcock's canal) was observed in 95 patients. The zone of entrapment was situated at the ischial spine between the sacrospinous ligament (or ischial spine) and the sacrotuberous ligament in 74% of patients.Anatomical variants were observed in 13 patients and 15 nerves. Seven patients presented an abnormal transligamentous course of the nerve (sacrotuberous or sacrospinous). A perineal branch of the fourth sacral nerve to the external anal sphincter was identified in 7 patients. In this population of patients with pudendal neuralgia, the pudendal nerve was stenotic in 27% of cases, associated with an extensive venous plexus that could make surgery more difficult in 25% of cases, and the nerve had an inflammatory appearance in 24% of cases. LIMITATIONS: We obviously cannot be sure that the anatomical variants identified in this study can be extrapolated to the general population, as our study population was composed of patients experiencing perineal pain due to pudendal nerve entrapment and their pain could possibly be related to these anatomical variants, especially a transligamentous course of the pudendal nerve. The absence of other prospective randomized clinical trials evaluating other surgical approaches also prevents comparison of these results with those of other surgical approaches. CONCLUSIONS: This is the first study to describe the surgical anatomy of the pudendal nerve in a population of patients with pudendal neuralgia. In more than 70% of cases, pudendal nerve entrapment was situated in the space between the sacrospinous ligament and the sacrotuberous ligament. Anatomical variants of the pudendal nerve were also observed in 13% of patients, sometimes with a transligamentous course of the nerve. In the light of these results, we believe that a transgluteal approach is the most suitable surgical approach for safe pudendal nerve decompression by allowing constant visual control of the nerve.Key words: Surgical, operative technique, pudendal, neuralgia, transgluteal approach.

Astragali radix: could it be an adjuvant for oxaliplatin-induced neuropathy?

Neurotoxicity is a major side effect of platinum derivatives both during and after treatment. In the absence of effective pharmacological compounds, the opportunity to identify safe adjuvant treatments among medicinal plants seems appropriate. Astragali radix is an adaptogenic herbal product recently analyzed in platinum-treated cancer patients. With the aim of evaluating the anti-neuropathic profile of Astragali radix, a previously characterized aqueous (Aqu) and two hydroalcoholic (20%HA and 50%HA) extracts were tested in a rat model of oxaliplatin-induced neuropathy. Repeated administrations significantly reduced oxaliplatin-dependent hypersensitivity with 50%HA, the most effective, fully preventing mechanical and thermal hypersensitivity. Ex vivo, 50%HA reduced morphometric and molecular alterations induced by oxaliplatin in peripheral nerve and dorsal-root-ganglia. In the spinal cord and in brain areas, 50%HA significantly decreased activation of microglia and astrocytes. Furthermore, 50%HA prevented the nephro- and hepato-toxicity induced by the anticancer drug. The protective effect of 50%HA did not alter oxaliplatin-induced apoptosis in colon tumors of Pirc rats, an Apc-driven model of colon carcinogenesis. The hydroalcoholic extract (50%HA) of Astragali radix relieves pain and promotes the rescue mechanisms that protect nervous tissue from the damages triggering chronic pain. A safe profile strongly suggests the usefulness of this natural product in oxaliplatin-induced neuropathy.

Chronic pudendal neuromodulation using an implantable microstimulator improves voiding function in diabetic rats.

Objective: Few studies have investigated the feasibility of using chronic pudendal neuromodulation for improving voiding function in patients with diabetes who are also experiencing urinary retention. The present study investigated the effects of chronic electrical stimulation (ES) of the sensory branch of the pudendal nerve on voiding function in diabetic rats. Approach: A custom-made implantable microstimulation system was designed and manufactured for chronic implantation in normal control (NC) and diabetic rats. After three or six weeks of pudendal neuromodulation, the intravesical pressure, external urethral sphincter electromyograms (EUS-EMGs), and urine flow rate (UFR) of all rats were simultaneously recorded to assess the effects of chronic pudendal ES on voiding function. Morphological changes in pudendal axons were assessed through hematoxylin and eosin (H&E) staining. Significance: This study demonstrated the feasibility of using chronic pudendal neuromodulation for improving voiding function in diabetic rats. These results may facilitate the development of an advanced neural prosthesis for restoring bladder function in clinical settings.

Pudendal Neuralgia Due to Pudendal Nerve Entrapment: Warning Signs Observed in Two Cases and Review of the Literature.

Pudendal neuralgia is a chronic neuropathic pelvic pain that is often misdiagnosed and inappropriately treated. The Nantes criteria provide a basis for the diagnosis of pudendal neuralgia due to pudendal nerve entrapment. The 5 essential diagnostic criteria are pain situated in the anatomical territory of the pudendal nerve, worsened by sitting, the patient is not woken at night by the pain, and no objective sensory loss is detected on clinical examination. The fifth criterion is a positive pudendal nerve block. We have also clarified a number of complementary diagnostic criteria and several exclusion criteria that make the diagnosis unlikely. When pudendal neuralgia due to pudendal nerve entrapment is diagnosed according to the Nantes criteria, no further investigation is required and medical or surgical treatment can be proposed. Nevertheless, a number of warning signs suggesting other possible causes of pudendal neuralgia must not be overlooked. These warning signs (red flags) are waking up at night, excessively neuropathic nature of the pain (for example, associated with hypoesthesia), specifically pinpointed pain, which can suggest neuroma and pain associated with neurological deficit. In these atypical presentations, the diagnosis of pain due to pudendal nerve entrapment should be reconsidered and a radiological examination should be performed. The 2 cases described in this report (tumor compression of the pudendal nerve) illustrate the need to recognize atypical pudendal neuralgia and clarify the role of pelvic magnetic resonance imaging (MRI), as MRI provides very valuable information for the evaluation of diseases involving the ischiorectal fossa. The presence of red flags must be investigated in all cases of pudendal neuralgia to avoid missing pudendal neuralgia secondary to a mechanism other than nerve entrapment.

The Important Liaison Between Onuf Nucleus-Pudendal Nerve Ganglia Complex Degeneration and Urinary Retention in Spinal Subarachnoid Hemorrhage: An Experimental Study.

OBJECTIVE: The Adamkiewicz artery (AKA) supplies pudendal nerve roots and conus medullaris. The aim of this study was to elucidate if there is any relationship between neurodegenerative changes of the Onuf nucleus (ON)-pudendal nerve ganglia complex secondary to vasospasm of the AKA after spinal subarachnoid hemorrhage (SAH). METHODS: This study was conducted on 22 rabbits, which were randomly divided into 3 groups: control (n = 5), sham (n = 5), and spinal SAH (n = 12). Experimental spinal SAH was induced at the L2 level. After 2 weeks, the ON-pudendal nerve ganglia complex and AKA were examined histopathologically. Bladder volume values were estimated, and results were analyzed statistically. RESULTS: Two animals died within the first week of experiment. Histopathologically, severe vasospasm of the AKA and neuronal degeneration and neuronal apoptosis were observed in the ON-pudendal nerve ganglia complex in 5 animals of the SAH group. The mean volume of the imaginary AKA, mean bladder volumes, and degenerated neuron densities of ON and pudendal nerve ganglia were estimated. We found that vasospasm of the AKA led to numerous neuron degenerations in ON and pudendal ganglia and consequently urinary retention (P < 0.005). CONCLUSIONS: ON-pudendal nerve ganglia complex degeneration secondary to vasospasm of the AKA may be a cause of urinary retention after spinal SAH.

Pudendal nerve and internal pudendal artery damage may contribute to radiation-induced erectile dysfunction.

PURPOSE/OBJECTIVES: Erectile dysfunction is common after radiation therapy for prostate cancer; yet, the etiopathology of radiation-induced erectile dysfunction (RI-ED) remains poorly understood. A novel animal model was developed to study RI-ED, wherein stereotactic body radiation therapy (SBRT) was used to irradiate the prostate, neurovascular bundles (NVB), and penile bulb (PB) of dogs. The purpose was to describe vascular and neurogenic injuries after the irradiation of only the NVB or the PB, and after irradiation of all 3 sites (prostate, NVB, and PB) with varying doses of radiation. METHODS AND MATERIALS: Dogs were treated with 50, 40, or 30 Gy to the prostate, NVB, and PB, or 50 Gy to either the NVB or the PB, by 5-fraction SBRT. Electrophysiologic studies of the pudendal nerve and bulbospongiosus muscles and ultrasound studies of pelvic perfusion were performed before and after SBRT. The results of these bioassays were correlated with histopathologic changes. RESULTS: SBRT caused slowing of the systolic rise time, which corresponded to decreased arterial patency. Alterations in the response of the internal pudendal artery to vasoactive drugs were observed, wherein SBRT caused a paradoxical response to papaverine, slowing the systolic rise time after 40 and 50 Gy; these changes appeared to have some dose dependency. The neurofilament content of penile nerves was also decreased at high doses and was more profound when the PB was irradiated than when the NVB was irradiated. These findings are coincident with slowing of motor nerve conduction velocities in the pudendal nerve after SBRT. CONCLUSIONS: This is the first report in which prostatic irradiation was shown to cause morphologic arterial damage that was coincident with altered internal pudendal arterial tone, and in which decreased motor function in the pudendal nerve was attributed to axonal degeneration and loss. Further investigation of the role played by damage to these structures in RI-ED is warranted.

Contribution of ultrasound in the assessment of patients with suspect idiopathic pudendal nerve disease.

OBJECTIVE: To assess if Ultrasound (US) is contributive in patients suspected of having idiopathic pudendal neuralgia. METHODS: Between July 2012 and April 2013, 10 consecutive female patients with suspected idiopathic pudendal neuralgia (mean age: 47±14 years; mean BMI: 24±3) were included. Two radiologists blinded to the clinical and neurophysiological data performed pudendal nerve evaluation with broadband linear array transducers (12-7 MHZ, and 17-5 MHZ). MRI was added to confirm US data. A third independent clinician, who did not perform electrodiagnosis and US, reviewed the data and scored US as "contributive" or "non-contributive": if US confirmed the clinical and neurophysiological diagnosis or if US findings were not useful. RESULTS: Ultrasound identified alterations to the pudendal nerve in 7/10 of cases (70%). In seven cases US revealed the presence of a diffusely or focally enlarged pudendal nerve confirmed by MRI. In these cases neurophysiological findings were suspicious for pudendal neuralgia in 5/7 cases, whereas in 2/7 cases they were inconclusive. CONCLUSION: High-resolution ultrasound (US) may demonstrate alterations to the pudendal nerve in patients with pudendal neuralgia. SIGNIFICANCE: US is useful in patients with suspected idiopathic pudendal nerve disease.

Pudendal afferents mapping in posterior sacral rhizotomies.

BACKGROUND: The effectiveness of pudendal afferents mapping in posterior sacral rhizotomies needs to be reviewed. OBJECTIVE: To evaluate the effectiveness of pudendal afferents mapping for both the dorsal penile or clitoral nerve and the inferior anal nerve to decrease the risk of postoperative bowel and bladder dysfunction when the sacral nerve roots are candidates for rhizotomies. METHODS: A retrospective review of 101 Asian children who underwent functional posterior rhizotomies with pudendal afferents mapping for spastic paresis was performed. RESULTS: Pudendal mapping was successful in 75 of 81 patients. The highest activity of afferent fibers of the dorsal penile or clitoral nerve was demonstrated at the S1 roots in 13.3%, at the S2 in 79.3%, and at the S3-5 in 7.3%. Considerable activity of the dorsal penile or clitoral nerve was recorded at 40% of the S1 roots, at 99.3% of the S2 roots, and at 52% of the S3-5 roots. The highest activity of afferent fibers of the inferior anal nerve was demonstrated at S2 roots in 42% and at S3-5 roots in 58%. Considerable activity of the inferior anal nerve was recorded at 10.7% of S1 roots, at 89.3% of S2 roots, and at 76.7% of S3-5 roots. The pathological S1 roots were divided into 3 to 4 rootlets, and the rootlets with significant afferent activity were preserved. None of the 75 patients experienced long-term bowel or bladder complications. CONCLUSION: Pudendal afferent mapping identified the sacral rootlets involved with genital and anal sensation. The preservation of such rootlets in sacral rhizotomies is considered to be important for minimizing postoperative bladder and bowel dysfunction.

Coccigodinia relacionada con uso de anillo vaginal anticonceptivo / Coccydynia related to the use of a contraceptive vaginal ring

La coccigodinia es un síndrome que se presenta con frecuencia en las consultas de Reumatología en forma de dolor en punta terminal del coxis, empeorando habitualmente al sentarse. Aunque la causa más frecuente es la postraumática local, existen diversas causas de dolor en el coxis. Presentamos un caso inhabitual en el que la coccigodinia comenzó poco después de instaurar un sistema de anticoncepción por anillo vaginal y remitió completamente al retirar este sistema (AU)

Coccydynia is a syndrome that rheumatologists encounter frequently in the form of tailbone pain, which is usually worse when sitting. Although the most common origin is trauma, there are several other possible causes of pain in the coccyx. We present an unusual case in which coccydynia developed shortly after the insertion of a contraceptive vaginal ring and remitted completely upon removal of this system (AU)