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Surgical treatment of the pudendal nerve.

Surgical treatment of the pudendal nerve.
Laparoscopic decompression of the pudendal nerve

The operation for laparoscopic decompression of the pudendal nerve is a radical method of solving the problem. Typically, it is used if the desired effect cannot be achieved with more conservative methods such as medication, physiotherapy, therapeutic blocks, or lifestyle changes. Not every patient is a candidate for surgery, and before proceeding, the likelihood of success must be assessed, taking into account all factors.

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Preparation for surgery


For successful intervention, a high level of skill from the operating surgeon, precision equipment, and careful examination of symptoms and results of instrumental diagnostics are necessary. Unfortunately, currently, only a small number of doctors in Russia and around the world are capable of performing pudendal nerve decompression laparoscopically.

Effectiveness of surgical decompression of the pudendal nerve

It is important to understand that success here does not mean complete and immediate healing but significant relief of pain and noticeable improvement in the patient's quality of life. There are many patients who have been completely relieved of pain, but there are also those who experience residual symptoms of the disease.
Dilanyan Oganes Eduardovich

There is no unified statistics for all surgeries ever performed worldwide, but there are reliable results from several studies. According to these data, in global practice, successful interventions range from 60% to 85%. However, each clinic and surgeon also keep their own records, which may differ from the averaged statistics. The percentage of complete or partial success of operations performed by O.E. Dilanyan is up to 83%, which is due to strict patient selection for surgery.
In the global medical community, a surgery is considered successful if it proves to be effective in 50% or more (evaluating the level of pain and discomfort).

Benefits of laparoscopic access

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There are five main approaches to nerve decompression surgery:

● transsacral access;

● access through the ischiorectal fossa;

● perineal access;

● Laparoscopy.

The latter option is minimally invasive: only four small incisions are required. A laparoscope is inserted into the abdominal cavity through an incision in the navel, to which a miniature camera is attached, thus providing visual control (the surgeon sees the working area on a computer screen). Two additional incisions are made along the pubic hairline - they are necessary for the introduction of instruments and sutures, that is, for the direct performance of the intervention.

During laparoscopic surgery, the nerve is freed from fibrous tissue and pressure from fibrous ligaments. If necessary, before completing the manipulations, a medication is injected into the operated area to prevent scarring.

The advantages of laparoscopic access are recognized worldwide:

The non-traumatic nature of the operation
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Short rehabilitation period.
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Minor blood loss.
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HIGH AESTHETIC RESULT
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Laparoscopy requires a very high level of surgical skill compared to traditional operations, as well as experience, good coordination of movements, and attentiveness. However, the result is worth it.

What to expect before and after the surgery


Some surgeons believe that before deciding on laparoscopic decompression, a series of pudendal nerve blocks should be performed. If they do not produce the desired result, discussing the possibility of minimally invasive intervention with the doctor is worthwhile.

Surgical treatment of pudendal nerve neuropathy is performed under general anesthesia, and hospitalization, depending on the patient's condition, lasts from 5-6 days.

In the absence of complications (which are unlikely), the patient may be able to get up and move freely as early as the next day after surgery, but still requires several days of relative rest. If a person has come from another city, the doctor may recommend staying in a hotel for several days to eliminate the possibility of a situation where emergency assistance would not be possible.

A typical practice situation

Laparoscopic nerve release was performed 18 months ago, and it seems the patient is much more satisfied with life. Previously, she suffered from severe pain exacerbated by walking. She also had to remove a neuroma - a small but unpleasant tumor that could also be a source of painful sensations.

- How's your health? Do you feel any pain or discomfort?

- Unfortunately, the pain hasn't completely gone away, but I feel much better. Before the surgery, I was in such bad shape that I could barely stand it, but after four months, I was back at work - at first part-time, and then full-time. Moreover, there are days when I hardly feel anything at all. It used to be impossible. And the nature of the pain has changed - it's more dull now, whereas before it felt like being cut alive.

- Remind me, are you still using any medications or undergoing physiotherapy?

- I always keep belladonna and diazepam suppositories at home. And until last year, I used to go to a masseur. My muscles have relaxed, it's much easier to move, though I still try to avoid long car rides. But if necessary, it's not a problem. You advised me to avoid sitting positions, right?

- That's advisable, especially during the first year or two. After all, the nerve was severely damaged and remains your "Achilles' heel." And have you stopped taking medications?

- Yes, last year. You said that after a few months, I could try to stop taking pregabalin, so I did. Though I made a mistake - I stopped taking the pills abruptly. Later, I read that I should have gradually reduced the dosage. It would have been wise to consult with you, of course.

- That's alright, if you managed to stop taking the medication, that's great. Can you quantify how much better you feel?

- About 80 percent, I'd say. There are still flare-ups, bursts of pain, but I can endure them, especially if I lie down and relax. They're short-lived. And, as I mentioned, there are days when I hardly feel anything at all. Doctor, do you think there's a chance my condition will further improve? And that I'll return to sports?

Before falling ill, the girl was a powerlifter and practiced bodybuilding. Of course, she had to give up these activities. Especially since engaging in such sports often triggers compression of the pudendal nerve.

- Improvement is possible; it's only been a year and a half, and many patients continue to recover even after that. As for sports, honestly, I can't say with certainty. I wouldn't recommend trying to beat old records - your nerve is too delicate for that. But many other doors are open: swimming, some forms of light athletics. I would gradually introduce different exercises and observe how your body reacts. But, of course, without overexertion.

- Thank you, doctor! Honestly, at first, after the surgery, I didn't believe in success, as I didn't feel better right away. But now I can confidently say that I would go through with it again... even if the effect wasn't as strong.

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Rehabilitation Period

During the recovery period, most patients use makeshift devices for local anesthesia - ice packs and cooling gel. They reduce postoperative discomfort, help reduce inflammation and swelling. It's also important to:

- take maximum care of the disinfection of laparoscopic sutures;

- gradually increase physical activity very cautiously;

- exclude the possibility of constipation to avoid excessive strain on the pudendal nerve.

The problem of constipation is especially relevant for patients who use opioid analgesics as pain relievers. If difficulty in defecation is likely, it's worth using microclysters or other preparations to facilitate bowel movements. You can start leading a full sex life approximately 6 weeks after decompression surgery, but this is a general recommendation - only your surgeon can provide exact timing.

Recovery

Releasing the nerve, relieving pressure on it, is not enough, especially if the patient has been ill for a long time. Ahead for the operated patient is a period of regeneration, during which the nerve is restored. Most people continue to take pain relievers for months after surgery.

During the rehabilitation period, there may be an increase in pain in the area innervated by the pudendal nerve, especially 3-4 months after surgical decompression, due to active regeneration. This is a temporary phenomenon that gradually subsides. Often, full recovery takes about a year, and some patients report improvement in their condition after 2-3 years.

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The time required to return to workability and the ability to lead an active lifestyle is individual for each patient. Many patients return to work within a few months, although in most cases, the pain has not completely subsided by that time. Nevertheless, its level decreases, and the person is able to perform their duties, using special devices to organize their workplace (chairs, cushions).

The muscles of the pelvis can be in a state of spasm both before and after surgical treatment of pudendal nerve compression. It is believed that therapeutic exercises help eliminate hypertonus. Also, for muscle relaxation, specialists recommend swimming (in any style except breaststroke, as it requires spreading the hips apart), but before starting the exercise, you need to obtain approval from the attending physician.

Pudendal nerve decompressionis the most complex and high-tech method of treating neuropathy, which also requires careful patient selection based on indications. It's not surprising that myths - prejudices that need to be dispelled - have arisen around this operation.

Myths about surgical decompression of the pudendal nerve

Myth N1: Laparoscopy is too risky and ineffective.
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Myth N2: If relief doesn't occur immediately, the surgery was unsuccessful.
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Surgery is a radical option, but it's a real way to reduce or eliminate pain and restore a person's ability to live a full life. If the decision to undergo surgery is made consciously, and the patient is informed about all the details and knows what to expect, there is a very high likelihood that they will ultimately be satisfied.

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