Laparoscopic treatment of pudendal nerve and artery entrapment improves erectile dysfunction in healthy young males.

Erectile dysfunction (ED) is increasingly becoming more common in young healthy males and is attributed mainly to psychogenic causes in these patients. Recent studies have reported that ED could be secondary to pudendal nerve or artery entrapment. This perspective assessed the efficacy of laparoscopic pudendal nerve and artery decompression in young patients suffering from refractory ED, associated to a pudendal nerve entrapment syndrome. After excluding patients with psychological ED and venous leakage, five young male patients with a history of both ED and pudendal nerve entrapment syndrome diagnosed based on the Nantes criteria were recruited. Pudendal nerve and artery release was performed using a laparoscopic transperitoneal approach. International Index for Erectile Function (IIEF-5) and erectile hardness score (EHS) improved significantly in all patients, 3 months after surgery. Pudendal nerve and artery entrapment could be therefore a reversible cause of ED in young healthy males, and its treatment by laparoscopic pudendal nerve and artery decompression seems to be safe and effective.

Laparoscopic transperitoneal pudendal nerve and artery release for pudendal entrapment syndrome.

INTRODUCTION: Pudendal nerve and artery entrapment is an underdiagnosed pathology responsible of several urinary, sexual and anorectal complaints. The aim of our study was to evaluate safety and feasibility of laparoscopic transperitoneal pudendal nerve and artery release in a large retrospective cohort of patients with pudendal nerve entrapment syndrome with both a short and long-term follow-up. Technical details and outcomes are also reported. METHODS: A series of 235 patients with pudendal syndrome underwent laparoscopic transperitoneal pudendal canal release between June 2015 and February 2020. Operative data were recorded prospectively for all patients. A complete history, pain visual analog scale (VAS) for perineodynia, and three scores evaluating the main symptoms (USP, IIEF-5, PAC-SYM) were obtained before and at least 24 months after surgery for 32 patients only. Post-operative complications were also evaluated using Clavien-Dindo classification at regular interval. RESULTS: The mean operating time per side was 33.9 ± 6.8 min and the average hospital stay was 1.9 ± 0.3 days. Blood loss was 20 cc ± 10 cc with no patients needing transfusion. The only significant per-operative complication was hemorrhage (600 ml) in one patient induced by a pudendal artery laceration, successfully treated by laparoscopic suturing. Post-operative complications were noted in 18.7% of patients with no serious Clavien-Dindo complications. Perineodynia VAS dropped from 6.8 ± 0.9 to 2.2 ± 1.8 after surgery (p < 0.001). Mean IIEF-5 scores significantly improved one month after the surgery (15.2 vs 19.3, p = 0.036). Mean USP scores significantly improved for the dysuria domain (4.2 vs 1.6, p = 0.021) but not for stress urinary incontinence (3.9 vs 4.1, p = 0.082) or overactive bladder symptoms (14.1 vs 13.8, p = 0.079). Mean PAC-SYM scores significantly improved after the procedure (1.8 vs 1.1, p < 0.001). CONCLUSION: A complete laparoscopic pudendal nerve and artery release, from the sciatic spine through the Alcock's canal, is a fast and safe surgery with promising functional results. A large prospective trial is needed to validate such an approach.

Clinical effect of computed guided pudendal nerve block for patients with premature ejaculation: a pilot study.

Background: Premature ejaculation has a complex etiology, and its pathophysiology is still unclear, with penile hypersensitivity being the most accepted hypothesis. The aim was to investigate the efficacy and safety of a computed tomography-guided pudendal nerve block at the level of the sacrospinous ligament and the Alcock's canal in patients with premature ejaculation refractory to conventional pharmacological treatment.Methods: This is a prospective pilot study involving five patients suffering from premature ejaculation refractory to standard treatment and clinical features of pudendal nerve entrapment. A CT-guided infiltration of ropivacaine and methylprednisone was done at the levels of sacrospinous ligament and Alcock's canal. Intra-vaginal ejaculatory latency time (IELT) was recorded several times for each patient before and after infiltration. International Index of Erectile Function (IIEF-5), Premature Ejaculation Diagnostic Tool (PEDT) and Sexual Quality of Life-Male version (SQoL-M) questionnaire were also evaluated before and after infiltration.Results: Overall IELT differed significantly before and after treatment (21.94 vs 215.42 s; p = 0.039). IIEF-5, PEDT and SQoL-M also differed significantly before and after treatment. No complications for the CT-guided infiltration were recorded.Conclusion: CT-guided pudendal nerve block at the sacrospinous ligament and the Alcock's canal was effective in improving premature ejaculation. Therefore, pudendal nerve entrapment may be a curable cause of sensory premature ejaculation.

In Search for a Common Pathway for Health Issues in Men--the Sign of a Holmesian Deduction.

The evidence for the existence of a common pathway for health issues in men is presented in this review. Several epidemiological studies have shown that conditions like cardiovascular diseases (CVD), metabolic syndrome, diabetes, lower urinary tract symptom (LUTS), erectile dysfunction (ED), prostate cancer, hypogonadism, depression and suicide can be associated as risk factors for each other. Thus, the risk of CVD is significantly increased in men with metabolic syndrome, ED, hypogonadism, prostate cancer and/or LUTS. In addition, the above mentioned conditions are more prevalent in atherosclerotic patients. In addition, growing evidence indicates that low androgen levels can cause metabolic syndrome. In addition, obesity, dyslipidaemia and diabetes can further reduce androgen levels potentiating their adverse effect. Low testosterone levels are also associated with a higher incidence of aggressive prostate cancer on biopsy and on definitive pathology, and lower probability of abiraterone response in the metastatic setting. Several recent studies point towards diffuse endothelial dysfunction and dysregulated pro-inflammatory state as the biological link between all these disorders. Our current hypothesis is that oxidative stress caused by these dysfunctions explains the pathogenesis of each of these conditions.