Anatomical basis of digital rectal examination.

PURPOSE: Rectal examination is difficult to carry out by students because of their lack of knowledge and fear. It is therefore necessary to search for methods in order to facilitate its practice. This work mainly focuses on the palpation of the posterior lateral area of the rectum. METHODS: This work bases itself on the study of the average length of indexes and on the anatomical study of the dissection and prints of two pelvises. In the lithotomy position, we can identify three successive levels of exploration of the posterior and lateral area of the rectum. These three levels are defined by the extremity of the index, and the distal and proximal interphalangeal articulations placed successively on the tip of the coccyx. A 180° rotation of the hand enables at each level to identify the parietal structures that the pad of the index comes across, but excludes the palpation of genital organs and rectum. RESULTS: The first level corresponds to the higher part of the anal canal, the ischioanal fossa and the ischium. The second level corresponds to the levator ani muscle, the ischioanal fossa and the pudendal canal. The third level corresponds to the sacrospinous ligament, the ischiatic spine and the internal obturator muscle. CONCLUSIONS: In spite of the significant differences between the lengths of the indexes, the use of these landmarks will facilitate the identification of parietal anatomical structures. The internal organs' palpation will depend on the patient's position, his efforts in pushing, the length of the index, and the way the examiner presses on the perineum.

[Pudendal nerve surgery in the management of chronic pelvic and perineal pain]. / La chirurgie du nerf pudendal dans la prise en charge thérapeutique des douleurs pelvipérinéales chroniques.

OBJECTIVE: To define the place of pudendal nerve surgery in pudendal nerve entrapment syndromes. MATERIALS AND METHODS: Description of the various surgical techniques and published results. RESULTS: The original surgical technique, which remains the reference technique, consists of performing surgical release of the pudendal nerve from the infrapiriformis foramen to Alcock's canal via a transgluteal approach. This surgical procedure is safe and gives encouraging results validated by a prospective, randomized protocol: 66 to 80% of patients are improved. Other transvaginal or transperineal approaches have also been proposed. CONCLUSION: Pudendal nerve surgery is a reasonable treatment option when all other treatments have failed. However, the various techniques proposed and their respective criticisms must be carefully evaluated.

[The pudendal nerve: clinical and therapeutic morphogenesis, anatomy, and physiopathology]. / Le nerf pudendal: morphogenèse, anatomie, physiopathologie, clinique et thérapeutique.

The pudendal is the king of the perineum. Most often originating in the S3 root, it is responsible for the teguments of the perineum (glans penis, clitoris, scrotum, and the labia majora, the skin of the central fibrous perineal body, anus), but also the erector muscles and the striated sphincters. The social nerve, it controls erection and the voluntary sphincters. It is also the nerve of the beginnings of sexual sensation and masturbation. Its injury is expressed in perineal pain, which, when positional, suggests a tunnel syndrome. The compression points have become well known: ligament pinching between the sacrotuberous and sacrospinous ligaments, the falciform process and the pudendal canal (Alcock canal). The data from questioning the patient, the results of the neurological exam, and the at least momentary response to infiltration define the Nantes criteria, which confirm the diagnosis. Treatment is medical, physical therapy, infiltration, and, as a last resort, surgery. The results have improved because of new technical norms, with 75% of operated patients benefiting from surgery. This disorder has become well known and should be remembered, thus sparing the patient from years of suffering and needless consultations for patients who do not present with organ disease, too often implicated instead of a true canal neuropathy, whose clinical manifestation and treatment have now been validated.

[Somatic perineal pain other than pudendal neuralgia]. / Les douleurs périnéales somatiques autres que les névralgies pudendales.

In addition to the well-established syndrome of pudendal compression, and given the rich nerve trunk innervation of the perineum, pain originating in other nerve trunks can occur and must be remembered. Nerves originating high in the thoracolumbar area (ilioinguinal nerve, iliohypogastric nerve, genitor femoral nerve) can be the seat of traumatic lesions occurring during surgical approaches through the abdominal wall or can undergo compressions when crossing the fascia of the large abdominal muscles. Misleading perineal irradiations do not resemble pudendal neuralgia and should suggest pain in these trunks whose cutaneous territories are not solely perineal and whose clinical expression as pain is does not occur in the seated position. Similarly, painful minor intervertebral dysfunction of the thoracolumbar junction is not simply in the mind and should be considered, searched for, and treated. Related more to pudendal neuralgia, pain in the inferior cluneal nerve, triggered by the seated position, should be considered when the pain reaches the lateral anal region, the scrotum, or the labia majora but not involving the glans penis or the clitoris. Specific treatments (physical therapy, infiltrations, surgery) have proven effective.

[Buttocks sciatic pain]. / Les sciatiques de la fesse.

Confusion between radicular and nerve trunk syndrome is not rare. With sciatic pain, any nerve trunk pain or an atypical nerve course should suggest nerve trunk pain of the sciatic nerve in the buttocks. The usual reflex with sciatic pain is vertebral-radicular conflict. The absence of spinal symptoms and the beginning of pain in the buttocks and not in the lumbar region should reorient the etiologic search. Once a tumor of the nerve trunk has been ruled out (rarely responsible for pain other than that caused by tumor pressure), a myofascial syndrome should be explored searching for clinical, electrophysiological, and radiological evidence of compression of the sciatic trunk by the piriform muscle but also the obturator internus muscle. Hamstring syndrome may be confused with this syndrome. Treatment is first and foremost physical therapy. Failures can be treated with classical CT-guided infiltrations with botulinum toxin. Surgery should only be entertained when all these solutions have failed.