Treatment of Pudendal Neuropathy to Restore Orgasmic Function
Pudendal nerve decompression surgery can successfully restore full orgasmic function in patients with pudendal neuropathy, with success rates of 83-86% for recovery of sexual sensation and function when conservative treatments fail. 1, 2, 3
Diagnostic Confirmation
Before considering treatment, confirm pudendal neuropathy through:
- Pinprick sensory testing of all six pudendal nerve branches (dorsal nerves to penis/clitoris, perineal nerves, inferior rectal nerves), which diagnoses pudendal neuropathy in 92% of patients 1
- Neurophysiologic testing including bulbocavernosus reflex latency and pudendal nerve terminal motor latency (PNTML) to document nerve dysfunction 2
- Document specific sexual symptoms: loss of genital sensation, inability to achieve orgasm, decreased orgasm intensity, or painful orgasms 3, 4
Treatment Algorithm
First-Line Conservative Management (14 weeks minimum)
Nerve protection and pharmacotherapy should be attempted first before considering surgical intervention 1:
- PDE5 inhibitors (sildenafil, vardenafil, tadalafil) can improve orgasm problems including decreased intensity and difficulty achieving climax 5, 6
- Testosterone replacement if morning testosterone <300 ng/dL, which may relieve orgasm problems 5, 6
- Pelvic floor physical therapy may improve sexual function, though evidence is primarily from prostate cancer populations 5, 6
- Vibratory therapy may reduce orgasm problems 5, 6
Second-Line: Pudendal Nerve Blocks
- Series of three pudendal nerve perineural injections given at 4-week intervals 1
- This serves both diagnostic and therapeutic purposes before considering surgery
Third-Line: Surgical Decompression
Surgical neurolysis should be offered when conservative treatments fail after 14 weeks 1:
Surgical Approach and Outcomes
Transgluteal approach provides access to compression sites from subpiriformis area through interligamentary space and pudendal canal (Alcock canal) 1
Common compression sites: between sacrotuberous and sacrospinous ligaments (most common), within Alcock canal, or at aberrant anatomical pathways 1
Success rates for sexual function restoration:
- 83% complete recovery of erogenous sensibility in men with loss of penile sensation 3
- 86% (6/7) improvement in erectile dysfunction in men with pudendal canal syndrome 2
- 88% (7/8) complete elimination of arousal symptoms in women with PGAD 4
- 67% restoration of normal erections 3
- 50% regained ejaculatory function 3
Time to improvement: 2-6 months postoperatively 2
Long-term durability: Cures documented >13 years with appropriate monitoring 1
Surgical Technique Specifics
For men: Neurolysis of dorsal nerve to penis at the inferior pubic ramus canal can restore sensation, erectile function, and ejaculatory function 3
For women: Bilateral neurolysis of the dorsal branch of the pudendal nerve to the clitoris eliminates arousal symptoms and restores normal sexual function 4
Alternative: Pudendal Neuromodulation
Chronic pudendal neuromodulation (CPN) is an effective alternative for patients who prefer a reversible option or have failed decompression 7:
- 75% (3/4) of patients met treatment goals and were satisfied 7
- Mean follow-up of 38 months with sustained benefit 7
- Also improves coexisting chronic pelvic pain, bowel, and bladder function 7
Critical Clinical Considerations
Bilateral surgery is often necessary as compression frequently occurs bilaterally (71% in one series) 3
Do not delay surgical referral indefinitely - the pathophysiology involves progressive axonopathy from ischemia and demyelination, suggesting that earlier intervention may prevent permanent nerve damage 1
Screen for coexisting erectile dysfunction which commonly accompanies pudendal neuropathy and requires concurrent management with PDE5 inhibitors 5, 6
Avoid confusing pudendal neuropathy with other causes of sexual dysfunction - the hallmark is sensory changes (numbness, pain, or altered sensation) in the distribution of pudendal nerve branches 1, 2, 3