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Laparoscopic Treatment of Pudendal Nerve and Artery Entrapment Improves Erectile Dysfunction in Healthy Young Males - Beyond the Abstract

Erection is a biopsychosocial process that involves vascular, neurological, endocrine, and psychological factors. Erectile dysfunction (ED) results from disturbance of any of these factors and is most of the time attributed to psychogenic causes in healthy young patients. However, recent studies have reported associated unrecognized organic causes of ED in 87% of patients. For instance, ED in young fit cyclists was demonstrated to be caused by pudendal artery and nerve mechanical compression between the sacrospinous ligament and piriformis muscle.1,2 Using a laparoscopic transperitoneal approach, we have operated on more than 200 patients in our center with pudendal nerve entrapment, diagnosed based on the Nantes criteria3 and validated by an operative finding of the pudendal nerve and artery entrapment. Alongside the improvement of pudendal nerve entrapment clinical features, in some healthy young patients, we have noticed an improvement of their erectile function suffering from a mild to moderate ED.


Our pilot study4 aimed to assess the efficacy of laparoscopic pudendal nerve and artery decompression in young patients suffering from ED, associated to a pudendal nerve entrapment syndrome. Ten young male patients with a concomitant history of ED and pudendal nerve entrapment syndrome were recruited. After excluding patients with psychogenic causes, and patients with venous leakage (using an intracorporeal injection of Prostaglandin E1), five males with a mean age of 28 years were enrolled. These five patients underwent laparoscopic transperitoneal pudendal nerve and artery decompression resulting in a significant improvement of their erectile function. The International Index of Erectile Function (IIEF-5) increased significantly one month after surgical decompression, and the beneficial effect persisted at three months. This post-operative significant improvement in all five patients establishes therefore a causality between the pudendal nerve and artery entrapment and ED. This is illustrated by the known chief anatomical and physiological roles of the pudendal artery (blood filling of sinusoidal spaces of corpora cavernosa and corpus spongiosum) and the pudendal nerve (sensory stimuli to the skin of the penis and scrotum, autonomic and motor relaxation of erectile tissue) in the erectile process.

The advent of the laparoscopic approach for pudendal canal decompression has widened the indications for surgical treatment of pudendal entrapment. The advantages of this approach compared to other surgical approaches (transgluteal, trans-ischiorectal, transperineal etc…) are that: (i) it is a minimally invasive procedure with (ii) easy access to the two main levels of entrapment (between sacrospinous and sacrotuberous ligaments, and the Alcock’s canal).

Pudendal nerve and artery entrapment could be therefore a reversible cause of ED in young healthy males. Clinicians should search for pudendal nerve entrapment symptoms in every young healthy patient presenting for ED. When these clinical features are present, laparoscopic transperitoneal pudendal nerve and artery decompression seem to be effective in this category of patients. Future studies are needed to confirm our findings.

Written by: Georges Mjaess MD1 (Twitter: @gmjaess), Fouad Aoun MD, MSc1,2 (Twitter: @FouadAoun6), Renaud Bollens MD3,4

  1. University of Saint Joseph, Faculty of Medicine, Beirut, Lebanon
  2. Urology Department, Institut Jules Bordet, Brussels, Belgium
  3. Department of Urology, Université Nord de France, St Philibert Hospital, GHICL, Lille, France
  4. Wallonie Picarde Hospital, Tournai, Belgium
References:

  1. Gemery, John M., Ajay K. Nangia, Alexander C. Mamourian, and Scott K. Reid. "Digital three‐dimensional modeling of the male pelvis and bicycle seats: Impact of rider position and seat design on potential penile hypoxia and erectile dysfunction." BJU international 99, no. 1 (2007): 135-140.
  2. Leibovitch, Ilan, and Yoram Mor. "The vicious cycling: bicycling related urogenital disorders." European urology 47, no. 3 (2005): 277-287.
  3. Labat, Jean‐Jacques, Thibault Riant, Roger Robert, Gérard Amarenco, Jean‐Pascal Lefaucheur, and Jérôme Rigaud. "Diagnostic criteria for pudendal neuralgia by pudendal nerve entrapment (Nantes criteria)." Neurourology and Urodynamics: Official Journal of the International Continence Society 27, no. 4 (2008): 306-310.
  4. Aoun, Fouad, Georges Mjaess, Karim Daher, Ghazi Sakr, Anthony Kallas Chemaly, Mohammad Salameh, Simone Albisinni, Fabienne Absil, Thierry Roumeguere, and Renaud Bollens. "Laparoscopic treatment of pudendal nerve and artery entrapment improves erectile dysfunction in healthy young males." International Journal of Impotence Research (2020): 1-5.
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