Restoration of Penile Sensation after Dorsal Nerve Trauma in Cismen

Purpose: Loss of penis sensation or development of a painful penis can occur after injury to the dorsal branch of the pudendal nerve. Attempted relief of this problem through neurolysis of the dorsal nerve in the inferior pubic ramus canal has been reported rarely. While recovery of genital sensibility has been discussed frequently in transmen, this subject has been reported rarely in cismen. The purpose of this report is to review our experience with recovery of sensation after decompression of the dorsal branch of the pudendal nerve. Methods: A retrospective chart review was carried out from 2014 to 2018, of cismen who have had decompression of the dorsal branch of the pudendal nerve bilaterally. Patients were included if there was a thorough Urologic evaluation for sources of penile pain other than pudendal nerve injury, trial of antibiotics if prostatitis was suspected, normal magnetic resonance imaging (MRI) of the pelvis, and underwent a successful pudendal nerve block if pain was part of the symptomatology. Patients were excluded if they had previous genital surgery. The changes in penile symptoms (erection, ejaculation, ejaculatory pain, erogenous sensation, numbness, pain) were evaluated post-operatively. Secondary measures included the mechanism of injury, mean length of penile symptoms, mean time to improvement of first symptom, symptom recurrence, post-operative complications, and mean follow-up time. Results: Mechanisms of injury in this cohort of 8 men were 3 cycling (38%), 3 falls (38%) and 2 prostatectomy (28%). The mean length of penile symptoms prior to surgery was 254 weeks. Mean follow-up time was 9 weeks. Mean time to improvement in first symptom was 8 weeks. Of the 8 men included in this study, 6 (75%) had surgery bilaterally. Of the 3 men who had erectile dysfunction, normal erections were restored in 2 (67%) patients. Of the 2 patients unable to ejaculate, 1 (50%) patient regained ejaculatory function. Of the 5 patients with ejaculatory pain, complete relief of pain occurred in 3 (60%) patients, with partial relief in 2 (40%) patients. Of the 7 patients with loss of penile sensation, complete recovery of erogenous sensibility occurred in 6 (86%) patients, with partial relief in 1 (14%) patient. Of the 6 patients with penile pain, complete relief of pain occurred in 3 (50%) patients, with partial relief in 3 (50%) patients. Of the 4 patients with numbness, 1 (25%) patient had a complete return of feeling, with partial return in 3 (75%) patients. Complications: one patient had relief of pain but some residual penile numbness. Conclusions: Neurolysis of the dorsal nerve to the penis can be successful in relieving pain, restoring sensation and erectile function in cismen who sustained an injury along the inferior pubic ramus. This approach may prove useful to transmen who have scarring about the dorsal nerve after transgender surgery

Persistent Genital Arousal Disorder (PGAD): Treatment by Neurolysis of Dorsal Branch of Pudendal Nerve

Introduction: Persistent genital arousal disorder (PGAD) is the female perception that they are in a state of sexual arousal, without the ability of the arousal to be satisfied by orgasm. Aims: It is the hypothesis of this study that PGAD results from a minimal degree of nerve compression of the dorsal branch of the pudendal nerve. If this hypothesis were true, then PGAD could be treated by neurolysis of the dorsal branch of the pudendal nerve. Methods: A retrospective chart review was carried out from 2010 through 2018, of those women having neurolysis of the dorsal branch of the pudendal nerve. Patients were included in the cohort if they had a diagnosis of PGAD. All patients were assessed for demographic and clinical differences. Comparison between the pre-operative and postoperative groups was performed with descriptive statistics. Main Outcome Measures: The changes in clitoral symptoms (arousal, numbness, pain) evaluated post-operatively. Results: Of the 8 women included in this study, 7 were followed more than 24 weeks since surgery. Six of these women had the surgery bilaterally, and each of these had an excellent result (100%), meaning elimination of the arousal symptoms, pain, and the ability to resume normal sexual intercourse. The patient with unilateral decompression of the dorsal branch of the pudendal nerve had some improvement in arousal symptoms. This patient was the only reported case of symptom persistence. Clinical Implications: Provides a new treatment approach for patients with PGAD. Strength & Limitations: The main strength of the study is that this is the first article to report treatment of PGAD with neurolysis of the dorsal branch of the pudendal nerve. The main limitations of the study are the sample size and analysis of retrospectively collected data. Conclusion: The relief of arousal symptoms supports the hypothesis that PGAD is due to a minimal degree of compression of the dorsal branch of the pudendal nerve

CRPS of the upper or lower extremity: surgical treatment outcomes

The hypothesis is explored that CRPS I (the "new" RSD) persists due to undiagnosed injured joint afferents, and/or cutaneous neuromas, and/or nerve compressions, and is, therefore, a misdiagnosed form of CRPS II (the "new" causalgia). An IRB-approved, retrospective chart review on a series of 100 consecutive patients with "RSD" identified 40 upper and 30 lower extremity patients for surgery based upon their history, physical examination, neurosensory testing, and nerve blocks. Based upon decreased pain medication usage and recovery of function, outcome in the upper extremity, at a mean of 27.9 months follow-up (range of 9 to 81 months), gave results that were excellent in 40% (16 of 40 patients), good in 40% (16 of 40 patients) and failure 20% (8 of 40 patients). In the lower extremity, at a mean of 23.0 months follow-up (range of 9 to 69 months) the results were excellent in 47% (14 of 30 patients), good in 33% (10 of 30 patients) and failure 20% (6 of 30 patients). It is concluded that most patients referred with a diagnosis of CRPS I have continuing pain input from injured joint or cutaneous afferents, and/or nerve compressions, and, therefore, similar to a patient with CRPS II, they can be treated successfully with an appropriate peripheral nerve surgical strategy

Non-invasive neurosensory testing used to diagnose and confirm successful surgical management of lower extremity deep distal posterior compartment syndrome

<p>Abstract</p> <p>Background</p> <p>Chronic exertional compartment syndrome (CECS) is characterized by elevated pressures within a closed space of an extremity muscular compartment, causing pain and/or disability by impairing the neuromuscular function of the involved compartment. The diagnosis of CECS is primarily made on careful history and physical exam. The gold standard test to confirm the diagnosis of CECS is invasive intra-compartmental pressure measurements. Sensory nerve function is often diminished during symptomatic periods of CECS. Sensory nerve function can be documented with the use of non-painful, non-invasive neurosensory testing.</p> <p>Methods</p> <p>Non-painful neurosensory testing of the myelinated large sensory nerve fibers of the lower extremity were obtained with the Pressure Specified Sensory Device™ in a 25 year old male with history and invasive compartment pressures consistent with CECS both before and after running on a tread mill. After the patient's first operation to release the deep distal posterior compartment, the patient failed to improve. Repeat sensory testing revealed continued change in his function with exercise. He was returned to the operating room where a repeat procedure revealed that the deep posterior compartment was not completely released due to an unusual anatomic variant, and therefore complete release was accomplished.</p> <p>Results</p> <p>The patient's symptoms numbness in the plantar foot and pain in the distal calf improved after this procedure and his repeat sensory testing performed before and after running on the treadmill documented this improvement.</p> <p>Conclusion</p> <p>This case report illustrates the principal that non-invasive neurosensory testing can detect reversible changes in sensory nerve function after a provocative test and may be a helpful non-invasive technique to managing difficult cases of persistent lower extremity symptoms after failed decompressive fasciotomies for CECS. It can easily be performed before and after exercise and be repeated at multiple intervals without patient dissatisfaction. It is especially helpful when other traditional testing has failed.</p

The virtual peripheral nerve academy: education for the identification and treatment of peripheral nerve disorders

Millions of people around the globe suffer peripheral nerve injuries caused by trauma and medical disorders. However, medical school curricula are profoundly deficient in peripheral nerve education. This lack of knowledge within the healthcare profession may cause inadequate patient care. We developed the Virtual Peripheral Nerve Academy (VPNA) as a reusable virtual learning environment to provide medical students with detailed education on the peripheral nervous system (PNS). Students are introduced to the PNS through virtual 3D rendering of the human body, wherein they visualize individual nerves through dissection and observe normal motor and sensory function associated with each nerve. PNS structures that are absent from traditional texts are included in this visualization, ranging from the innervation of joints to the normal anatomic variation required for differential diagnosis of pain after an injury. Detailed modules on peripheral nerve disorders allow students to observe pathophysiological mechanisms, associated symptomatology, and appropriate treatments. Students are briefed on a patient clinical case, then interact with a patient avatar to learn the appropriate diagnostics, including physical exam maneuvers and electrodiagnostic testing. Interactive modules on peripheral nerve surgeries detail surgical techniques. The VPNA data and analytics dashboards allow medical students and course instructors to assess skill improvement and identify specific learning needs. The built-in learner management system and availability on both computer-based and virtual reality platforms facilitate integration into any existing medical school curricula. Ultimately, this immersive technology enables every medical student to learn about the peripheral nervous system and gain competency in treating real-life nerve pathologies

Dorsal clitoral nerve injury following transobturator midurethral sling

Transobturator slings can be successfully used to treat stress urinary incontinence and improve quality of life through a minimally invasive vaginal approach. Persistent postoperative pain can occur and pose diagnostic and therapeutic dilemmas. Following a sling procedure, a patient complained of pinching clitoral and perineal pain. Her symptoms of localized clitoral pinching and pain became generalized over the ensuing years, eventually encompassing the entire left vulvovaginal region

Scapular winging: anatomical review, diagnosis, and treatments

Scapular winging is a rare debilitating condition that leads to limited functional activity of the upper extremity. It is the result of numerous causes, including traumatic, iatrogenic, and idiopathic processes that most often result in nerve injury and paralysis of either the serratus anterior, trapezius, or rhomboid muscles. Diagnosis is easily made upon visible inspection of the scapula, with serratus anterior paralysis resulting in medial winging of the scapula. This is in contrast to the lateral winging generated by trapezius and rhomboid paralysis. Most cases of serratus anterior paralysis spontaneously resolve within 24 months, while conservative treatment of trapezius paralysis is less effective. A conservative course of treatment is usually followed for rhomboid paralysis. To allow time for spontaneous recovery, a 6–24 month course of conservative treatment is often recommended, after which if there is no recovery, patients become candidates for corrective surgery

Development and Validation of a Symptom-Based Activity Index for Adults With Eosinophilic Esophagitis

Standardized instruments are needed to assess the activity of eosinophilic esophagitis (EoE), to provide endpoints for clinical trials and observational studies. We aimed to develop and validate a patient-reported outcome (PRO) instrument and score, based on items that could account for variations in patients’ assessments of disease severity. We also evaluated relationships between patients’ assessment of disease severity and EoE-associated endoscopic, histologic, and laboratory findings