The aim of this study was to assess the efficacy of laparoscopic transperitoneal pudendal decompression in the improvement of refractory Lower Urinary Tract Symptoms (LUTS) in young males presenting with clinical features of pudendal nerve entrapment, with no known comorbidities that could explain their LUTS.

This is a prospective pilot study which includes patients suffering from refractory LUTS and clinical features of pudendal nerve entrapment, recruited consecutively. From January 2019 till September 2020, we prospectively enrolled young male patients with no comorbidities. These patients were (i) men aged between 18 and 40 years old, (ii) having LUTS diagnosed as primary bladder neck dysfunction or from an unknown etiology, with a hypersensitive bladder on previous urodynamics, (iii) who were refractory to standard medical therapy, (iv) who had some clinical features of pudendal nerve entrapment (e.g. allodynia or hyperpathia, rectal foreign body sensation, etc.) but not meeting all the essential Nantes criteria, and most importantly (v) having on clinical examination an asymmetric exquisite tenderness on the palpation of one of the ischial spines (which is usually considered as a complementary diagnostic Nantes criterion), a painful skin rolling test (Kibler test) and abnormal sensibility at the level of the perineum. To note, patients did not have necessarily pudendal pelvic pain, even if it is considered as an essential criterion for diagnosis. Not all clinical features of pudendal nerve entrapment were present in all patients, but the clinical signs found on clinical examination (excquisite tenderness, Kibler test and abnormal sensibility) were present in all patients. These patients underwent under general anesthesia laparoscopic transperitoneal pudendal unilateral decompression of their affected side (detected on history taking and clinical examination).  Our study was approved by our institutional review board, and all patients agreed to participate in the study and have signed a written informed consent. Age, body mass index (BMI) and median duration of refractory LUTS were noted. International prostate symptom score (IPSS) was evaluated before and 3 months after the procedure. Uroflowmetry was also done with evaluation of maximal flow (Qmax), urinated volume (Vu), and post-residual volume (PVR) before and 3 months after the procedure. Our aim was to investigate a significant improvement of IPSS and Qmax after 3 months of pudendal decompression.

Five consecutive patients (age: 34±4 years; BMI: 23.6±2 Kg/m2) were prospectively enrolled. These patients had voiding and/or storage LUTS and were refractory to standard medical therapy (alpha adrenergic blockers, anticholinergics, etc.). Median duration of refractory LUTS was 37 months. Median IPSS differed significantly, respectively before and 3 months after the procedure (18 vs. 8; p=0.042); likewise, median Qmax differed significantly, respectively before and 3 months after the procedure (12 vs. 18 ml/sec; p=0.042). Median Vu and PVR did not differ significantly before and after the procedure (Vu: 203 vs. 250 ml; p=0.223; PVR: 20 vs. 12; p=0.144). Quality of life evaluated by the 8th subscore of IPSS differed significantly before and after the procedure (5 vs. 1; p=0.042). Subscores of and total IPSS in each patient were presented in Table 1. Characteristics of the five patients (IPSS, Qmax, urinated volume and PVR) before and after the pudendal decompression were presented in Table 2. We should note that other features of pudendal nerve entrapment syndrome were also improved after surgery; data were not included because it is not the aim of the present manuscript.

LUTS in young males are usually refractory to standard medical therapy and the etiology and pathophysiology of these LUTS are still unknown in the literature. Pudendal nerve entrapment syndrome can explain LUTS in young males, especially when other clinical features of pudendal nerve entrapment are depicted in the history and clinical exam, not necessarily pudendal pain. Our study has shown a significant improvement in IPSS and Qmax laparoscopic pudendal transperitoneal decompression. Thus, it seems that this treatment is effective in improving LUTS in these select patients. We think that pudendal entrapment in its first stages causes irritation of the pudendal nerve before causing its definitive lesion. This irritation may reflect in the clinical setting by LUTS. Voiding LUTS are due to the impingement of the motor/autonomic part of the nerve, while storage LUTS are due to the impingement of the sensory/autonomic part of the nerve. The autonomic fibers of the pudendal nerve provide the conscious need to urinate. When there is pudendal nerve entrapment, there is a continuous conscious need to urinate due to continuous nerve stimulation by the inflammation, even though the bladder is empty. We believe that this bladder hypersensitivity is what explains voiding dysfunction in these individuals, who do not have bladder outlet obstruction (pudendal nerve does not innervate the bladder neck). These LUTS could sometimes appear solely in a patient and precede the emergence of the other pudendal entrapment symptoms that constitute the essential Nantes criteria. These LUTS are the result of an excessive excitatory-like signal that is caused by nerve irritation. The complete list of criteria will be achieved once the lesion of the pudendal nerve takes place.

Pudendal nerve entrapment syndrome should be considered as a main differential diagnosis of LUTS in young males with no known comorbidities. Physicians should search for pudendal nerve entrapment features in a young male patient with refractory LUTS, especially any asymmetric exquisite tenderness on the palpation of the ischial spines, a painful skin rolling test and abnormal sensibility at the level of the perineum during the clinical examination. When these features are present, laparoscopic transperitoneal pudendal decompression of the affected side relieves LUTS in these select patients.