Pudendal nerve entrapment at the level of sacrospinous ligament or Alcock’s canal; laparoscopic management

Objective: Pudendal nerve entrapment may occur at multiple sites along the course of the nerve. The Nantes criteria have been proposed for diagnosing pudendal nerve entrapment syndrome. However, it is clinically possible to discriminate pudendal nerve entrapment at the level of the sacrospinous ligament from Alcock's canal. Methods: A step-by-step description of the surgical technique is provided based on video images. Results: A 38-year-old woman presented with sitting pain. She experienced pain from the clitoris to the anus on the left side for 2 years. Her pain score was 8/10 according to the visual analog scale. She experienced pain in the left sacrospinous ligament on palpation and showed Tinel's sign (+). The left pudendal nerve block relieved the pain for approximately 2 hours. Pudendal nerve entrapment was diagnosed based on the Nantes criteria. The pain was refractory to conservative treatment. A laparoscopic pudendal nerve release was planned. The surgery was completed uneventfully. After 1 month, her score decreased to 3/10. The Nantes criteria, which have been proposed for diagnosing pudendal nerve entrapment syndrome, were primarily developed to diagnose entrapment at the level of Alcock's canal and/or at the interligamentous plane. Therefore, the Nantes criteria do not discriminate entrapment at the level of the sacrospinous ligament from Alcock's canal. Conclusion: It is clinically difficult to discriminate pudendal nerve entrapment at the level of the sacrospinous ligament from Alcock's canal. Therefore, if a decision is made to perform laparoscopic pudendal nerve release, combined decompression at both sites may be considered at the sacrospinous ligament and Alcock's canal if no obvious cause is identified pre-and intraoperatively.