Neurourology and Urodynamics 27:96 (2008)

LETTER TO THE EDITOR

Re: Popeney C, Ansell V, Renney K. 2007. Pudendal NerveEntrapment as an Etiology of Chronic Perineal Pain:

Diagnosis and Treatment. Neurourol Urodynam 26:820–3

To the Editor:

Popeney et al.1 conducted a detailed study on 58 patientssuffering from chronic perineal pain, treated by surgicaldecompression of the pudendal nerve with the positivetreatment response in 60% of cases. In the discussion of theirresults, they mentioned a present-day problem of the special-ists in the pudendal nerve field: whether there are some otherplaces where one or more branches of the pudendal nerve canbe compressed and thus mimic the clinical picture of thepudendal nerve trunk entrapment inside the pudendalcanal or in a close proximity to ischial spine. One possibleanatomical site of such an out-of-pudendal-canal compressionis the subpubic concavity, where the branch of the pudendalnerve, the dorsal nerve of penis or dorsal nerve of clitorisis running inside the tight osteofibrotic canal2 in a closeproximity to bone.3 Previously, we have identified anddescribed in detail a groove on the pubic bone whichaccommodates the dorsal nerve of penis in males or dorsalnerve of clitoris in females and termed it the sulcus nervidorsalis penis/clitoridis.3 Later, we introduced a hypothesisthat the clinical signs of a sub-group of patients with thesymptoms of the Alcock’s syndrome might be caused by anoveruse injury in cyclists—a repetitive prolonged pressure ofthe nose of the saddle against the site where the dorsalnerve of penis runs adjacent to the ventromedial border of theischiopubic ramus—in the sulcus nervi dorsalis penis.4 Thesedata indicate the close proximity of pubic bone and the dorsalnerve of penis might play a causative role in the developmentof the dorsal nerve of penis/clitoris entrapment. Suchcompression should be suspected when the decreased glan-dular and penile sensitivity together with the genital numb-ness and the erectile dysfunction in males or the decreasedclitoridal sensitivity and the genital numbness in femalesoccur. Contrary, when these symptoms do not occur, thecompression of dorsal nerve of penis/clitoris should notbe suspected. Hypothetically, the simultaneous presence ofthe compression of pudendal nerve trunk together with thedorsal nerve of penis/clitoris compression might cause diag-nostic challenge. Only the future clinical data might verifyours and other’s hypotheses of the pathogenic role of closeproximity of the pubic bone and dorsal nerve of penis/clitorisin a sub-group of patients suffering from pudendal nerveentrapment syndrome.

Jiri Sedy*Institute of Experimental Medicine

ASCRPrague, Czech Republic

REFERENCES

1. Popeney C, Ansell V, Renney K. Pudendal nerve entrapment as an etiology ofchronic perineal pain: Diagnosis and treatment. Neurourol Urodyn 2007;26:820–3.

2. Hruby S, Ebmer J, Dellon L, et al. Anatomy of pudendal nerve at urogenitaldiaphragm—New critical site for nerve entrapment. Urology 2005;66:949–52.

3. Sedy J, Nanka O, Walro JM, et al. Sulcus nervi dorsalis penis/clitoridis:Anatomic structure and clinical significance. Eur Urol 2006;50:1079–85.

4. Nanka O, Sedy J, Jarolım L. Sulcus nervi dorsalis penis: Site of origin of Alcock’ssyndrome in bicycle riders? Medical Hypotheses 2007;69:1040–5.

Reply:

We thank you for your input. Of importance to clinicians isthe different symptom complexes that may arise from variedanatomical entrapment sites. In this case (entrapment underthe subpubic concavity of the dorsal nerve of penis/clitoris, aswell as entrapment at the urogenital diaphragm), neuropathicpain (positive sensory findings on exam) is absent andnumbness of the genitalia is present (negative sensoryfindings on exam). The neurophysiologic findings would alsodiffer. Reporting these findings across specialities is ofimportance. As you can see, making the effort to report thesefindings will continue to bring clarity on the subject.

Dr. Charles A. PopeneyFort Bend Neurology

Sugar Land, Texas

DOI 10.1002/nau.20494

Published online 24 July 2007 in Wiley InterScience

No conflict of interest reported by the author(s).Christopher Chapple led the review process.*Correspondence to: Jiri Sedy, Academy of Sciences of the Czech Republic,Institute of Experimental Medicine, Videnska 1083, Prague 142 20, CzechRepublic. E-mail: jirisedy@hotmail.comReceived 11 May 2007; Accepted 15 May 2007Published online 20 July 2007 in Wiley InterScience(www.interscience.wiley.com)DOI 10.1002/nau.20470

� 2007 Wiley-Liss, Inc.