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Clitoral Hyperstimulation following Trans-obturator tape-A case report

Dr Mona Modi, Dr L. Geddes, Mr. D. SalvesenLister Hospital, East and North Hertfordshire NHS Trust.

Introduction

The treatment of incontinence using transurethral slings started in the early 20th century. The use of the transobturator tape procedure (TOT) was introduced in 2001. It can be both performed using the inside-out or outside-in technique. Both procedures have been reported with very few complications. We report a case of a 62-year-old woman with persistent clitoral hyper stimulation following the TOT procedure.

Dissection to demonstrate branches of the dorsal nerve of clitoris (DNC). PN-Perineal nerve, C Clitoris; ISischial spine, OC obturatorcanal, Ob.Int.M obturatorinternus muscle, Ob.Nveobturator nerve, SP symphysispubis, SSL sacrospinousligament, U urethra (Ref 6)

Case

A 62-year-old multigravid woman presented with a one year history of worsening symptoms of urinary stress and urge incontinence. Sixteen years previously, she had undergone a colposuspension operation that was successful but her symptoms over time had returned. Her medical history was unremarkable. Urodynamic studies were performed and the results were consistent with her having urethral sphincter incompetence. She was counselled regarding the treatment options and underwent a TOT procedure using the outside-in technique. Immediately postoperatively, her symptoms of stress incontinence resolved completely. However, early in her post operative recovery she noted an abnormal sensation around the clitoris. She did not bring this to the attention of any medical staff for several months. She appeared to have hypersensitivity of the clitoris, which she described as there being a sensation of continuous arousal. These symptoms worsened during sexual intercourse. When she did present to the clinic the only relief she could obtain was from placing icepacks in her groin. Examination in the clinic revealed no obvious abnormality and having considered the possible causes it was concluded that the symptoms might be due to irritation of or a neuroma of the dorsal nerve to the clitoris caused by the transobturator tape. As the symptoms were not improving with time a decision was taken to remove the tape. On removal of the tape there was an initial worsening of the symptoms. She was then commenced on oral Gabapentin at a dose of 100mg per day, gradually increasing the dose every three days. At a dose of 300 mg three times a day, the sensation decreased and then resolved. After a few weeks however we tried to wean off Gabapentin but it was not possible to do so as she was still symptomatic and so a decision was made to continue it for long term.After removal of the TOT, the stress incontinence returned and she has now been referred for consideration of a repeat colposuspension operation.

Anatomy of Dorsal Nerve of Clitoris

The anatomy of the dorsal nerve of the clitoris is well acknowledged. It branches from the pudendal nerve close to the ischial spine and traverses along the medial aspect of the ischiopubic ramus. As it descends the pubic symphysis, it passes the ischiopubic ramus and then journeys down the anterior pubis and ultimately connects to the clitoris.

Discussion

References

The transurethral sling is a very popular surgical approach used for the treatment of stress incontinence. The TOT approach to mid urethral sling placement was described first in 2001 by Delorme (3). It was developed after the retropubic transvaginal tape procedure to avoid the blind passage into the retropubic space, thus addressing the risk of complications involving the bladder, bowel and vascular supply. The procedure is highly reproducible with an accurate trajectory, therefore reducing the chances of injury to these surrounding structures. The TOT procedure has few immediate post-operative and early postoperative complications. These include haemorrhage, haematoma and urinary retention. Long-term complications such as vaginal wall erosion , de novo urge symptoms and dyspareunia have been described (4) and thus patients need to be warned of these preoperatively. There have been many cadaver dissections determining the trajectory of this nerve and its intimate associations with its surrounding neurovascular structures. There is conflicting evidence regarding the theoretical risk of injury to the DNC by the TOT procedure. Tate SB et al 2009 (5) demonstrated the actual distance between the obturator foramen border and the nerve. They found that the nerve in all specimens had not taken an aberrant course of traversing the foramen. This study concluded that the introducer cannot come in to contact with the nerve, as it would have to pass through the ischio-pubic ramus, which is not anatomically possible. However, Delorme reported the course of the dorsal nerve of the clitoris (DNC) from anatomical studies and acknowledged that injury to the DCN could occur with TOT procedure causing altered sexual function such as arousal, orgasmic function or pain. A similar conclusion was made by Bonnet et al.

In this case the precise cause of the neurological symptoms and the level of the nerve injury or irritation remain uncertain. However, consideration needs to be given to warning patients about the possibility of this rare complication occurring.

1. Achtari C, McKenzie B.J, Hiscock R et al 2006. Anatomical study of the obturator foramen and dorsal nerve of the clitoris and their relationship to minimally invasive slings. International Urogynecology Journal. 17:330-334. 2. Bonnet P, Waltregny D, Reul O ET AL 2005. Transobturator vaginal tape inside out for the surgical treatment of female stress urinary incontinence: anatomical considerations. The Journal of Urology 173: 1223-1228. 3. Delorme E. Transobturator urethral suspension: mini-invasive procedure in the treatment of stress urinary incontinence in women. Prog Urol 2001;11:1306-13. 4. Kaelin-Gambirasio I, Jacob S, Boulvain M, et al 2009. Complications associated with transobturator sling procedures: analysis of 233 consecutive cases with a 27 months follow-up. BMC Women’s Health. 9: 28 5. Tate SB, Culligan PJ, Acland RD. 2009. Outside-in transobturator midurethral sling and the dorsal nerve of the clitoris. The International Urogynaecological Association. DOI 10.1007/S00192-009-0955-1

6. Achtari C, McKenzie B.J, Hiscock R et al 2006. Anatomical study of the obturator foramen and dorsal nerve of the clitoris and their relationship to minimally invasive slings. International Urogynecology Journal. 17:330-334.