Health Organization for Pudendal Education

I am a 62 year old female and started having perineal pain 3.5 years ago with no cause. After extensive searching/treatments/doctors I am strongly leaning towards surgery. The prickly pain and burning occurs on my right side between my labia and anus after sitting for a few minutes and gets much more intense as the day progresses. Pretty much have completed all protocols (except DRG stimulator) with no permanent pain relief.

I live in Florida so will have to fly to Boston and stay in a hotel/Air BNB in Nashua for the procedure and recovery. I chose Dr. Conway because he takes insurance and has a very informative YouTube video that answered most of my questions. The video is 3 years old so I'm hoping recent advancements have improved outcome. My Televisit is 8/28/24.

Please respond with any information on success/failure with this surgery and/or Dr. Conway along with recovery experience.

Hi Lyn,

It sounds like you've done your research. Dr. Conway is very knowledgeable and experienced. As with all practitioners, there are some successes but not 100% so you just need to go into it with your eyes wide opened knowing what the potential risks are. You can ask him at your telehealth visit. Wishing you luck with your upcoming appointment.

Violet

Hi Lyn,

I’m almost a year post-op from a left sided TG approach with Dr. Conway. Met all the Nantes criteria, exhausted almost all the conservative measures besides loading up on meds etc etc. He helped me quite a bit, I would say I am maybe 60-70% better. Unfortunately in my case I believe my root cause is secondary to a moderate scoliosis causing significant strain and rotation of my pelvis which still causes me some pain and discomfort. I can’t imagine where I’d be had I not pursued my surgery with him though. Very individualized decision for each person here though and as Violet said, good to do your research - the recovery is difficult for the first 6 months atleast I’d say. I’m very active normally so it was hard to take a backseat. Wishing you the best !

Thank you for the information! Yes, I too am very active and we travel and hike quite a bit so it’s going to be really hard with recovery. Did your post surgery pain really last for six months? What Activities were painful for the six months? (Sitting standing walking running…?)

Spend an hour poking around Dr Hibner’s website.

https://azccpp.com/patient-friendly-pud ... y-handout/

(I had tg surgery in 9/22 - send me a message if you need to talk.)

Lyn, just saw ur post on choosing Dr
conway doing your surgery. Did you complete the surgery and How are you doing? thanks

Another consideration.

The best review of surgical approach to Transperineal and Transgluteal Approach to PNE is:
https://pmc.ncbi.nlm.nih.gov/articles/PMC10990758/

It mainly reviews the Transperineal and Transgluteal approach to PNE. Both of these approaches were pioneered in the last few decades, initially by Dr. Shafik in Egypt and the Nantes group. However, overall numbers in terms of percentage of actual cures, or marked improvements is most often below 80%, and sometimes much lower.

There have been some encouraging case series. Aaron Filler, Neurosurgeon, had an “outlier” report with “87% excellent results” and did a lot for the field with promoting his very accurate pain diagram. However, he has not published results since and his encouraging numbers have not been reproduced. He makes every patient do a relatively worthless 1.5 Tesla MR Neurography and the average cost for evaluation and whatever treatment he decises upon is $100k to 250K. That is as outlandish as it sounds as it has no relation to the amount of time or surgical effort required for his services. I cannot recommend anyone start down that pathway.

Dr. A. Lee Dellon is now retired. He was a master Plastic Surgeon who happened to devote his career to Nerve Decompression Surgery. He also had an approximately 86% “excellent result” rate. However, he was extremely careful with patient selection and his operative criteria would exclude many of the patients with PN from compression who follow this site.

He was an innovator, and many plastic surgeons learned from him how to do both the Trans-perineal and Trans- Gluteal Approach. It should be mentioned that while the transperineal approach could be advantageous for the few cases with compression within the Alcock’s canal, that this is the minority of cases. The Trans-gluteal gives better view of the SS and ST ligament but it is a challenge because of the amount of tissue trauma, bleeding and swelling that occurs with that external approach. In addition, the steady hand needed to do microsurgery around the very narrow Pudendal Nerve is totally “Surgeon Dependent”. To any of you who have had a Gluteal Muscle Cut to have a Posterior Hip Replacement and had the subsequent 4 to 6 weeks of pain will relate to the pain involved with surgery on both gluteal muscles.

For reasons of much greater magnification, the “super - human steadiness of instrumentation”, and minimal local tissue trauma and bleeding near the PN and the SS/ST Ligaments the Robotic Laparoscopic Approach is on the rise, especially in the last 2 years. It is only a matter of time where this will replace the external approach for most patients with PN, just as it has in Prostate Cancer surgery and some Gynecology procedures.

The article linked at the top mentions the “regular” laparoscopic approach and notes it as promising. What will follow, the evolution to HD resolution magnification and the Da Vinci instruments will likely change the approach, and more likely the pain relief that is dearly needed in this nerve compression condition.

There are some doing this already and experience with this superior tool is growing rapidly. I have had my surgery and am a month out and already 90% better. I resisted the peripheral approach for years, and even “older versions” of the laparoscopic approach until more experience had been obtained. No big series yet, but the intraoperative pictures alone show what a major advance this is.

I am sharing on this site because I saw how many people are looking into this approach. It may turn out to be the best for you. I think it important though to make people aware that there is a new approach since 2023 that should also be explored.

I discuss in detail my experience in the "Active Topic area under " Pudendal Nerve is a simple nerve compression..."

Your input is much appreciated. Haven't had a chance to read that article yet but it looks very interesting. I am very lucky to be 90-some percent better since surgery but I had the trans-ischio-rectal fossa approach which doesn't seem to be in use anymore. From what I have heard, even Dr. Bautrant uses the laparoscopic approach now instead of the TIR.

Violet

So glad to hear about your success! Regardless of approach, the key is adequate decompression and not injuring the nerve further from the procedure or post op swelling/scarring.

There enough people that have improved with the "external approaches" that strongly suggest it is a valid approach for somewhere between 50% to 85% of patients. The main message is that decompressing the nerve via cutting the ST Ligament and the obdurate aponeurosis and cutting or removing the SS ligament can accomplish that regardless of approach.

In general, the overall success rate of the external approaches is not at the level that the average risk benefit of surgery is met. For instance, if your Carpal Tunnel Surgery had those kind of numbers, a referring Internist such as myself would not rush to recommend it. The less successful the surgery, the greater the risk of complications dominating the reported surgical results.

In addition, exposure and ability to see what you are doing is critical to good surgical outcomes in surgery on skinny, tiny nerves. Robotic surgery is ideal for that. Poor visualization leads to more soft tissue trauma and greater chance of iatrogenic nerve injury. Leads to a higher likelihood of swelling and scarring post - op that can actually "recompress" whatever decompression the surgeon can get.

Lastly, about 1 in 7 patients have significant anatomic variation that leads to even tinier off-shoots of the PN branches. Those variant branches are easily cut or traumatized if he surgical field is not pristine or the surgeon is less experienced. If missed, that leads to a significant failure rate from surgery in those patients. This alone is a somewhat insormountable obstacle for a well >90% success rate. You need that kind of success rate to justify the risk of surgery for any approach to become the standard of care.

Robotic surgery, thus far, has achieved those results in other surgeries in the area, such as prostate cancer. One reason is the far superior visualization of the tiny periprostatic nerves that need to be spared to prevent surgical complications. I expect this approach will replace external approaches in the long run.

I would disagree, if someone has tried conservative methods and there isn’t any other option and pain killers do not control the pain etc, then you would accept an even poorer chance of success. The days of doctors acting as gate keepers and denying patients the right to choose should have gone by now.

Say for example if someone was involved in a road traffic accident would you not recommend surgery if it could preserve life even surgical success was only 40-50%. This is a decision that should be made by the patient and nobody else, after discussion with their surgeon! It is really sad that quality of life means nothing it seems.

I appreciate this wasn’t quite what you meant but I do have a stance on risk, and it seems people do not take into the patient’s typical context in these situations. Carpel tunnel really does not compare as it’s easy to diagnose in the first place and a commonly performed procedure. As a result, you would expect far higher success rates, you need to compare apples with apples, not apples and oranges.

kimc wrote: ↑Tue Jan 13, 2026 6:32 pm So glad to hear about your success! Regardless of approach, the key is adequate decompression and not injuring the nerve further from the procedure or post op swelling/scarring.

There enough people that have improved with the "external approaches" that strongly suggest it is a valid approach for somewhere between 50% to 85% of patients. The main message is that decompressing the nerve via cutting the ST Ligament and the obdurate aponeurosis and cutting or removing the SS ligament can accomplish that regardless of approach.

In general, the overall success rate of the external approaches is not at the level that the average risk benefit of surgery is met. For instance, if your Carpal Tunnel Surgery had those kind of numbers, a referring Internist such as myself would not rush to recommend it. The less successful the surgery, the greater the risk of complications dominating the reported surgical results.

In addition, exposure and ability to see what you are doing is critical to good surgical outcomes in surgery on skinny, tiny nerves. Robotic surgery is ideal for that. Poor visualization leads to more soft tissue trauma and greater chance of iatrogenic nerve injury. Leads to a higher likelihood of swelling and scarring post - op that can actually "recompress" whatever decompression the surgeon can get.

Lastly, about 1 in 7 patients have significant anatomic variation that leads to even tinier off-shoots of the PN branches. Those variant branches are easily cut or traumatized if he surgical field is not pristine or the surgeon is less experienced. If missed, that leads to a significant failure rate from surgery in those patients. This alone is a somewhat insormountable obstacle for a well >90% success rate. You need that kind of success rate to justify the risk of surgery for any approach to become the standard of care.

Robotic surgery, thus far, has achieved those results in other surgeries in the area, such as prostate cancer. One reason is the far superior visualization of the tiny periprostatic nerves that need to be spared to prevent surgical complications. I expect this approach will replace external approaches in the long run.