TransvaginalPudendalNerveBlock

Author:HemantKSatpathy,MDChiefEditor:ChristineIsaacs,MDmore...

Updated:Oct21,2014

Overview
Blockingthepudendalnervewithinjectionoflocalanestheticisusedforvaginal
deliveriesandforminorsurgeriesofthevaginaandperineum.Useofthisnerve
blockforvaginaldeliverywasreportedasearlyas1916.[1]However,theprocedure
didnotbecomepopularuntil195354,whenKlinkandKohlimplementedthe
modifiedtechnique.[2,3]
Thesensoryandmotorinnervationoftheperineumisderivedfromthepudendal
nerve,whichiscomposedoftheanteriorprimarydivisionsofthesecond,third,and
fourthsacralnerves.Thepudendalnerves3branchesincludethefollowing:
1.Dorsalnerveofclitoris,whichinnervatestheclitoris
2.Perinealbranch,whichinnervatesthemusclesoftheperineum,theskinof
thelabiamajoraandlabiaminora,andthevestibule
3.Inferiorhemorrhoidalnerve,whichinnervatestheexternalanalsphincterand
theperianalskin
Apudendalnerveblocktargetsthepudendalnervetrunkasitentersthelesser
sciaticforamen,about1cminferiorandmedialtotheattachmentofthe
sacrospinousligamenttotheischialspine.Here,thenerveismedialtotheinternal
pudendalvessels.Thisnerveisaccessedby2approaches,transvaginaland
transcutaneous(orperineal).Theformerapproachismorereliableandisusedmost
often,exceptwhenanengagedheadmakesvaginalpalpationmoredifficult.The
anatomicalbasisforbothapproachesistoblockthenerveproximaltoitsterminal
branches.

Indications
Whileneuroaxialanalgesiacontinuestoreplacepudendalnerveblockasthe
techniqueofchoice,thereareandwillalwaysremainsituationsinwhichanesthesia
serviceisunavailable.Inthisevent,pudendalblockprovidesasuitablealternative
forthefollowing:
Analgesiaforthesecondstageoflabor
Repairofanepisiotomyorperineallaceration
Outletinstrumentdelivery(toassistwithpelvicfloorrelaxation)
Usedinthepastasanalternativetoneuroaxialanalgesiainassistedtwin
andbreechdeliveries
Minorsurgeriesofthelowervaginaandperineum

Contraindications
Seethelistbelow:
Patientrefusal
Patient'sinabilitytocooperate
Patientsensitivitytolocalanesthetics
Presenceofinfectionintheischiorectalspaceortheadjacentstructures,
includingthevaginaorperineum
Coagulationdisorders

Anesthesia
Seethelistbelow:
Lidocaine1%isoftenusedforpudendalnerveblock.Agentsthatcouldbe
usedinsteadinclude2chloroprocaine2%,bupivacaine0.25%,prilocaine
1%,ormepivacaine1%.
Becauseofitsshortdurationofaction,2chloroprocaine2%isusedless
often.However,itsrapidonsetofactionprovidesanadvantageiftheblockis
performedimmediatelybeforedelivery.Anotheradvantageof2
chloroprocaine2%comesfromitsrapidmetabolismandshortintravascular
halflife,whichdecreasetheriskofmaternalandfetaltoxicity.
StudiesbyKuhnertetalshownoclinicallysignificantdifferenceinthe
neonatalneurobehaviorat4hand24hafterdelivery,regardlessofthetype
ofanestheticused.[4]
Althoughsomeobstetricianscontendthattheadditionofepinephrinetothe
localanestheticsolutionimprovesthequalityoftheblock,Schierupetal
failedtodemonstratesuchimprovementinthequalityofanesthesiaintheir
studyofaddingepinephrinetomepivacaine.[5]Interestingly,theadditionof
epinephrineslightlyprolongedtheintervalbetweentheblockadministration
anddelivery.Maternalvenousbloodmepivacaineconcentrationswere

slightlyhigherinthegroupwithoutepinephrine,butnosuchdifferenceswere
notedinumbilicalcordbloodsamples.

Equipment
Seethelistbelow:
Iowatrumpetorsimilarguide(eg,Kobak)tofacilitatetheplacementofthe
needle(seeimagebelow)

Iowatrumpet.

Needle,usually6in,2022gauge(ga)
Syringewithfingerring,10mL
Localanesthetics(eg,lidocaine1%)
Sterilegloves
Resuscitationequipmentandmedicationsincaseanadversereactiontothe
anestheticisencountered

Positioning
Seethelistbelow:
Theblockisperformedwiththepatientinthelithotomyposition.

Technique
Seethelistbelow:
Usually,novaginalpreparationisneeded.
Palpatetheischialspine.Thisisusuallydonetransvaginallybutcanalsobe
donethroughtherectum.
Besuretouseaneedlewithaguide(eithertheIowatrumpetortheKobak
needleguide)tolimitthedepthofsubmucosalpenetrationandtoprevent
injurytothevaginaandthefetus.
Toperformaleftsidedblock,palpatetheischialspinewiththeindexfingerof
thelefthand,holdthesyringeintherighthand,andguidetheneedle
betweentheindexandmiddlefingerofthelefthandtowardtheischialspine.
Theauthorsthefollowing3injectiontechnique:
Placetheendoftheguidebeneaththetipoftheischialspine.
Pushtheneedleintothevaginalmucosa.
Aspiratetoensurethattheinjectionisnotintravascular.
Raiseamucosalwhealwith1mLoflocalanesthetic.
Advancetheneedlethroughthevaginalmucosauntilittouchesthe
sacrospinousligament1cmmedialandposteriortotheischialspine.
Infiltratethetissuewith3mLoflocalanesthetic.
Next,advancetheneedlefurtherthroughthesacrospinousligament
foradistanceof1cmuntilalossofresistanceisappreciated.
Thetipnowliesintheareaofthepudendalnerve.Atthispoint,the
pudendalvesselsliejustlateraltothepudendalnerve,socaremust
betakentoavoidintravascularadministration.Aspiratetoconfirmthe
needleplacementisnotintravascularpriortoinjectinglidocaine.
Injectanother3mLoflocalanestheticsolutionintothisregion.
Subsequently,withdrawtheneedleintotheguideandmovethetipof
theguidetojustabovetheischialspine.
Atthisnewlocation,reinserttheneedlethoughthemucosaandagain
inject3mLoflocalanesthetic.
Manypractitionersuseasingle10mLinjectioninsteadofthe3injection
techniquedescribedabove.Thesingleinjectionisdoneaftertheneedleis
introducednearly1cmthroughthesacrospinousligamentmedialand
posteriortotheischialspine.
Toblocktherightsideofthepelvis,repeatthesestepsusingtherighthandto
holdtheneedleandneedleguide(seeimagebelow).

Pudendalblock,transvaginalapproach.

Thisblockcouldbeattemptedunderultrasonographic,CT,orfluoroscopic
guidance.Althoughimaginghelpsdelineatetheanatomiclandmarkfor

needleplacement,itisrarelyusedbyobstetriciansandgynecologists.

Additionalanesthesia
Seethelistbelow:
Eveninthebesthands,pudendalanesthesiaislessthan100%reliable.The
patientmustbecheckedbilaterallyforlossofanalwinkreflexbefore
proceedingwiththesurgicalprocedure.Ifmildstimulusdoesnotelicita
reflexresponse,apinchconfirmstheeffectivenessofbilateralanesthesia.
Asmallerrepeatdosecanbeusedifanadequateblockisnotseen,butcare
mustbetakentoavoidtoxicserumlevels.
Appropriatemonitoringofthepatientandthefetusismandatory,and
intravenousaccessshouldbereadilyavailable.Provisionsshouldbemade
forrapidresuscitationshouldtoxicityoradversereactionsoccur.
Keepinmindthatthepudendalblockprovidesinadequateanesthesiafor
midforcepsdelivery,deliveriesthatrequireuterinemanipulation,postpartum
examinationandrepairoftheuppervaginaandcervix,andmanual
explorationoftheuterinecavity.[6]
Underthesecircumstances,theadditionofintravenousnarcoticsmay
provideappreciable,thoughnottotal,relieffrompain.
Withsuchanapproach,cautionmustbeexercisedtoavoiddosages
orcombinationsofnarcoticsandsedativesthatmightobtundthe
patientandcausepossibleairwayobstructionoraspiration.

Timingofprocedure
Seethelistbelow:
Timingofblockplacementisimportant,sinceatleast510minutesare
requiredfortheinfiltrationtotakeeffect.
MostUSobstetriciansperformpudendalblockimmediatelypriortodelivery.
Thispracticereflectstheconcernthatperinealanesthesiamayprolongthe
secondstageoflabor.
Anesthesiamaylast2060minutes,dependingontheagentusedwithor
withoutepinephrine.
Inpatientswithoutneuroaxialanalgesia,thepudendalblockcanbe
performedwhenthepatientreportsvaginalorperinealpain.
Withearlypudendalnerveblock,theobstetricianmayrepeattheblock,if
necessary,solongasthemaximumdoseoflocalanestheticisnotexceeded.

Efficacy
Seethelistbelow:
Efficacyvariesdependingontheexperienceoftheobstetrician.
Unilateralorbilateralfailureiscommon,withsuccessratesofonly50%with
thetransvaginalrouteandapproximately25%withthetransperinealroute.[7]
Obstetricianstypicallyperformsimultaneousperinealinfiltration,especiallyif
theblockwasnotplaceduntiljustpriortodelivery.Ifdeliveryoccursbefore
thepudendalblockhasbecomeeffective,anepisiotomycanstillbemade
withoutpain.Bythetimeoftherepair,thepudendalblockusuallyhas
becomeeffective.

Pearls
Seethelistbelow:
Pudendalnerveblockdoesnotabolishsensationtotheanteriorpartofthe
perineum,astheperineumissuppliedbybranchesoftheilioinguinaland
genitofemoralnerves.
Failuretowaitasufficienttimeafterinjectionisacommonreasonforblock
failure.
Pudendalblockdoesnotabolishthepainofuterinecontractionsandcervical
dilatationthissensationistransmittedbythesympatheticfibersderivedfrom
thespinallevelsofT10L2.
Thisblockdoesnothelprelaxtheuterus.
Theobstetricianshouldbealerttothetotaldoseoflocalanestheticgiven,
especiallyincasesofrepetitivepudendalnerveblocksorpudendalnerve
blockinassociationwithperinealinfiltration.Whenlidocainewithout
epinephrineisused,thedoserecommendedis4.5mg/kg.Whenlidocaine
withepinephrineisused,therecommendeddoseis7mg/kg.Themaximum
doseoflidocaineusedshouldnotexceed300mg.Whenbupivacainewithout
epinephrineisused,therecommendeddoseis2.5mg/kg,withthemaximum
dosenottoexceed175mg.Whenusedwithepinephrine,themaximumdose
ofbupivacainethatcouldbeusedisupto225mg.
Besuretouseaneedlewithaguide(eithertheIowatrumpetortheKobak
needleguide)tolimitthedepthofsubmucosalpenetrationandtoprevent
injurytothevaginaandthefetus.

Complications
Potentialcomplicationsshouldbeexplainedtothepatientpriortogettinginformed
consent.Thesecomplicationsareuncommonbutmaybeserious.Direct
intravascularinjectionsorsystemicabsorptionofanexcessivedoseoflocal
anestheticmayresultinsystemictoxicities.Otherrisksincludethefollowing:
Lacerationofthevaginalmucosaisapotentialcomplication.
Thesecondstageoflabormaybeprolonged[8]duetoalossofthebearing
downreflex,particularlywhenlocalanestheticsarecombinedwith
epinephrine(doesnotaffectincidenceofinstrumentdelivery).[9]
Systemicanestheticcomplications,thoughrareandusuallytransient,may
includepalpitation,tinnitus,dysarthria,drowsiness,confusion,lossof

consciousness,convulsions,hypotension,andbradycardia.
Hematomas(vaginal,retroperitoneal,andischiorectal)frominjurytothe
pudendalarterycanbeacomplicationofpudendalblock,particularlywith
defectivecoagulation.[10]Hematomasareusuallysmall,andsurgical
interventionisrarelyneeded.
Infection(retropsoasandsubglutealabscess)hasoccasionallybeen
reported,spreadingsuperiorlyalongthepsoasmuscleorlaterallyalongthe
obturatorinternus.Infrequentoccurrenceanddiagnosticdifficultiesmake
theseabscessesespeciallydangerous.[11,12,13]Maintainahighsuspicion
forinfectionwhenseverepaininthebackorhip,limitationofmotion,and,
especially,increasingfeverfollowpudendalanesthesiapriortovaginal
delivery.
Ischialregionparesthesiaonthefirstpostpartumday,[9]orsacral
neuropathy,mayoccur.
NeedlestickinjurywithassociatedriskofexposuretoHIVandother
bloodbornediseasesmayresult,astheneedleguidedoesnotuniformly
protectthephysicianandtheprocedurerequiresmultipleblindneedle
punctures.
Fetalcomplicationsareuncommonbutmayresultfromfetaltraumaandor
directfetalinjectionoflocalanesthetic.[14,15]Possibleintoxicationbylocal
anestheticsshouldbeconsideredwhenneonataldistressisseenatbirth
followingtheuseofpudendalblock.Typicalfeaturesincludehypotonia,
papillarymydriasisfixedtolight,apnea,andseizures.Completerecovery
usuallyoccurs.

ContributorInformationandDisclosures
Author
HemantKSatpathy,MDFellow,DivisionofMaternalFetalMedicine,EmorySchoolofMedicine
HemantKSatpathy,MDisamemberofthefollowingmedicalsocieties:AmericanCollegeofObstetriciansandGynecologists,AmericanMedicalAssociation,Societyfor
MaternalFetalMedicine,AAGL
Disclosure:Nothingtodisclose.
Coauthor(s)
AlfredDFleming,MD,FACOGAssociateProfessorofObstetricsandGynecology,AssociateProfessor,DepartmentofRadiology,Chairman,DepartmentofObstetricsand
Gynecology,AssistantDeanforClinialMedicalEducation,CreightonUniversitySchoolofMedicineCoDirectorofPerinatalUltrasound,DepartmentofObstetricsand
Gynecology,CreightonUniversityMedicalCenter
AlfredDFleming,MD,FACOGisamemberofthefollowingmedicalsocieties:AmericanCollegeofObstetriciansandGynecologists
Disclosure:Nothingtodisclose.
KatieAFossen,MDResidencyinObstetricsandGynecology,CreightonUniversitySchoolofMedicineAffiliatedHospitals
KatieAFossen,MDisamemberofthefollowingmedicalsocieties:AlphaOmegaAlpha,AmericanCollegeofObstetriciansandGynecologists,AmericanCollegeof
Physicians,AmericanMedicalAssociation,AmericanMedicalStudentAssociation/Foundation,AmericanMedicalWomensAssociation
Disclosure:Nothingtodisclose.
DonaldRFrey,MDAssociateProfessor,DepartmentofFamilyMedicine,DrRolandLKleebergerEndowedChair,CreightonUniversitySchoolofMedicineChief,Family
MedicineService,CreightonUniversityMedicalCenterMedicalDirector,StJosephVillaSkilledNursingFacility
DonaldRFrey,MDisamemberofthefollowingmedicalsocieties:AmericanAcademyofFamilyPhysicians,AmericanGeriatricsSociety,AmericanPublicHealth
Association,SocietyofTeachersofFamilyMedicine
Disclosure:Nothingtodisclose.
SpecialtyEditorBoard
MaryLWindle,PharmDAdjunctAssociateProfessor,UniversityofNebraskaMedicalCenterCollegeofPharmacyEditorinChief,MedscapeDrugReference
Disclosure:Nothingtodisclose.
ChiefEditor
ChristineIsaacs,MDAssociateProfessor,DepartmentofObstetricsandGynecology,DivisionHead,GeneralObstetricsandGynecology,MedicalDirectorofMidwifery
Services,VirginiaCommonwealthUniversitySchoolofMedicine
ChristineIsaacs,MDisamemberofthefollowingmedicalsocieties:AmericanCollegeofObstetriciansandGynecologists
Disclosure:Nothingtodisclose.
AdditionalContributors
AlexMacario,MD,MBAProfessorofAnesthesia,ProgramDirector,AnesthesiaResidency,Professor(Courtesy),DepartmentofHealthResearchandPolicy,Stanford
UniversitySchoolofMedicine
AlexMacario,MD,MBAisamemberofthefollowingmedicalsocieties:AmericanMedicalAssociation,AmericanSocietyofAnesthesiologists,CaliforniaMedical
Association,InternationalAnesthesiaResearchSociety
Disclosure:Receivedconsultingfeefor:Merck.
Acknowledgements
Iappreciatethesupportofmywife,Jayashree,andmyparents.

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