proctology = ideal field for major ambulatory

surgery (MAS)
feasibility for every proctological disease in the
elective setting
nerve blocks in proctology is not “a new thing”

2 admissions
23 complications
(0.6%)
“local anaesthesia
and posterior
perineal block”

local anaesthesia in
proctology

submucosa below the
dentate line
intersphinteric plane
external an parallel to

what do we mean when we say “nerve blocks
in proctology”?

blocking the PUDENDAL
S2-S4 branches of
(internal) NERVE
sacral plexus

50% sensitive
perineum and external genitals
skin (scrotum, labia, perineum
y anus)

20% motor
(AES, UES, levator ani,
bulbocavernosus and
ischiocavernosus and
deep+superficial perineum
muscles)

two different levels of blockade
TRUNK : at the ischial spine, before any division
PERIPHERAL : just perianal or ischiorectal 360º (only perineal
nerve)

two different levels of blockade
TRUNK : at the ischial spine, before any division
PERIPHERAL : just perianal or ischiorectal 360º (only perineal
nerve)

nerve blocks in proctology may be used
as…..
anaesthetical technique of choice
low dose of midazolam / fentanil
+
EMLA
+
pudendal blockade before surgery (central, with nerve stimulation or
not, or peripheral)

complement to reduce postoperative pain and the need of
analgesic treatment
surgery under general / spinal anaesthesia
+

trunk blockade and the use of
nerve stimulator

ischial spine is always the
reference

20-ml syringe with mixture of local anaesthetic &
10-cm IM needle
cross between upper margin of anus and ischial
spine for punction
stimulating current of 2-4 mA is used until

Prospective RCT series,
50/50 patients

under
spinal anaesthesia

hemorrhoidectomy

trunk bilateral PN block
Bupivacaine / not (nerve
stimulator)
MEANretention
DURATIONfor
OFboth
no urine
POSTOPERARIVE
groups
ANALGESIA: 23.8 vs 3.6
HOURS

complement to reduce postoperative pain and the need of
analgesic treatment
surgery under spinal anaesthesia
+
block performed when surgery is finished (central with nerve
stimulation)

WORKS!!!

complement to reduce postoperative pain and the need of
analgesic treatment
surgery under SPINAL anaesthesia
+
block performed when surgery is finished (central with nerve
stimulation)

complement to reduceWORKS!!!
postoperative pain and the need of
analgesic treatment
surgery under GENERAL anaesthesia
+
block performed when surgery is finished (central with nerve
stimulation)

patients in the group of PN
blockade had…….
less urinary
retention
higher patients discharging
as MAS
lower pain in
routine
faster return to normal
activities
higher degree of
satisfaction

VAS of pain was
significatively lower for
rest, sitting and walking
in the group of patients
operated with pudendal
block

anaesthetical technique of choice
low dose of midazolam / fentanil
+
EMLA
+
pudendal blockade before surgery (central with nerve stimulation)

WORKS!!!

9.1 vs. 3.1
h.

urinary retention 7.5% vs.
69.6%

anaesthetical technique of choice
low dose of midazolam / fentanil
+
EMLA
+
pudendal blockade before surgery (peripheral)

WORKS!!!

pudendal block (peripheral) is better than spinal
anaesthesia (being independent of the use of

anaesthetical technique of choice
low dose of midazolam / fentanil
+
EMLA
+
pudendal blockade before surgery (peripheral)

WORKS!!!

prospective RC study, 120 patients
local perianal vs trunk blockade of
pudendal nerve (no stimulator) as the only
anaesthetic technique

Trunk blockade of pudendal nerve is better
than peripheral (better VAS in first p.o. +8h &

infiltrations / pudendal nerve blockades are strongly
recommended in order to control postoperative pain

CONCLUSIONS
There are scientific evidences of adequate level in the literature reporting
the effectiveness of the blockade of pudendal nerves in proctology
Although blocking the main trunk seems more effective, the most feasible
technique is peripheral blockade just in the ischiorectal fosa o purely
perianal. Both of them are easy to perform and have a very low rate of
potential complications
Its use will decrease the postoperative pain and the need of analgesic
medication in the postoperative period; then, the most part of the patients
will be properly treated in major ambulatory surgery programs without
hospital admission
We, the surgeons, are in the need to help as much as we can to patients
who need an hemorrohoidal or any proctological operation, and avoiding
pain in any way is a key factor.