Abstract: Pudendal Nerve Blocks for Vaginoplasty in Gender Confirmation Surgery

Abstract

INTRODUCTION: General (GA) and spinal anesthesia (SA) are common and effective ways to control pain during pelvic surgeries, such as vaginoplasty for gender confirmation surgery (GCS). Many surgeons working in this field are seeking different modalities to improve postoperative pain control. Higher healthcare costs and poor patient satisfaction may result from inadequate pain control in the immediate postoperative period.1 Furthermore, GCS patients are more susceptible to develop postoperative deep vein thrombosis (DVT) due to their continuous use of hormonal therapy as there is a lack of evidence for benefits of preoperative holding of hormonal therapy.2,3 Therefore, early ambulation is especially important in this patient population. The aim of this study is to evaluate the outcomes after pudendal nerve blocks (PNB) as an adjunct to general anesthesia during genital GCS surgery. PATIENTS AND METHODS: This is a prospective, randomized, single blinded control trial for patients who underwent male-to-female (MtF) genital GCS. Patients received either general anesthesia (GA group) only or general anesthesia with bilateral pudendal nerve blocks (PNB group). The blocks were performed at the end of the case by the surgeon via anterior approach to the perineum. Postoperative pain was managed by a multimodal pain management including scheduled acetaminophen and oral oxycodone as needed. A numeric pain scale (0 to 10) was used to assess pain at different time points. Consumption of oral analgesics, time to ambulate, complications, and patient satisfaction were recorded and compared between the groups. RESULTS: From February 2017 to December 2017, twenty patients were included in the study. The PNB group (n=10) required a lower average of total oral oxycodone during hospitalization compared to the GA group (n=10) (65 mg versus 375 mg of oral oxycodone; p < 0.05). The average numeric pain rating for the first 6 days for the PNB group was lower than that of the GA group (1.9 versus 5.5; p < 0.05). More patients from the PNB group were able to ambulate on postoperative day 1 (80% versus 30%; p < 0.05). A higher percentage of patients from the PNB group reported higher satisfaction regarding their postoperative pain management compared to the GA group (4.6 versus 2.5; p <0.05). One patients from the PNB group experienced pain at injection site that resolved with oral analgesic. CONCLUSION: Based on these results, we believe that pudendal nerve blocks are safe, efficacious and effective adjuncts to general anesthesia. The minimal complications and promising results regarding pain control and patient satisfaction make this technique a powerful tool during genital confirmation surgery. References: 1. Collins L, Halwani A, Vaghadia H. Impact of a regional anesthesia analgesia program for outpatient foot surgery. Can J Anaesth. 1999. doi:10.1007/BF03012972. 2. Oger E, Alhenc-Gelas M, Lacut K, et al. Differential effects of oral and transdermal estrogen/progesterone regimens on sensitivity to activated protein C among postmenopausal women: A randomized trial. Arterioscler Thromb Vasc Biol. 2003;23(9):1671–1676. doi:10.1161/01.ATV.0000087141.05044.1F. 3. Shatzel JJ, Connelly KJ, DeLoughery TG. Thrombotic issues in transgender medicine: A review. Am J Hematol. 2017;92(2):204–208. doi:10.1002/ajh.24593.