A 70-year-old multiparous woman undergoes a right-sided sacrospinous ligament suspension f… — USMLE Step 2 CK

A 70-year-old multiparous woman undergoes a right-sided sacrospinous ligament suspension for symptomatic vaginal vault prolapse following a hysterectomy performed 15 years ago. Two hours after arriving in the post-anesthesia care unit, she complains of excruciating, sharp, burning pain in her right gluteal region that radiates to the right perineum and labia majora. She is highly distressed and rates the pain as $10$ on a $10$ -point scale despite receiving adequate doses of intravenous morphine. Vital signs show a temperature of $37.1^\circ\text{C}$ ( $98.8^\circ\text{F}$ ), blood pressure of $135/85\text{ mmHg}$ , and heart rate of $98/\text{min}$ . Neurological examination reveals normal motor strength in her lower extremities bilaterally, with intact patellar and Achilles reflexes. However, there is marked hyperalgesia over the right perianal and perineal area. The surgical site shows no active vaginal bleeding, and her abdomen is soft and non-tender. Which of the following is the most appropriate next step in management?

A
Computed tomography scan of the abdomen and pelvis
Reexploration of the surgical site and suture removalAnswer
C
Observation and initiation of oral gabapentin therapy
D
Measurement of post-void residual bladder volume
E
Administration of intravenous broad-spectrum antibiotics

Answer

The most appropriate next step is immediate reexploration of the surgical site and suture removal to release the entrapped pudendal nerve.

The correct answer is reexploration of the surgical site and suture removal. This patient is presenting with classic signs of pudendal nerve entrapment following a sacrospinous ligament suspension. The sacrospinous ligament extends from the ischial spine to the sacrum. The pudendal nerve and internal pudendal vessels run immediately posterior to the ischial spine. If a suspension suture is placed too far laterally (too close to the ischial spine), it can compress or ligate the pudendal nerve. This manifests in the immediate postoperative period as severe, sharp, burning, or shooting pain in the distribution of the pudendal nerve (gluteal region, perineum, and vulva), often accompanied by sensory deficits or hyperalgesia. The pain is notoriously resistant to standard postoperative opioid analgesia. Because the entrapment is mechanical, medical management is ineffective, and any delay in treatment risks permanent ischemic damage to the nerve. Therefore, the definitive and most appropriate next step is to immediately return the patient to the operating room to cut and remove the entrapping suture.

Step-by-Step Solution

Analyze the patient's surgical procedure and timeline.

The patient underwent a right sacrospinous ligament suspension 2 hours ago.

Identifying the specific procedure highlights the regional anatomy at risk, specifically the sacrospinous ligament, ischial spine, and the pudendal neurovascular bundle.

Evaluate the character and location of the postoperative symptoms.

The patient has acute, severe, opioid-resistant burning pain radiating to the right gluteal and perineal region with associated hyperalgesia.

These sensory symptoms map directly to the distribution of the right pudendal nerve, indicating acute nerve entrapment rather than normal incisional pain or an infectious complication.

Determine the appropriate intervention for acute iatrogenic nerve entrapment.

The entrapping suture must be physically removed immediately.

Mechanical compression causes rapidly progressive nerve ischemia; conservative or medical management will lead to permanent neurological damage and chronic pain.

Key Concept

Recognition and immediate surgical management of pudendal nerve entrapment following sacrospinous ligament suspension.

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