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Rare anatomical variant of the pudendal neurovascular bundle: Description of its course and potential clinical importance

Anatomical variations in the course of the pudendal nerve have been implicated in clinical conditions related to neuralgia and nerve compression. A transgluteal approach has been advocated previously for surgical access to the pudendal nerve as it enters the lesser sciatic foramen. However, as with any surgical approach, one must be aware of anatomical variants that complicate treatment. We performed 20 gluteal dissections on 10 cadavers at the Hackensack‐Meridian School of Medicine at Seton Hall University and an additional 48 gluteal dissections on 24 cadavers at the SUNY Downstate College of Medicine for a total of 68 pudendal nerves. Results confirmed that most individuals possessed a pudendal neurovascular bundle lying directly over the ischial spine. None of the cadavers exhibited the transligamentous route (through the sacrospinous ligament) reported previously in the clinical literature. However, one individual out of 68 exhibited a rare anatomical variation of a pudendal bundle lying over the sacrotuberous ligament. This same individual exhibited the normal anatomical configuration on the contralateral side. Such a configuration could complicate a surgical approach when, lying over the sacrotuberous ligament, it may be mistaken for a secondary or tertiary branch of the inferior gluteal neurovascular bundle. Despite the rare nature of the anatomical variant found in this study, its presence should be documented to reduce the chances of injury to a patient undergoing pudendal release surgery. Further work should be done to increase sample size and better reflect the true occurrence of this variant among asymptomatic individuals. Additionally, further information is needed to document the clinical impact of this variant on the patient population.