Introduction:
Pudendal neuralgia is a complex condition associated with neuropathic pain and urinary, anorectal, and sexual dysfunction. In refractory patients, surgical decompression of the pudendal nerve has shown clinical benefit, while neuromodulation has emerged as a strategy for pain and bladder function modulation. However, evidence regarding their combination within the same surgical procedure remains limited.

Objective:
To evaluate baseline, perioperative, and functional outcomes of laparoscopic pudendal nerve decompression combined with neuromodulation in a single-stage procedure.

Retrospective single-center study including 9 women with refractory pudendal neuralgia and severe lower urinary tract symptoms (LUTS), all operated on by the same surgeon using simultaneous laparoscopic decompression and neuromodulation. The protocol included a 2–4 week test phase, followed by a 1-month washout period and subsequent permanent implantation in responders. Clinical, perioperative, functional, and safety variables were analyzed. Pain was assessed using the Visual Analog Scale (VAS), and functional outcomes (LUTS, urinary incontinence, dyspareunia, and fecal incontinence) were recorded at 1, 3, and 6 months. Descriptive statistics and exploratory longitudinal analysis were performed using the Friedman test and pairwise Wilcoxon comparisons.

Mean age was 54.6±14.5 years. All patients presented severe neuropathic pain (VAS 10) and preoperative LUTS. Mean VAS decreased to 7.89 at 1 month, 5.67 at 3 months, and 3.33 at 6 months, with statistically significant differences (χ² = 25.26; p = 0.00001; Kendall’s W = 0.936). LUTS decreased from 100% to 33.3% at 1 month and resolved completely at 6 months. Resolution of urinary and fecal incontinence and significant improvement in dyspareunia were observed. No intraoperative complications occurred, while postoperative complications were reported in 33.3%, with a reintervention rate of 11.1%.

This study supports a potential synergistic effect between pudendal nerve decompression and neuromodulation, with progressive and clinically meaningful improvements in pain and LUTS. In comparison with the only prospective series available in the literature., our cohort represents a distinct clinical phenotype characterized by severe neuropathic pain associated with significant urinary dysfunction, highlighting the relevance of this approach in functional urology. The more gradual pain improvement observed may be explained by our sequential neuromodulation protocol, suggesting a time-dependent consolidation of therapeutic benefit. The complete resolution of LUTS and improvement in other pelvic floor domains reinforce the concept of a broader pelviperineal neuropathic syndrome involving both sensory and functional components. Despite encouraging efficacy and intraoperative safety, the observed postoperative morbidity and study limitations (small sample size, retrospective design, lack of control group) warrant cautious interpretation and support the need for prospective comparative studies.

In this preliminary series, laparoscopic pudendal nerve decompression combined with neuromodulation demonstrated technical feasibility, absence of intraoperative complications, and relevant functional improvement in pain and urinary symptoms. Compared with current literature, this study provides a detailed characterization of the neuropathic pain + severe LUTS phenotype and proposes a structured sequential protocol.