Stress urinary incontinence (SUI) significantly impacts quality of life. Mid-urethral slings, including the transobturator approach, are the gold standard treatment. Performing surgery under local anesthesia may reduce morbidity, enable intraoperative cough testing, and improve recovery.1 However, concerns about pain and tolerability remain, and the role of pudendal nerve block is not well established.2
The aim of this study was to evaluate the feasibility, safety, tolerability and short-term efficacy of transobturator sling (TOT) placement under pudendal anesthetic nerve block (PANB) in women with moderate or severe stress urinary incontinence (SUI).

This prospective cohort study included 70 consecutive women diagnosed with moderate or severe SUI. SUI severity was defined with the use of 1–3–5 cough stress test. 3 All patients underwent transobturator sling placement (Dynamesh-SIS®) using the inside-out technique under bilateral PANB using a standardized mixture of lidocaine and ropivacaine diluted in saline (5ml at each side); extra local anesthetic was administered as appropriately at the surgical site with the same solution.1,2 No sedation or regional/general anesthesia was used. Sling tensioning was adjusted intraoperatively using cough stress testing.
Preoperative assessment included demographic characteristics, POP-Q evaluation, multichannel urodynamic testing, pelvic floor ultrasound, and validated questionnaires (ICIQ-UI-sf, ICIQ-FLUTS, ICIQ-VS).
Feasibility outcomes included successful completion of the procedure under PANB, need for anesthetic escalation, operative time, and intraoperative complications. Pain was assessed using a visual analogue scale (VAS, 0–10) intraoperatively and at 1, 3 and 6 hours postoperatively.
To further explore determinants of intraoperative tolerability, a linear regression analysis was performed using intraoperative VAS as the dependent variable. The model included age, body mass index (BMI), genital hiatus (GH), and total vaginal length (TVL) as covariates.
Short-term efficacy at 6 months was assessed using the cough stress test (1–3–5 classification) and patient-reported outcomes (ICIQ-UI-SF, ICIQ-FLUTS, PGI-I, PGI-S).

Seventy women were included, of whom 80% presented with severe and 20% with moderate SUI. All procedures were completed successfully under PANB, without conversion to sedation or regional/general anesthesia, corresponding to a feasibility rate of 100%.
No intraoperative complications were observed. Mean operative time was 33.1 ± 6.8 minutes, indicating that the procedure can be performed efficiently in a purely local setting.
Pain scores were consistently low. Mean intraoperative VAS was 2.8 ± 1.5, with a rapid postoperative decline to 1.6 ± 0.6 at 1 hour, 0.6 ± 0.7 at 3 hours, and 0.3 ± 0.4 at 6 hours.
Regression analysis did not identify any statistically significant predictors of intraoperative pain. BMI demonstrated a small positive association (β=+0.023 per kg/m², p=0.554), while GH showed a larger but still non-significant effect (β=+0.422 per cm, p=0.196). Age (β=−0.002 per year, p=0.898) and TVL (β=+0.012 per cm, p=0.930) had negligible influence. Overall, the model suggests that intraoperative discomfort is not meaningfully affected by patient habitus or pelvic floor anatomical parameters.
At 6-month follow-up, objective cure (negative cough stress test) was achieved in 95.7% of patients, while 4.3% demonstrated only mild residual SUI. Significant improvement was observed in all patient-reported outcomes, with marked reductions in ICIQ-UI-SF and ICIQ-FLUTS scores (p<0.001), and high levels of patient satisfaction reflected in PGI-I and PGI-S.

Transobturator sling placement under PANB was consistently feasible and well tolerated, even in a cohort predominantly composed of women with severe SUI. Pain levels remained low throughout the perioperative period and were not influenced by patient-specific factors, supporting the reliability of the anesthetic approach.

TOT placement under pudendal anesthetic nerve block represents a highly feasible and effective option for women with moderate to severe SUI. The absence of anesthetic escalation, the low pain VAS scores, and the excellent short-term outcomes support its use in ambulatory settings without compromising efficacy.

Ford AA, Rogerson L, Cody JD, Aluko P, Ogah JA. Mid-urethral sling operations for stress urinary incontinence in women. Cochrane Database Syst Rev. 2017 Jul 31;7(7):CD006375. doi: 10.1002/14651858.CD006375.pub4.
Slopnick EA, Sears SB, Chapman GC, Sheyn DD, Abrams MK, Roberts KM, Pollard R, Mangel J. Pudendal Nerve Block Analgesia at the Time of Vaginal Surgery: A Randomized, Double-Blinded, Sham-Controlled Trial. Urogynecology (Phila). 2023 Oct 1;29(10):827-835. doi: 10.1097/SPV.0000000000001351. Epub 2023 Apr 4. PMID: 37093572; PMCID: PMC10919352.
Grigoriadis T, Giannoulis G, Zacharakis D, Protopapas A, Cardozo L, Athanasiou S. The "1-3-5 cough test": comparing the severity of urodynamic stress incontinence with severity measures of subjective perception of stress urinary incontinence. Int Urogynecol J. 2016 Mar;27(3):419-25. doi: 10.1007/s00192-015-2808-4. Epub 2015 Aug 4. PMID: 26239956.