Piriformis Surgery.

The piriformis sits deep in the buttock, and the pudendal nerve runs directly beneath it, between the piriformis and the sacrospinous ligament. When the piriformis becomes overcontracted or hypertonic, it squeezes the nerve at exactly this point. In Dr Bollens' clinical experience, this is where the majority of compression happens, more often than in Alcock's canal, which is the site most commonly discussed but accounts for a smaller share of cases.

This is also why the pain often follows a pattern many patients recognise: worse when seated, sometimes easing at night once the muscle relaxes during sleep, and frequently made worse the day after sexual activity, since the pudendal nerve is heavily stimulated during arousal.

Surgery is not the first step. Most patients improve with a combination of postural correction, targeted piriformis stretching, deep tissue massage, and botulinum toxin injections into the muscle, which can relax it for up to six months at a time. Some patients manage their symptoms indefinitely this way, repeating the injection two or three times a year instead of proceeding to surgery.

Piriformis surgery becomes a realistic option when conservative treatment plateaus, or when it is being used as a second-stage procedure after a pudendal nerve decompression that only partially resolved symptoms. In Dr Bollens' experience, when the first surgery does not fully succeed, the piriformis muscle is frequently the reason: it stays contracted and continues pressing on the nerve even after the ligament causing the original entrapment has been released.

The approach is posterior, through the buttock, using an endoscope and small instruments to reach the piriformis muscle directly and release it. This is different from the pudendal nerve decompression itself, which is done anteriorly, through the abdomen, laparoscopically.

Open surgery for the piriformis muscle is technically possible, and it is how the procedure is typically performed elsewhere: by opening the buttock to access the muscle directly. Dr Bollens developed the endoscopic alternative himself, and by his own account he remains, at the time of writing, the only surgeon offering this specific procedure through a minimally invasive approach. Among piriformis surgeons more broadly, this makes his practice unusual: it replaces what would otherwise require open surgical access with a small set of incisions and an endoscope.

For the pudendal nerve decompression itself, minimally invasive surgery is not a matter of surgeon preference, it is the only way the procedure can be done at all, since the nerve sits too deep in the pelvis for open access. What sets the piriformis procedure apart is that here, an open approach is the norm, and the minimally invasive version is Dr Bollens' own development.

Recovery time depends on which nerve was compressed and how the surgery was performed, not just how long the incision takes to heal. In Dr Bollens' clinical experience, patients recovering from piriformis release typically notice their most severe symptoms ease within 3 to 6 months. This is meaningfully faster than recovery from a pudendal nerve decompression through the abdomen, where symptom improvement is usually gradual over 6 to 24 months.

That difference is consistent with what would be expected anatomically. The piriformis sits closer to the surface and the muscle itself heals relatively quickly, while pudendal nerve decompression involves a deeper dissection and the nerve itself needs time to recover its function, a process that published research on pudendal decompression surgery also describes as gradual, continuing to improve for many months after the operation rather than resolving all at once.

As with any nerve surgery, individual recovery varies, and these figures describe typical patterns rather than a guarantee for any one patient.

Most patients go home the same day or the next day, since the procedure is minimally invasive. Light activity, including walking short distances, is usually possible within the first day or two, with a gradual return to normal activity over the following weeks under your physiotherapist's guidance. Prolonged hot baths, intense exercise, and swimming are typically avoided in the initial weeks while the surgical site heals.

As with any surgery, piriformis release carries some risk. Reported complications from piriformis and deep gluteal endoscopic procedures in the published literature include bleeding or hematoma formation, infection, temporary or, rarely, permanent nerve-related sensation changes, and scarring or adhesions at the surgical site that can occasionally delay healing. Independent published case series of endoscopic piriformis release report low complication rates overall, which is one of the reasons the endoscopic approach is generally preferred over open surgery where available.

Symptoms can also recur after surgery in a minority of patients, which is one reason some patients benefit from a staged approach, starting with the less invasive option and moving to surgery only if needed. Your consultation with Dr Bollens will cover the specific risks relevant to your case.

Endoscopic piriformis release, as a category of surgery, is supported by published outcome data beyond Dr Bollens' own practice. A study following 239 patients after piriformis syndrome surgery found around 83% achieved satisfactory results, with no surgical complications recorded during the first year of follow-up. Other published research puts pain relief rates for piriformis surgery generally at around 80%. A 2024 case series from the American Hip Institute followed 18 patients for a minimum of two years after endoscopic piriformis release and sciatic neurolysis: every patient reported symptom relief, average patient satisfaction was 8.3 out of 10, and complication rates were low. A separate study from the Orthopaedic Centre Antwerp followed patients for a median of several years and found pain scores dropped from an average of 7.4 to 1.9 out of 10 after surgery, with the improvement holding at long-term follow-up.

These studies describe endoscopic piriformis release generally, performed by different surgeons using their own technical variations, not Dr Bollens' specific approach. They are included here because they show the underlying procedure, releasing the piriformis endoscopically to decompress a trapped nerve, is a recognised and studied technique, not an experimental one. What is specific to Dr Bollens, by his own account, is applying this endoscopic approach to relieve pressure on the pudendal nerve rather than the sciatic nerve, and offering it where open surgery remains the norm elsewhere.

You may be a candidate for piriformis surgery if:

• You have chronic buttock, perineal, or genital pain that has not responded to physiotherapy, postural correction, or botulinum toxin injections
• You had a pudendal nerve decompression that helped, but did not fully resolve your symptoms
• Imaging or a diagnostic injection into the piriformis muscle has confirmed it as a source of your pain
• Sitting reliably makes your symptoms worse, and they ease when lying down or during sleep

A focused consultation with Dr Bollens will confirm whether the piriformis is the primary source of your symptoms, or whether another structure is involved.