Damage or irritation to the pudendal nerve in the pelvis can result in pelvic pain, sexual dysfunction, and difficulties with urination or defecation. Getting the proper diagnosis and a personalized pudendal neuralgia treatment plan from a healthcare provider trained in pelvic health is critical for optimizing function and maintaining your quality of life.
Unfortunately, pudendal neuralgia is a condition that is often unrecognized and misdiagnosed as it presents similarly to other chronic pelvic pain conditions, resulting in ineffective or inappropriate treatment. This can result in patients with pudendal neuralgia receiving a diagnosis several years after the onset of symptoms, or after having seen multiple providers.
In this article, we provide information about the causes and symptoms of pudendal neuralgia, as well as how it is diagnosed by our pelvic floor physiotherapists. We will also be highlighting pudendal neuralgia treatment options, including physical therapy treatment strategies.
Table of Contents:
- What is Pudendal Neuralgia?
- Pudendal Neuralgia Causes
- Pudendal Neuralgia Symptoms
- Diagnosing Pudendal Neuralgia
- Pudendal Neuralgia Treatment
- Conclusion
What is Pudendal Neuralgia?
Pudendal neuralgia is a chronic condition that stems from damage or injury to the pudendal nerve. The pudendal nerve is responsible for a combination of sensory, motor, and autonomic functions. As a result, damage to the nerve can resulting in complex symptoms,[i] including pelvic pain.
The pudendal nerve runs through the pelvic and gluteal region, along the pelvic floor muscles, and supplies the lower gluteal region; perineum (area between glutes and genitals); area around anus and rectum; external genital area, external gonads, and erectile tissue.[ii]
The pudendal nerve can also become entrapped along various points due to its path between pelvic ligaments, resulting in variable pain that moves around the pelvic region.ii Pudendal neuralgia affects both genders, however two thirds of cases are in people with internal reproductive organs.iii
However, once diagnosed, symptoms are typically relieved through pudendal neuralgia treatment tailored to the individual, which can include non-invasive options like medication and physiotherapy, or surgery in cases where less invasive options have been exhausted.
Pudendal Neuralgia Causes
There is no one specific cause for pudendal neuralgia, but rather it is a result of the pudendal nerve becoming damaged, compressed, stretched, or irritated either through a large traumatic incident or repetitive microtrauma overtime.iv
Some common causes that may result in pudendal nerve irritation include:ii,iii,iv
- Individual anatomy that predisposes a person to pudendal nerve entrapment
- Pudendal nerve radiation
- Prolonged sitting resulting in nerve compression
- Repetitive hip flexion exercises such a cycling, jogging, other sports activities, producing cumulative, repetitive microtrauma to the nerve
- Direct trauma to the nerve through falls, MVAs, pelvic surgeries, and childbirth
Pudendal Neuralgia Symptoms
The primary symptom of pudendal neuralgia is pelvic pain that is typically described by patients as burning, tingling, aching, stabbing, and/or shock-like.i Pain may be felt on one side of the pelvis or both.
The typical pain distribution is around the vulva, vagina, clitoris, perineum, and rectum; or around the penis, scrotum, perineum, and rectum. Pain typically worsens throughout the day, is aggravated when sitting, and is eased by standing or lying down.
Other common symptoms include:ii,iii,iv
- Sexual dysfunction
- Difficulties with urination and/or defecation with or without pain
- Reduced awareness of defecation
- Coccyx pain with referred pain to calf, foot, and toes
Pudendal Neuralgia Diagnosis
Pudendal neuralgia is difficult to diagnose. The diagnosis is solely based on clinical features and symptoms, and may be similar to other pelvic floor conditions.ii Common methods of diagnosis include:iii,iv
- Conducting an MRI which may provide information regarding structures surrounding the nerve to see if there is nerve entrapment. It is important to note than an MRI is not always a conclusive test.
- Ultrasound of pelvic floor muscles and ligaments as tight muscles and ligaments may result in nerve compression
- Use of a pudendal nerve block which would alleviate pain in most cases of pudendal neuralgia
- Use of Robert Nantes’ diagnostic criteria for pudendal neuralgia which highlights five essential clinical features that must be observed to allow for a diagnosis:
- Pain is found only in the areas innervated by the pudendal nerve
- Pelvic pain worsened by sitting, however pain is absent or relieved when sitting on a toilet
- The patient is not awakened by pain while sleeping
- No objective sensory loss on clinical examination
- Using an anesthetic on the pudendal nerve (ex. pudendal nerve blocker) has a positive effect
A pelvic floor physiotherapy examination may aid in diagnosing pudendal neuralgia and includes:
- Visual examination of the pelvic region
- Palpation for tenderness and muscle spasms in the pelvic region
- Palpating along the pathway of the pudendal nerve
- Testing the sensation each pudendal nerve branch using pinprick testing
Common differential diagnoses for pudendal neuralgia include chronic pelvic pain and sciatica. In people with prostates, differential diagnoses include prostatitis, prostatodynia, and idiopathic proctalgia. In people with internal genitals, differential diagnoses include vulvodynia, endometriosis, and vaginismus.iii
Pudendal Neuralgia Treatment
Optimal non-invasive, first-line option for patients to relieve symptoms from pudendal neuralgia include physiotherapy and medication use. Medications prescribed by physicians for PN typically fall under the category of a muscle relaxant, analgesic, or anti-convulsant [ii].
Physiotherapy treatment strategies can include:iii,iv,v
- Education on the pain mechanism based on each individual’s case
- Conducting a movement assessment to identify movement patterns that are contributing to symptoms as pain may be aggravated by hip flexion exercises, cycling, and/or jogging
- Education regarding optimal movement patterns to limit pain
- Pelvic floor assessment to obtain further information about pelvic musculature and their ability to contract and relax
- Internal manual therapy to facilitate healthy muscle contraction and relaxation, which can help treat muscle spasms, trigger points, and muscle guarding around the pudendal nerve
- Exercises to help relax tense muscles around the pudendal nerve and provide temporary relief
- Exercises to help strengthen the pelvic floor
- Education on self-pelvic floor massage
- Education regarding the use of a sit pad if deemed appropriate to reduce pressure off the pudendal nerve and pelvic floor muscles and distribute pressure to ischial tuberosities
If physiotherapy treatment is not deemed to be effective for the patient, other more invasive methods of pudendal neuralgia treatment can be implemented. This may include the use of pudendal nerve block injections, Botox injections to aid in relaxing tense muscles around the pudendal nerve, and/or decompressing the pudendal nerve through surgery.iv,v
Conclusion
Long-term pelvic pain as seen in pudendal neuralgia and other pelvic floor conditions can be extremely debilitating. However, once diagnosed, symptoms are typically relieved through pudendal neuralgia treatment tailored to the individual. The appropriate pudendal neuralgia treatment can allow you to maintain function and quality of life.
Pelvic floor physiotherapy can be a great non-invasive treatment option for those with pelvic pain and includes but is not limited to education, internal manual therapy, movement assessments, and exercises. At Propel Physiotherapy, our experienced and knowledgeable pelvic floor physiotherapists can help with creating a tailored management and treatment plan you.
References
[i] Leslie S, Antolak S, Feloney M, Soon-Sutton T. Pudendal neuralgia. Treasure Island, FL: Stat Pearls; 2022.
[ii] Pudendal neuralgia. 2019 May 3. Available from: https://www.nhs.uk/conditions/pudendal-neuralgia/#:~:text=Pudendal%20neuralgia%20is%20long%2Dterm,around%20the%20anus%20and%20rectum.
ii Pudendal neuralgia. Available from: Physiopedia, Pudendal Neuralgia
iv Pudendal neuralgia. 2022 February 9. Available from: https://www.whria.com.au/for-patients/pelvic-pain/pudendal-neuralgia/
v What is pudendal neuralgia and how can pelvic floor physiotherapy help?. 2022 September 28. Available from: https://feminapt.com/blog/what-is-pudendal-neuralgia-and-how-can-pelvic-floor-therapy-help.
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