What Causes Pudendal Nerve Pain
What Causes Pudendal Neuralgia
Pudendal neuralgia can be caused by various mechanisms. These can be separated into three basic categories:
The pudendal nerve is anatomically vulnerable to compression and entrapment along its course. Patients with anatomical predispositions or biomechanical abnormalities are more susceptible to compression injuries. Patients may have a silent or asymptomatic compression for an extended period of time. Then, an exacerbating and inflaming factor such as surgery, hematoma, cycling, prolonged sitting, stress and tension-holding patterns, horseback riding, etc. causes entrapment, nerve dysfunction and symptoms.
Sacral or radicular type factors causing nerve compression or inflammation at the sacral or nerve root level. Possible examples being benign or malignant tumors and trauma to the area.
The pudendal nerve is also vulnerable to tension injuries. A variety of factors can put undo tension on the nerve causing it to lengthen beyond its normal limits and result in neural inflammation. Possible factors include vaginal childbirth, constipation with repetitive straining to defecate and squatting with heavy weights. Pelvic floor dysfunction, genital prolapse, and so-called descending perineum syndrome can also contribute to nerve tension injury. Fixation along the nerve pathway will result in the nerve becoming more likely to be injured with-any of the above factors.
Side Effects And Risks
The procedure is typically safe, with few side effects or complications. The most common side effect is discomfort at the injection site.
Less common side effects include bleeding, infection and temporary leg numbness or weakness caused by the medication spreading to the sciatic nerve. Serious complications may include pudendal nerve damage or structural injury to the bladder and rectum.
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Conservative Treatment Of Pudendal Neuralgia
Conservative Treatment is very beneficial in reducing the pain of pudendal neuralgia. Self management is important and consultation with different specialists may also be needed. The main focus of the treatment in pudendal neuralgia is to reduce the irritability of the pudendal nerve. Making some changes in daily life helps in achieving this. Even after making lifestyle changes, the nerve takes time to settle down and heal. Understanding and avoiding the triggering factor of the nerve pain helps in managing pudendal neuralgia. Learning how to modify ones life around the pain makes it easier to cope with this condition. Armed with the right knowledge, significant reduction can be achieved of the pain from pudendal neuralgia and patient can live a normal and functional life.
Some of the lifestyle changes which need to be made include:
Acupuncture For Pudendal Neuralgia
Acupuncture;can also help with persistent pain in the perineal region due to pudendal neuralgia, especially the pain occurring from a difficult birth. Acupuncture is especially a good alternative for patients who are having significant side effects from the medications and other treatment for pudendal neuralgia.
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How Is It Diagnosed
As with our other pelvic pain conditions that we manage, much of the diagnosis is made in a thorough history. Often patients will state that sitting increases symptoms and standing decreases symptoms somewhat. On exam, altered skin sensitivity may be noted. Pressure on the pudendal trunk may produce pain.
A pudendal nerve block can be both therapeutic and diagnostic. It may produce significant pain relief for several hours to several weeks. If the block results in pain relief, it suggests that at least some of the pain is originating from the pudendal nerve.Electrophysiologic evaluation can help confirm the site of entrapment and the type of nerve damage. The studies consist of EMG testing of the eternal anal sphincter, sacral reflex, pudendal nerve terminal motor latency and somatosensory evoked potential studies.
The Route Of The Pudendal Nerve Reveals The Extent Of The Pain It Can Cause
One of the reasons that Pudendal neuralgia is underdiagnosed and inappropriately treated is because it is easily confused with other problems. In the illustration below we can see the route of the pudendal nerve and how closely it passes by and through other structures that can be blamed for symptoms. Namely the sacrum.
In this illustration we see the influence damaged sacrotuberous and sacrospinous ligaments can have on the pudendal nerve.; Damaged sacrotuberous and sacrospinous ligaments can be responsible for groin-related pain. One possible cause of this pain is pudendal nerve compression or dysfunction.;
- The pudendal nerve emerges from the S2, S3, and S4 roots ventral rami of the sacral plexus.
The pudendal nerve travels between two muscles, the piriformis and coccygeus muscles. It can get trapped there.
Getting trapped between the sacrotuberous and sacrospinous ligaments
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What Is The Treatment For Pudendal Nerve Entrapment Syndrome
The condition may be amenable to treatment in a number of ways. General measures may include:
- Avoid prolonged periods of sitting, particularly in cyclists who have this condition.
- Use a foam ring-cushion so there is no pressure on the centre when sitting
- Avoid straining when passing urine or opening the bowels
- See a physiotherapist to learn relaxation techniques for the pelvic floor
Various medical treatments may be tried to alleviate neuropathic pain including nerve stabilising agents. These may include:
- Tricyclic antidepressants such as amitriptyline
- Anticonvulsants such as carbamazepine and sodium valproate
- Nerve stabilisers such as gabapentin and pregabalin.
Where medical treatments are not successful in relieving symptoms, surgical treatments may be tried. Surgical treatments include local anaesthetic nerve blocks, botulinum toxin injections to relieve pelvic floor spasm, injections of corticosteroids to reduce swelling and inflammation, and surgical decompression of the pudendal nerve.
Surgical decompression of the nerve can be variably effective. Surgery may not be completely effective in all cases for various reasons, for example, irreversible damage to the nerve due to the effects of prolonged or severe nerve compression, processes which irreversible affect nerve function , inadequate surgical decompression, surgical decompression of the incorrect site, and chronic pain syndromes.
Physiotherapy Can Help Pudendal Neuralgia
In 2012, there was a study conducted in Australia in which 25 men with pudendal neuralgia without medical cause were treated with physical therapy, exercise and postural education. ;Average duration of symptoms for all men was 4 years. ;Over a 3-month period, each man attended an average of 4 or 5 visits . ;By the end of that time, 20 men reported that their symptoms had completely resolved. ;The remaining five men reported their pain had dropped to 1 out of 10 on average, compared to levels averaging 5 out of 10 before they started treatment. ;
When the men were contacted 3 months after the end of treatment, their results had not changed significantly. ;During that period, nine of the 25 men had experienced at least one flare up, but reported that their home exercises had been effective in bringing the symptoms back under control.
Aside from pain, there was improvement in some of the other problems that the men had been suffering with . ;The level of change in these other problems was variable, but the improvements were still present when the men were asked about them 3 months later.
This study shows that in some cases, physiotherapy interventions can dramatically help pudendal neuralgia and other pudendal nerve symptoms, sometimes fairly rapidly.
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Symptoms For Pudendal Neuralgia
Overall, pudendal neuralgia can result in extreme pain that makes it difficult to complete everyday tasks. Specifically, symptoms of pudendal neuralgia include:
- Aching, burning or stabbing pain in the pudendal nerve region
- Pain that increases when sitting down
- Genital pain
- Painful ejaculations
- Pain with bowel movements or urination
Pudendal neuralgia may be a sensitive matter for both men and women. When you come in for your appointment, we listen to your concerns and follow up with a series of screenings and tests to ensure a proper diagnosis of PN or PNE. Combining non-surgical options, physical therapies, and traditional medicine, we develop the best treatment plan for you.
Treatment For Pudendal Nerve Entrapment Syndrome
Most of the patients we see have already had a long history of testing and diagnosis elimination scans. This includes for women a vaginal examination, for men a rectal examination. The goal of these examinations is to palpitate or apply pressure to the branches of the pudendal nerve to reproduce a pain response of nerve sensation. Many will have already had an MRI or CT scan to document nerve compression. Some would have had nerve conduction studies to assess damage or compression of the pudendal nerve.
Many also had nerve blocks. A painkiller not only improves pain but isolates the cause of the problem on the pudendal nerve. If pain relief is achieved, even in the very short term, then there is confidence the problem is the pudendal nerve.
Because a nerve block does not work, for some, this should not rule out the pudendal nerve. In a May 2020 study in the journal Pain Medicine , researchers noted that two common methods of nerve blocks using ultrasound guidance, one injection is given at the ischial spine or the other option the injection is given at the Alcocks or Pudendal canal were on average 80% accurate for hitting their mark.
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What Is Pudendal Nerve Entrapment Syndrome
Pudendal nerve entrapment syndrome is an unusual condition which arises from compression of the pudendal nerve and causes chronic pain in the saddle sites: the perineal, perianal and genital areas
It is one form of;vulvodynia . The pudendal nerve entrapment syndrome may also affect men.
Pudendal nerve entrapment syndrome is also called Alcock syndrome.;
Recovery Time For Pudendal Neuralgia
Often times patients ask us how long it will take for the pain of pudendal neuralgia to go away.; Unfortunately, until taking a full history and examination and creating an Individualized Treatment Plan it is hard to say how long a patient will feel this pain. Our goal is to minimize the pain with our treatment protocol in conjunction with pelvic floor physical therapists and anything else we have discussed in our treatment plan. We do see a significant improvement in our patients symptoms and pain scores
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Does Pudendal Neuralgia Go Away
Unfortunately there is no cure for pudendal neuralgia. Rather, pudendal neuralgia, as any chronic pain condition, is managed through a variety of measures involving everyday life, from work to leisure activity adjustments, as well as medical interventions. The crucial element in the process is that you, the patient, are the driver of this management plan.
Lifestyle changes
Avoid or minimize specific physical activities that are known to irritate the pudendal nerve. Spending hours on a bicycle is an activity to avoid, as is horse riding. Other activities that may contribute to pudendal neuralgia are trampoline jumping, bench pressing and excessive core muscle exercises.
Manage your sitting: the aim is to avoid pressure on the perineum, which is the area inside the sit bones, as this could lead to compression of the nerve. Coccyx-cut-out memory foam cushions are available commercially. You can increase the size of the cut-out to accommodate your particular need.
When you sit, do not take any weight on the perineum, all the weight is on your bottom and sit bones. Decrease your sitting by standing at your desk for part of the day. You may need to adjust the height of your desk to allow this.
Bowel and bladder management strategies
Physical therapy
Physiotherapy treatments aim to relax and/or stretch the often over-contracted pelvic floor muscles and thus decrease the pressure on the;pudendal nerve.
TENS
Medication
Acupuncture
Diagnosis Of Pudendal Neuralgia
Pudendal neuralgia can be very difficult to diagnose, as no specific test exists.27 Therefore, diagnosis of this condition relies heavily on a proper history and physical examination.
History should first be directed at identifying symptoms of pudendal neuralgia . Then, an inciting event should be explored. It is very important to establish how and when the injury occurred, and whether symptomatology was immediate or gradual. Commonly, surgery, vaginal delivery, or pelvic trauma is identified. Pudendal nerve entrapment is rarely idiopathic. Therefore, if there is no identifiable event, causes other than pudendal nerve entrapment should be ruled out.
One of the greatest authorities in surgical decompression of the pudendal nerve, Professor Roger Robert from Nantes, France, published his own criteria to diagnose pudendal neuralgia in 2008 . These criteria have been validated27 and are based on the consensus of mostly European physicians with extensive experience treating pudendal neuralgia. The study showed that patients meeting all the required criteria have better outcomes from decompression surgery than patients who only partially meet them.
Table 2. Nantes criteria for the diagnosis of pudendal neuralgia
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Inclusion criteria |
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|
|
MRI, magnetic resonance imaging; CT, computed tomography; PNMTL, perineal branch of the posterior femoral cutaneous nerve
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Pudendal Nerve Entrapment What Is It And What Are Its Symptoms
Pudendal nerve entrapment is a very painful condition. Discover where the compression of this nerve takes place and the symptoms it causes.
Pudendal nerve entrapment is an extremely painful condition. It consists of understanding a nerve that is located in the pelvis area and, in turn, this can be due to different causes. For example, from a blow to the pelvic area, the nerve can be trapped. Similarly, it can occur if you have or have had pelvic tumors. However, there are much more common causes.
Now that you know some of the causes that can lead to pudendal nerve entrapment, the following are some of its symptoms. If you identify with any of them, it is important that you go to a professional for a medical check-up and thus rule out any problem.
Your Pelvic Pain Symptoms May Seem Strange But They Can Be Correlatedespecially To #8
Your pelvis is one of the most important headquarters of your body. It does much of the heavy lifting for your mobility and positioning. When its functioning properly, you can easily take on your daily tasks of sitting, standing, walking, and relieving yourself.;
So when one of your pelvis core nerves gets damaged or compressed, discomfort can show up in any or all of your day-to-day actions.;
The main nerve of the perineum is the pudendal nerve. It controls motor functions for your urination and defecation. Its also involved in the sensations you experience in your pelvis and genitals.1 It runs through a canal and between muscles and ligaments.;
Unfortunately, the nerves path has several opportunities to become pinched or stretched. If the pudendal nerve gets trapped in between a muscle, ligaments, or the canal, your pelvic functions can become seriously impaired.
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Pudendal Nerve Pain Symptoms
Pudendal neuralgia symptoms can take many forms and may affect large areas of the lower body, including some of its most sensitive regions. Symptoms blamed on compression of the nerve often do not correlate by location or by duration, since many diagnosed patients experience lasting pain when continuing compression should cause numbness and functional loss. Below are listed the most common symptomatic expressions associated with pudendal nerve syndromes:
Pain is the main complaint for most patients. This pain might affect the general sacral and pelvic regions or specific areas of the lower anatomy, including the buttocks, hips, anus, perineum, as well as the internal or external genitals. General pelvic floor pain may accompany symptoms in both genders. Pain is often positionally-dependent or based on particular ranges of movement or activities.
Urinary or fecal incontinence is relatively common and might cause severe lifestyle restrictions and emotional consequences for the victim.
Sexual dysfunction is also commonplace, with patients reporting diminished sensations, exaggerated sensations, inability to climax, uncontrolled climax, pain upon sexual stimulation or inability to perform sexually. Some patients report persistent arousal even when not engaged in sexual thoughts or activities.
Constipation and/or the inability to urinate may replace incontinence or coexist, making for a double torment of opposing symptomologies.
Diagnosis of Pudendal Neuralgia
Pudendal Nerve Entrapment Syndrome Is Mostly Underdiagnosed And Inappropriately Treated
This is a conversation we have with many first-time patients after an examination. It goes something like this:
Based on the examination, it can be realistically determined that your symptoms of pain, dysfunction, difficulty walking, and the other things you mentioned are being caused by pelvic instability and sacral instability causing compression of your pudendal nerve, we would like to begin treatment based on pudendal nerve entrapment.
The patient will then say something to the effect of:
Whats that? How come my doctors never talked to me about this? I have been going to doctors for years. What is sacral instability? What is pudendal nerve entrapment?
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Adductors Pudendal Nerve And Pelvic Floor Pain
From Dynamic Lower Bodycourse
Pelvic floor muscles such as levator ani, coccygeus and obturator internus attach to the front, back and sides of the pelvis and sacrum and form the bottom of the core. These muscles must be able to contract to maintain continence, and to relax allowing for urination and bowel movements, and in women, sexual intercourse.;
Resembling a hammock or a sling, this small ensemble of muscles and fascia support the bladder, uterus, prostate and rectum. Evaluation of the pelvic floor complex must include restoring mobility of the surrounding joints to rule out protective muscle guarding due to misalignment. Special emphasis should be placed on the lumbosacral, sacroiliac, sacrococcygeal and pubic symphysis joints and their muscular attachments. Unilateral adductor hypertonicity is an oft-overlooked culprit in pelvic floor disorders. As the pudendal nerve and its branches, travel from the sacrum through the pelvic floor to innervate the vaginal, penile and rectal areas, they can become entrapped and in time, painful. In this Technique Tuesday video taken from my Lower Body home-study course, I offer a simple approach for dealing with pelvic floor hypertonicity and protective guarding.
Working through the adductors to influence the pelvic floor:
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