Pudendal Neuralgia

What is Pudendal Neuralgia?

Pudendal neuralgia is a type of chronic pain that’s caused by issues with the pudendal nerve. This nerve plays several roles in the body relating to sensation, movement, and automatic bodily functions. Because of this, any inflammation or damage to the nerve can lead to problems with the bladder, bowel, sexual function, and automatic responses in the body, as well as pain in the area between the genitals and the anus, also known as the perineum. The injuries usually affect the feelings in the pelvis and perineum more than movement or automatic responses.

Usually, pudendal neuralgia affects both sides of the body and causes perineum pain that can get worse when sitting. This condition affects more than half of the patients who have pudendal nerve entrapment, where the nerve gets pinched. However, this is often misdiagnosed in the early stages and can be difficult to treat, resulting in chronic, severe, and disabling pain.

Diagnosing pudendal neuralgia mostly depends on the symptoms, also known as the “Nantes” criteria. Unfortunately, this condition is usually diagnosed only after a person has suffered from painful symptoms for many years and has gone through many evaluations, medication trials, procedures, interventions and surgeries. Gynaecologists, colorectal surgeons, and urologists often treat this condition. However, as it often goes undiagnosed, many individuals have imperfect or inadequate treatment, which significantly impacts their quality of life. This condition is known to cause severe consequences such as depression, opioid addiction, and even suicide under certain circumstances.

Yet, if managed properly, one can control symptoms in the long term, and some have reported complete relief up to 20 years following treatment.

Treatment for pudendal neuropathy is similar to that for carpal tunnel syndrome. The treatment could involve protective measures for the nerve, physical therapy, drug treatment, nerve blocks, sacral nerve stimulation, and even surgeries to relieve pressure on the pudendal nerves. However, it must be noted that pudendal neuralgia and nerve entrapment are not well known or studied, hence research on the best treatment strategy is lacking. The details provided here are based on the best medical literature reviewed by peers and expert opinion.

What Causes Pudendal Neuralgia?

The pudendal nerve mainly consists of fibers from certain nerves in the lower spine. It goes just in front of the piriformis muscle (a muscle in the buttocks), passes between this muscle and another muscle called the coccygeus, and then goes through a hole in the pelvis called the greater sciatic foramen. After that, it travels between two ligaments: the sacrotuberous and sacrospinous. This journey can be thought of like a “clamp” or “lobster claw,” where the nerve might get compressed or squeezed.

Once past the ligaments, the pudendal nerve continues on through a canal called Alcock’s canal. It then splits into nerves that go to the perineum (the area between the genitals and the anus), the penis or clitoris, and the rectum. But it’s worth noting that the structure of these nerves can vary in different people.

Pudendal nerve entrapment, or when the nerve gets scrunched in a particular spot, is typically classified into four types based on where the nerve is getting trapped:

Type I: Below the piriformis muscle as the pudendal nerve leaves the greater sciatic notch.

Type II: Between the sacrospinous and sacrotuberous ligaments; this is the most common place for the nerve to get trapped.

Type III: Within Alcock’s canal.

Type IV: The nerve branches only (inferior rectal nerves, superficial and deep perineal nerves, and the dorsal nerve of the penis or clitoris).

Pudendal neuralgia, which is pain in the areas served by the pudendal nerve, typically happens due to repetitive, minor injury to the nerve. Prolonged overuse of pelvic floor muscles can cause changes in the bone structure of the pelvis, and this can cause nerve damage. If this isn’t treated, it can result in mild localized symptoms, most often in the bladder, developing into broader, more severe, pain. Severe pain may show up in several spots and is often mistaken for various structural and organ diseases. Over time, the pain can become chronic and disabling.

This pain can also be caused by indirect traumas, like viral infections (for example, HIV and herpes zoster), multiple sclerosis, and diabetes. Stress isn’t a cause, but it can make any nerve pain worse. Herpes simplex infections, benign tumors, and metastatic lesions to the nerve pathway are less common causes of pudendal neuralgia.

Common causes of pudendal neuralgia include:

Injury during childbirth because of the stretching of the pelvic muscles from the fetal head.

Chronic constipation.

Direct trauma, such as falls, car accidents, or pelvic surgeries.

Prolonged sitting (for example, in people who work at a desk or on a computer, judges, musicians, drivers, chess players, or engineers).

Radiation therapy (for example, for prostate, rectal, or gynecological cancer).

Repetitive hip flexing, like when doing exercise, jogging, or cycling.

Risk Factors and Frequency for Pudendal Neuralgia

Pudendal neuralgia, or PN, is a condition that often goes unnoticed, so it’s hard to know how many people it actually affects. However, it’s estimated that about 1 in 100,000 people in the general population have it. According to one study, this could be as high as 1% of the population. Both men and women can get PN, but it’s more common in women. Even children can be affected, especially if they have abnormalities in their nerve pathways from birth.

• Pudendal neuralgia is often not diagnosed, so the number of people who have it may be higher than we know.
• It’s estimated to affect about 1 in 100,000 people, but some studies suggest it could be as common as 1 in 100 people.
• Both men and women can be affected, but it’s more common in women.
• Children can also get PN, especially if they have certain birth defects relating to the nerve pathways.
• Among those seeking pain control consultations, 4% are diagnosed with pudendal neuralgia, with women being more affected than men (ratio of 7 women to 3 men).

Health professionals who frequently treat PN suspect that it might actually be a lot more common than these estimates suggest.

Signs and Symptoms of Pudendal Neuralgia

Pudendal neuralgia (PN) is a health condition that can present in people with chronic pain in the pelvic region, notably in the area between the lower abdomen and upper thighs. The pain could be more pronounced in the genital and perineal areas and may also be accompanied by sexual, bladder, or bowel dysfunction. Often, the pain is not severe in the morning but worsens throughout the day. Patients may describe the pain as burning, tingling, aching, stabbing, or even like an electric shock.

• The condition often worsens when sitting and eases when standing, lying down or seating on a toilet.
• Referred sciatic pain, pain in the inner thigh, post-ejaculation pain, discomfort after intercourse, and erectile dysfunction may be experienced.
• Neuropathic pain in areas outside pudendal nerve innervation could occur such as in the lower abdomen, inner thigh or lower back.

The pain can either be confined to the perineum or be felt in other areas like the vulva, vagina, clitoris, perineum, and rectum in women and the glans penis, scrotum, perineum, and rectum in men. Sometimes, specific types of perineal pain can indicate central sensitization, including allodynia (pain due to clothing contact) or a foreign-body sensation in the vagina or rectum. Further symptoms associated with PN can include frequent urination, painful urination, urgency, symptoms similar to interstitial cystitis, painful ejaculation, painful sex, painful nocturnal orgasms, and persistent sexual arousal. Regular activities like repetitive hip flexion, prolonged sitting, and falls also need to be taken into account during diagnosis.

During a physical examination, the doctor visually evaluates the genital and rectal area for any obvious lesions. Males may undergo an examination of the testis, epididymis, vas deferens, and prostate for any tenderness and masses, while females may have the pelvic floor and obturator internus muscles examined for muscle spasms and tenderness. A certain tactile sensation test may be administered to men and women, which covers the glans penis or clitoris, posterior scrotum or labia, and posterior anal skin bilaterally. Pain provoked by the palpation of medial pudendal nerve pathway to and over the ischial spine and Alcock’s canal can be a sign of mid-nerve pudendal injury. In some cases, patients with PN may also have other peripheral mononeuropathies that need to be considered for a comprehensive evaluation.

Testing for Pudendal Neuralgia

Pudendal neuralgia (PN) is a condition that’s usually diagnosed by observing certain symptoms, commonly referred to as the “Nantes” criteria. These symptoms include:

• Pain in the area between the genitals and the rectum (perineum) that gets worse when sitting and improves when standing, lying down, or sitting on the toilet
• Pain that doesn’t wake the patient up at night
• No specific sensory loss found during a neurological examination
• Symptoms improving with a nerve block injection (a treatment that numbs the pudendal nerve)

While there aren’t any definitive tests for diagnosing PN, some tests can be helpful for both diagnosis and monitoring of the condition. These include abdominal, lower back, and pelvic scans (MRI and CT) which can be used to rule out other potential causes of the symptoms, and to guide nerve block injections.

Other possibly useful tests include Neurophysiological Studies. These are tests that involve sending stimuli to nerves and measuring their responses.

For example, one common test is Quantitative warm thermal threshold sensitivity testing. It involves testing the ability of the patient’s pudendal nerve to sense changes in temperature. Patients with nerve damage (neuropathy) often have a reduced ability to detect these changes, responding only when the temperature gets high enough to cause pain.

Another test is Pudendal nerve terminal motor latency testing (PNTML), which measures how quickly signals travel along the pudendal nerve. This is somewhat invasive as it requires a rectal or vaginal examination. Axonal damage and demyelination can both be identified through this test. The test can also be beneficial to monitor treatment results.

Somatosensory evoked potential (SSEP) testing can also be used. This is a test that measures the nerve’s response to stimuli. This can be a valuable tool in identifying and limiting nerve damage caused by compression (a pinched nerve).

Many doctors also recommend pudendal nerve block injections for diagnosis. The procedure involves injecting a local anesthetic into the area where the pudendal nerve enters a small opening in the pelvis, guided by imaging techniques. Often, these injections can indicate whether a patient could benefit from a surgical procedure to relieve nerve compression.

During the procedure, the patient’s pain levels are monitored before, during, and after the injection to assess the effectiveness of the block. A reduction in pain of 50% or more is considered a good result. However, this method is not perfect and up to 20% of blocks may not provide substantial relief, even in cases where the diagnosis is confirmed.

While rare, complications can occur and may include pain and infection at the injection site, bleeding, nerve damage, and reactions if the injection enters a blood vessel.

Overall, while PN can’t be definitively diagnosed through specific tests, these tools can be invaluable for both diagnosis and treatment monitoring.

Treatment Options for Pudendal Neuralgia

Pudendal neuropathy is a painful condition that affects the pudendal nerve, which runs through the pelvis. The symptoms can be very similar to carpal tunnel syndrome.

Treatment options for pudendal neuropathy often begin with simple, non-invasive steps to avoid further damage to the nerve. This could include physical therapy and pain-relief medication. In some cases, doctors may give monthly injections to numb the pudendal nerve. If these initial treatments aren’t effective, there are other options, such as a type of pacemaker for the sacral nerve or surgery to ease pressure on the pudendal nerves.

However, it’s important to remember that not all treatments advertised in the media are necessarily effective or based on solid scientific evidence. Treatments outside of recognized, standard medical practices should be approached with caution and used as part of a clinical trial.

Patients should consider simple steps to ease pudendal neuropathy symptoms, such as using a donut-shaped cushion to take pressure off the nerve when sitting. Avoiding activities that can worsen symptoms, such as long periods of sitting or certain exercises, can also help. Some people may find these actions alone relieve their symptoms.

Living with pudendal neuropathy can also take a toll on a person’s mental health. Alongside physical treatments, it could be beneficial to engage in therapies designed to support mental wellbeing, such as cognitive-behavioral therapy.

Drugs like amitriptyline and gabapentin might be used to help control symptoms of neuropathic pain associated with pudendal neuropathy. It’s important to work closely with a doctor to find the right medication, as dosages and effects can vary greatly between people.

If the affected nerve doesn’t improve despite treatment, a doctor may recommend blocking the pudendal nerve. This involves injecting medication around the nerves to relieve pain. In some cases, relieving nerve pressure through surgery might help address long-term, unresponsive pudendal neuropathy. Alternatives such as sacral neuromodulation – a device a bit like a pacemaker for the nerve – could also be considered.

While many procedures have been proposed to treat pudendal neuropathy, sticking to accepted and proven treatment paths and discussing all options with a healthcare professional is essential. Unfortunately, there isn’t enough scientific evidence yet to confirm many advanced treatment options for this condition. Despite this, there are many paths to explore and discuss with a healthcare professional when seeking relief from pudendal neuropathy.

What else can Pudendal Neuralgia be?

In men, one common incorrect diagnosis is pudendal neuralgia (PN). Some researchers have tried to clear up confusion by classifying prostatitis (inflammation of the prostate) into 4 categories, one of which is chronic pelvic pain syndrome (CPPS). This means that a person with PN could be mistakenly diagnosed with CPPS. Doctors should check if the prostate is inflamed by looking for white blood cells in prostate fluids or semen. If a patient who was first diagnosed with prostatitis or CPPS doesn’t get better with treatment, PN should be investigated. A possible test for PN is a pudendal nerve block. The European Association of Urology has identified 23 syndromes that cause chronic pelvic pain. Doctors should also consider other conditions like interstitial cystitis and diseases of the vas deferens, epididymis, and testicles, especially if treatment isn’t working. A detailed examination of male genitalia can identify diseases of the vas deferens, epididymis, and testicles.

In women, doctors should consider other conditions like interstitial cystitis and diseases of the uterus or ovaries, like endometriosis, vestibulitis, and anorectal pathologies. They should also consider other nerve issues in the abdomen and pelvis that might affect the pudendal region.

• Chronic pelvic pain syndrome (CPPS)
• Interstitial cystitis
• Endometriosis
• Vestibulitis
• Anorectal pathologies

Pediatricians need to be aware of the possibility of PN in children with bladder and bowel issues and pain in the abdomen and pelvis. This is because PN can often be because of birth defects. To test sensation in children, a toothpick can be used instead of a safety pin for a less scary experience.

What to expect with Pudendal Neuralgia

Most people find that treatment for pudendal neuralgia, which is a kind of nerve pain, helps relieve their symptoms. One of these treatments is called a pudendal nerve block, which can successfully reduce pain and let people get back to their regular routines. Some people have even reported being pain-free for more than 12 to 20 years after this treatment. It’s been found that the pudendal nerve block treatment works for about 80% of patients.

Surgery can offer longer-term relief for about 60% to 80% of the people who get it. Even though some people may enjoy immediate relief after surgery, for most, it takes time. Improvement in symptoms is gradual, and can take from 6 to 24 months or even longer. Because of this, it’s important for doctors to communicate realistic expectations to patients and monitor them after surgery.

There are also alternative treatments available for cases where other treatments haven’t worked. These include sacral neuromodulation, cryotherapy, pulse radiofrequency ablation, and lipofilling. Sacral neuromodulation, in particular, is safe, minimally invasive, widely available, and often underused for treating pudendal neuralgia. Although the medical research is lacking on these treatments, they have shown promise in small, short-term studies.

There are several factors that can influence the success of these treatments:

– The extent of the nerve damage and the length of time the nerve has been compressed.
– The skills and experience of the doctors providing the treatment.
– The availability of different treatment options and how often extra services, like pain management and physical therapy, are used.
– It’s important to understand that symptoms can still stick around during the normal healing process even after treatment.
– Patients with pudendal neuralgia often experience something called central sensitization, which can make symptoms persist or feel more intense.
– If other nerve issues are happening at the same time as pudendal neuralgia, they may need separate treatment.

Also, if patients have pain in the lower abdominal or groin area, they might need a specific kind of nerve surgery to help with this.

One of the main reasons symptoms of pudendal neuralgia come back is because people start too quickly getting back to activities that caused the pain in the first place. Activities like cycling, exercising, jogging, and sitting for long periods can aggravate the condition. For instance, after surgery to remove or decompress a particular ligament in the pelvic region, certain activities like lifting or squatting can compress the nerve against another ligament, reigniting the injury and bringing the symptoms back.

Possible Complications When Diagnosed with Pudendal Neuralgia

Complications tied to Pudendal Neuralgia (PN) treatment come in various forms. Even with supportive therapies such as prolonged standing instead of sitting, some people may feel pain in their feet. Negative side effects from medicinal treatment are relatively common and could warrant a switch in medication. Issues stemming from pudendal nerve blocks are rare, but include bruising (hematoma), infection, and pain at the site of the injection. Very few cases of newborn reaction to anesthesia (neonatal anesthetic toxicity) have been reported during pain relief for childbirth.

Pudendal nerve blocks can cause side effects indirectly from the injected steroids. These include feelings of unease or anxiousness (agitation and anxiety), and possibly higher blood sugar in diabetics. The needle used for the injection might accidentally penetrate the nerve – a rare complication that can lead to immediate pain, sacral neuropathy, or sense of tingling or prickling (paresthesia) in the ischial region, lasting for more than 6 weeks.

Another rare issue is the infiltration of lidocaine and bupivacaine into the bloodstream, identified by a metallic taste after administration. A large dose can cause significant heart problems, although this is highly unusual. Checking the needle for blood isn’t always a foolproof method to prevent this. If medication does infiltrate, temporary pain increase is common, potentially due to a colder agent being injected into the bloodstream or local pressure from the amount of injected fluid.

Surgical complications specific to pudendal decompression include damage to a small branch of the nerve, cutting of the sacrotuberous ligament, and reports of incomplete cutting of the sacrospinous ligament. Full pain relief right after surgical decompression is uncommon. More typically, pain slowly lessens over several months and this should not be considered a complication of the surgery or procedure.

Common Side Effects:

• Foot pains
• Negative side effects from medication
• Complications from pudendal nerve blocks: bruising, infection, injection site pain
• Newborn reaction to anesthesia when used during childbirth
• Side effects from injected steroids: agitation and anxiety, potentially elevated blood sugar in diabetics
• Penetration of nerve by injection needle leading to pain or numbness
• Infiltration of lidocaine and bupivacaine into the bloodstream leading to metallic taste and potentially heart problems
• Incomplete pain relief after surgical decompression

Preventing Pudendal Neuralgia

It’s essential to prevent PN (peripheral neuropathy, a condition that affects the nerves) as soon as it’s diagnosed. People who work with athletes, like sports doctors, therapists, trainers, and coaches need to know about this condition. Even the athletes themselves need to stay informed so they can spot the symptoms early. For example, cyclists often still ride their bikes despite feeling numbness in their penile or perineal areas (areas around the genitals). Using a bicycle seat that’s split in two can help with this.

During gym sessions and sports, you might start showing symptoms of nerve damage. It’s important these symptoms are noticed as soon as possible.

The patients should also learn about the importance of giving the affected nerve rest. This can be done using a special pad when you sit down, which helps to reduce direct pressure on the area. Also, managing stress levels can be very beneficial. Sometimes, patients might forget that pain relief doesn’t always have to come from strong, potentially addictive drugs. Non-opioid medications and therapies can also help reduce the pain signals that come from damaged nerves.