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Pudendal Neuralgia

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(Redirected from Pudendal Nerve Injury)

Other Names

  • Pudendal Nerve Injury
  • Pudendal Neuralgia
  • Pudendal Nerve Syndrome
  • Pudendal Syndrome
  • Pudendal nerve entrapment
  • Alcock canal syndrome
  • Pudendal canal syndrome
  • Pudendal neuropathy
  • Cyclist's syndrome

Background

  • This page refers to pudendal neuralgia, a form of chronic pelvic pain attributed to the pudendal nerve

History

  • The first case of pudendal neuralgia was published by Robert and Labat in 1987[1]

Epidemiology

  • Chronic pelvic pain syndromes affect 5.7% to 26.6% of the US population[2]
  • Incidence is estimated at 1 in 100,000, though true incidence likely higher due to difficulty in diagnosis[3]

Introduction

Possible locations for pudendal nerve compression (circled)[4]
Posterior view of pelvis demonstrating the pudendal neurovascular bundle. The gluteus maximus muscle was cut to show the deeper structures. The pudendal nerve and artery run in the interligamentous plane between the sacrospinous and sacro-tuberous ligament and subsequently into Alcock’s canal.[5]
Anatomy of the pudendal nerve. (A) Illustration shows the course and branches of the pudendal nerve. (B) Illustration shows the location of Alcock’s (pudendal) canal. (C, D) 3-T axial and coronal T1 turbo spin echo (TSE) MR images show ischial tuberosity (triangle), the pudendal neurovascular bundle (dotted line) inside the pudendal canal coursing anteriorly along the deep aspect of obturator internus (arrows) lateral to the ischiorectal fossa (asterisk).[6]

General

  • A form of chronic pelvic pain which can be caused by mechanical or non-mechanical injury to the pudendal nerve
  • Patients present with perineal and genital pain, sexual, bladder, bowel and anatomic dysfunction[7]
  • The diagnosis is primarily clinical but often missed or delayed as it is easily confused with other pelvic pain syndromes
  • Because of its complexity, PN requires a multiple disciplinary approach to care and pain control including urology, gynecology, general surgery, pain management and physical therapy

Mechanism of Injury: Mechanical

  • Pelvic surgery for pelvic organ prolapse, especially with mesh
    • Seen in up to 0.17% of pelvic surgery[8]
  • Childbirth
  • Chronic constipation
  • Prolonged sitting
  • Repetitive hip flexion (cycling, jogging)
  • Direct traum
    • One study suggested 54.8% of pelvic trauma[9]
  • In a study of patients who underwent pudendal nerve decompression found causes to be:[10]
    • Surgery (35.2%)
    • Trauma (15.4%)
    • Vaginal delivery (5.5%)
    • Intense lower extremity exercise (4.4%)
    • Anal intercourse (3.3%)
    • No cause (36.2%)

Mechanism of Injury: Non-Mechanical

  • Viral infections (zoster, HIV)
  • Tumors or metastatic lesions
  • Radiation
  • Multiple sclerosis
  • Diabetes mellitus

Anatomy of the Pudendal Nerve

  • One of the major somatic nerves of the sacral plexus
  • Nerve Roots: S2-S4
  • Consists of sensory, motor and autonomic nerve fibers
    • Sensory: innervates the external genitalia of both sexes and the skin around the anus, anal canal and perineum
    • Motor: innervates various pelvic muscles, the external urethral sphincter and the external anal sphincter

Risk Factors

Sports

  • Cycling
  • Jogging

Differential Diagnosis

Differential Diagnosis Groin Pain

Clinical Features

Nerves of the groin and pelvis, the pudendal nerve is marked in mustard yellow[11]
Patient's symptoms according to Nantes criteria.[12]

History

  • Burning pain in the distribution of the pudendal nerve
    • Females - Vulva, vagina, clitoris, perineum, rectum
    • Males - Glans penis, scrotum, perineum, rectum
  • Commonly report hyperalgesia, allodynia or paresthesias
  • May have associated symptoms of urinary frequency, urgency, symptoms of painful bladder and dyspareunia
  • Classic presentation is unilateral, however bilateral has been reported
  • Pain is worse while sitting, relieved with standing or lying down
  • Commonly worse when sitting on chair than on toilet
    • This allows descent of levator ani with less compression of nerve
  • Patients may report sensation of sitting on an object or foreign body in vagina
  • Patients commonly favor sitting on a certain side[13]
  • Pain can be also be associated with sciatic pain, medial thigh pain, suprapubic pain, pain after ejaculation, worsening discomfort hours after intercourse, erectile dysfunction, increased urinary frequency or urgency

Physical Exam

  • Pain can sometimes be reproduced
    • Most commonly at the ischial spine, however this varies on site and severity of entrapment
  • Rectal and vaginal exams should be performed
    • Helpful to exclude prostatitis, interstitial cystitis, endometriosis, etc[14]

Nantes criteria[15]

  • Pain in the distribution of the pudendal nerve
  • Worsened by sitting (except sitting on the toilet)
  • Does not awaken the patient from sleep
  • No objective sensory loss (this indicates a sacral nerve root lesion)
  • Relieved by pudendal nerve block

Excluding Pudendal Neuralgia

  • Presence of Prutitis
  • Pain not in areas served by pudendal nerve (exclusively coccygeal, gluteal, pubic or hypogastric pain)
  • Pain is paroxysmal
  • Imaging identifies cause of pain

Evaluation

Normal pudendal nerve anatomy. Axial T1W (a, d) and T2 SPAIR (b, c, e, f) images demonstrate the normal appearance of the pudendal nerve (arrows) at the ischial spine (a, b), Alcock's canal (c, d) and its branches, i.e. inferior hemorrhoidal nerves (e) and perineal branches (f). Notice the intermediate signal of the normal nerves with the main trunks are best seen on T1W images and smaller branches are best seen on T2W images.[16]
Palpation guided pudendal nerve block

Neurophysiological Testing

  • Involves placing a probe on the area of concern, slowly raising temperature[17]
    • Easiest and most common test
    • Positive if the patient does not detect temperature changes until it produces pain
  • Biothesiometry functions similarly, but uses vibration instead of heat
  • Pudendal nerve terminal motor latency test[18]
    • Uses the inferior rectal nerve for diagnosis/ monitoring of PN
    • Invasive, requires rectal or vaginal examination
  • Electromyography
    • Test the bulbocavernosus reflex, latency testing, somatosensory evoked potentials
    • Often characterized as painful and unpleasant by patients

MRI

  • Both MRI and functional MRI (fMRI) have been described
  • Can potentially localize site of entrapment, rule out other causes
  • Should be obtained before any surgical intervention

CT

  • Role in PN not entirely clear
  • Can be used to exclude other pathology

US

  • Can help identify site of compression
  • One study found it 89% sensitive, 67% specific[19]

Pudendal Nerve Block

  • Can be considered both diagnostic and therapeutic
    • Approaches have been described including palpation guided, ultrasound, CT or fluoroscopy
    • Ultrasound is the most common
  • A block is described as succesful if[20]
    • 50% or more pain relief within 5 minutes, full effect at 20 minutes
    • Anesthetizes the anesthetizes the posterior perineum, anus, lower vagina, vulva/scrotum, and penis
    • No anesthesia should occur at the anterior perineum, cervix, upper vagina
  • Efficacy was found to be 80% even in confirmed cases[21]
    • Largely due to technical challenges and provider training

Classification

Locations of Entrapment

  • Type I entrapment at the greater sciatic notch
  • Type II entrapment between the sacrospinous and sacrotuberous ligament
    • Most common site of entrapment
  • Type III entrapment in the pudendal or Alcocks canal
  • Type IV entrapment of terminal branches

Management

Summary of treatments for pudendal neuralgia[5]

Nonoperative

  • Indications
    • First line for all non-mechanical etiologies
  • General
    • Sit pad or doughtnut
    • Avoid prolonged sitting
    • Cessation of hip flexion exercises
    • This provides relief in 20-30% of patients (need citation)
  • Initial therapy
    • Behavioral modification avoiding triggering activities
    • Pelvic Floor Physical Therapy
    • Analgesics
  • Physical Therapy
    • Relax the pelvic floor muscles
    • Works best for patients whos pain is due to muscle spasm
    • Treatment course is typically 6-12 weeks
  • Transcutaneous Electrical Nerve Stimulation (TENS)
    • Shown to be helpful as an adjunct to physical therapy[22]
  • Osteopathic Manipulative Medicine
    • One case series showed benefit in 5 subjects for up to 6 months[23]
  • Cognitive Behavioral Therapy
    • Helps address anxiety, depression, hopelessness in patients with chronic pain[24]

Pharmacologic Therapy

Procedures

  • Pudendal Nerve Block
    • Used therapeutically and diagnostically
    • Can be used up to monthly
    • Lose efficacy for 1/3 of patients after 2 years[25]
    • Response to nerve block predicts surgical success if needed[26]

Operative

  • Indications
    • Failure of conservative therapy
    • Obvious mechanical compression
  • Technique
    • Surgical decompression

Novel/ Investigational Procedures

  • Sacral Neuromodulation
    • Uses implanted lead which delivers low amplitude stimulation to block sacral nerve reflex
    • One prospective study demonstrated significant pain relief at 12 months[27]
  • Pulsed radiofrequency Ablation (pRFA)
    • Similar success to pudendendal nerve blocks
    • TWo studies found sustained relief for 89% of patients at six months[28][29]
  • Pudendal Nerve Cryoablation
  • Peripheral Nerve Stimulation
  • Mesenchymal Stem Cells
    • One case report describes use of MSC with improvement in pain and meantal health at 12 months[30]
  • Repetitive transcranial magnetic stimulation (rTMS)

Rehab and Return to Play

Pelvic Floor Muscle Exercises[31]

Rehabilitation

  • Emphasis on
    • Pelvic floor muscle relaxation
    • Postural correction
    • Gradual reconditioning

Return to Play/ Work

  • Etiology is variable, there is no specific RTP criteria
  • Follow general ACSM principles[32]
    • Confirmation of anatomical and functional healing
    • Restoration of sport-specific skills
    • Psychosocial readiness
    • Compliance with governing body regulations

Prognosis and Complications

Prognosis

  • General
    • Prognosis is guarded and variable, with chronicity and treatment resistance common
    • Misdiagnosis and delayed treatment is common

Complications

  • Chronic Pain
  • Sexual Dysfunction
    • Including dyspareunia, decreased libido
  • Urinary dysfunction
    • Including frequency, urgency, difficulty
  • Bowel Dysfunction
    • Including constipation, painful defecation, fecal incontinence
  • Pschological including anxiety, depression
  • Impairment in activities of daily living

See Also

References

  1. ↑ Robert, Roger, et al. "Decompression and transposition of the pudendal nerve in pudendal neuralgia: a randomized controlled trial and long-term evaluation." European urology 47.3 (2005): 403-408.
  2. ↑ Gish, Brandon, et al. "Neuromodulation for the management of chronic pelvic pain syndromes: A systematic review." Pain Practice 24.2 (2024): 321-340.
  3. ↑ Hibner, Michael, et al. "Pudendal neuralgia." Journal of minimally invasive gynecology 17.2 (2010): 148-153.
  4. ↑ Murer, Sébastien, et al. "Advances in the therapeutic approach of pudendal neuralgia: a systematic review." Journal of Osteopathic Medicine 122.1 (2021): 1-13.
  5. ↑ 5.0 5.1 Conic, Rosalynn RZ, Prabhleen Kaur, and Lynn R. Kohan. "Pudendal neuralgia: a review of the current literature." Current Pain and Headache Reports 29.1 (2025): 38.
  6. ↑ Fritz, Jan, et al. "Magnetic resonance Neurography–Guided nerve blocks for the diagnosis and treatment of chronic pelvic pain syndrome." Neuroimaging Clinics 24.1 (2014): 211-234.
  7. ↑ Murer, Sébastien, et al. "Advances in the therapeutic approach of pudendal neuralgia: a systematic review." Journal of Osteopathic Medicine 122.1 (2021): 1-13.
  8. ↑ Cardosi, Richard J., Carol S. Cox, and Mitchel S. Hoffman. "Postoperative neuropathies after major pelvic surgery." Obstetrics & Gynecology 100.2 (2002): 240-244.
  9. ↑ Beco, Jacques, et al. "Pelvic trauma and pudendal syndrome (post-traumatic pudendal syndrome)." Pelviperineology: Multidisciplinary Pelvic Floor Journal (2018).
  10. ↑ Hibner, Michael, et al. "Pudendal neuralgia." Journal of minimally invasive gynecology 17.2 (2010): 148-153.
  11. ↑ Yoon, Sung-Jung, et al. "Pudendal Nerve Neuralgia/Entrapment." Posterior Hip Disorders: Clinical Evaluation and Management (2018): 189-195.
  12. ↑ Ghizzani, Anna, et al. "Differentiating overlapping symptoms of vulvodynia and pudendal neuralgia." British Journal of Pain 13.1 (2019): 54-58.
  13. ↑ Khoder W, Hale D. Pudendal neuralgia. Obstet Gynecol Clin North Am. 2014 Sep;41(3):443-52. doi: 10.1016/j.ogc.2014.04.002. Epub 2014 Jul 9. PMID: 25155124.
  14. ↑ Turner, Maria LC, and Stanley C. Marinoff. "Pudendal neuralgia." American journal of obstetrics and gynecology 165.4 (1991): 1233-1236.
  15. ↑ Labat, Jean‐Jacques, et al. "Diagnostic criteria for pudendal neuralgia by pudendal nerve entrapment (Nantes criteria)." Neurourology and Urodynamics: Official Journal of the International Continence Society 27.4 (2008): 306-310.
  16. ↑ Wadhwa, Vibhor, et al. "Pudendal nerve and branch neuropathy: magnetic resonance neurography evaluation." Acta Radiologica 58.6 (2017): 726-733.
  17. ↑ Beco, Jacques, Laurence Seidel, and Adelin Albert. "Normative values of skin temperature and thermal sensory thresholds in the pudendal nerve territory." Neurourology and Urodynamics 34.6 (2015): 571-577.
  18. ↑ Kaur, Jasmeen, Stephen W. Leslie, and Paramvir Singh. "Pudendal nerve entrapment syndrome." (2019).
  19. ↑ Mollo, Murielle, et al. "Evaluation of diagnostic accuracy of colour duplex scanning, compared to electroneuromyography, diagnostic score and surgical outcomes, in pudendal neuralgia by entrapment: a prospective study on 96 patients." Pain 142.1 (2009): 159-163.
  20. ↑ Labat, J. J., et al. "Adding corticosteroids to the pudendal nerve block for pudendal neuralgia: a randomised, double‐blind, controlled trial." BJOG: An International Journal of Obstetrics & Gynaecology 124.2 (2017): 251-260.
  21. ↑ Antolak, Stanley, Christopher Antolak, and Lisa Lendway. "Measuring the quality of pudendal nerve perineural injections." Pain Physician 19.4 (2016): 299.
  22. ↑ Eid, Marwa M., et al. "Effectiveness of transcutaneous electrical nerve stimulation as an adjunct to selected physical therapy exercise program on male patients with pudendal neuralgia: A randomized controlled trial." Clinical Rehabilitation 35.8 (2021): 1142-1150.
  23. ↑ Origo, D., and A. G. Tarantino. "Osteopathic manipulative treatment in pudendal neuralgia: A case report." Journal of Bodywork and Movement Therapies 23.2 (2019): 247-250.
  24. ↑ Masheb, Robin M., et al. "A randomized clinical trial for women with vulvodynia: Cognitive-behavioral therapy vs. supportive psychotherapy." Pain® 141.1-2 (2009): 31-40.
  25. ↑ Basol, Gulfem, et al. "Transvaginal pudendal nerve blocks in patients with pudendal neuralgia: 2-year follow-up results." Archives of Gynecology and Obstetrics 306.4 (2022): 1107-1116.
  26. ↑ Mauillon, J., et al. "Results of pudendal nerve neurolysis-transposition in twelve patients suffering from pudendal neuralgia." Diseases of the colon & rectum 42.2 (1999): 186-192.
  27. ↑ Guo, Kai-kai, et al. "Sacral nerve stimulation in patients with refractory pudendal neuralgia." Pain Physician 25.4 (2022): E619.
  28. ↑ Ji, Feng, et al. "Therapeutic Efficacy of Ultrasound‐Guided High‐Voltage Long‐Duration Pulsed Radiofrequency for Pudendal Neuralgia." Neural Plasticity 2021.1 (2021): 9961145.
  29. ↑ Fang, Hongwei, et al. "Clinical effect and safety of pulsed radiofrequency treatment for pudendal neuralgia: a prospective, randomized controlled clinical trial." Journal of Pain Research (2018): 2367-2374.
  30. ↑ Venturi, Marco, et al. "Pudendal neuralgia: a new option for treatment? Preliminary results on feasibility and efficacy." Pain Medicine 16.8 (2015): 1475-1481.
  31. ↑ Caetano, Aletha. "Incontinence: physical activity as a supporting preventive approach." Urinary Incontinence (2012): 69.
  32. ↑ Herring, Stanley A. "The team physician and return-to-play issues: a consensus statement." Medicine & Science in Sports & Exercise 34.7 (2002): 1212-1214.
Created by:
John Kiel on 13 June 2019 09:39:57
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27 August 2025 18:39:45
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