Pudendal Neuralgia

Terms Related to Pudendal Neuralgia

• Alcock's canal syndrome: compression of the pudendal nerve in a passageway located on the side of the pelvis.
• Pudendal nerve compression syndrome: a condition caused by pressure on this nerve.
• Perineal neuralgia: nerve pain felt in the area between the genitals and the anus.

What is pudendal neuralgia?

Pudendal neuralgia is pain felt in the area innervated by the pudendal nerve, including the genitals, perineum, and anus. The perineum is the area between the genitals and the anus. This perineal pain can become persistent. Compression, injury, or other damage to the nerve may be the cause, but the cause is not always identified.

The pudendal nerve is formed from nerve branches called S2, S3, and S4, near the sacrum, the bone at the base of the spine. It runs between two ligaments in the pelvis and then through Alcock’s canal. A ligament is a band of tissue that connects bones. The nerve transmits sensations from part of the genital organs and the anal region. It also controls certain muscles of the pelvic floor—the group of muscles at the base of the pelvis—as well as the external sphincters. These ring-shaped muscles help control the release of urine and stool. ¹

Damage to a nerve can disrupt the messages it transmits. It can cause pain or changes in sensation. Urinary, bowel, or sexual difficulties should also be evaluated, as several other conditions can cause them.

La fréquence exacte de la Pudendal Neuralgia reste mal connue. Les cas décrits concernent souvent des adultes d’âge moyen ou avancé, et les femmes sont plus représentées dans plusieurs séries Clinics. Ces observations ne permettent pas de calculer la fréquence dans toute la population, selon le chapitre clinique sur la Pudendal Neuralgia².

What are the causes of pudendal neuralgia?

Pudendal neuralgia may be caused by nerve compression, an injury sustained during childbirth or surgery, or another type of nerve damage. Prolonged sitting and certain activities, such as cycling, can contribute to the symptoms. Pelvic floor muscles that remain tense may also contribute to the pain, even in the absence of nerve compression.

Une compression peut survenir entre les ligaments sacrotubéreux et sacroépineux, deux bandes de tissu du bassin. Ce passage est distinct du canal d’Alcock, situé dans l’enveloppe d’un muscle sur le côté du bassin.¹ Une étude décrivant des observations pendant des chirurgies distingue ces sites; elle ne mesure pas leur fréquence chez toutes les personnes ayant une douleur périnéale³.

An anatomical review describes possible links between the sacrotuberous ligament, pain around the pelvis, and compression of the pudendal nerve. Its precise role in pelvic stability remains a matter of debate. ⁴ The presence of this ligament is therefore not sufficient to explain your pain.

The pudendal nerve can be compressed at various locations: ¹

• Between the sacroiliac and sacrotuberous ligaments
• In the Alcock Canal, another leg of his journey
• Near the deep pelvic muscles, particularly the internal obturator and the piriformis
• By scar tissue after surgery

Cycling can put pressure on the area between the genitals and the anus. The riding position and the saddle can affect this pressure, according to a review of perineal problems related to cycling. ⁵ Pain or numbness while cycling warrants adjusting the activity and seeking an evaluation.

• Office work involving prolonged sitting
• Long bike rides, especially if the saddle or riding position causes symptoms
• History of pelvic or gynecological surgery
• Difficult or instrument-assisted delivery
• Chronic constipation with repeated straining

What are the symptoms of pudendal neuralgia?

Pudendal neuralgia can cause a burning pain or electric shocks in the perineum, genitals, or anal region. It may be accompanied by tingling. The pain is often worse when sitting and less severe when standing or lying down.

The pain may affect one side or both sides. Describe the painful area, when the pain occurs, and what causes it to change. A burning or tingling sensation alone is not enough to identify the nerve responsible.

• Urinary problems: frequent or sudden urge to urinate, burning sensation when urinating
• Intestinal problems: constipation, pain during bowel movements
• Sexual dysfunction: pain during intercourse, difficulty achieving or maintaining an erection, pain after orgasm
• Abnormal sensations: feeling of a foreign object in the rectum or vagina, changes in sensitivity

These symptoms can limit work, intimate relationships, and daily activities. An evaluation helps determine their cause and select the appropriate treatment. The involuntary loss of urine or stool is known as urinary incontinence or fecal incontinence. A new loss of control requires urgent evaluation, as explained below.

How is pudendal neuralgia diagnosed?

A healthcare professional diagnoses pudendal neuralgia based on your symptoms, how they have progressed over time, and a physical examination. The healthcare professional will assess the location of the pain, factors that affect it, and signs of other possible causes, such as an infection or a problem with the pelvic organs.

The evaluation includes a detailed questionnaire about your symptoms:

• Where exactly do you feel the pain?
• What makes it worse or better?
• How long have you had these symptoms?
• Which activities or positions are problematic?

The Nantes criteria help identify neuralgia caused by compression of the pudendal nerve. Their combination points toward the diagnosis; no single sign on its own confirms it. ⁶ The five main criteria are:

• Pain in the area innervated by the pudendal nerve
• Pain worsened by sitting
• Pain that does not wake you up at night
• No loss of sensation was measured during the examination
• Relief following a pudendal nerve block, an injection that temporarily reduces the transmission of nerve signals

Your physical therapist can assess your movements, your breathing, and your pelvic floor’s ability to contract and then return to a relaxed state. A vaginal or rectal exam may be recommended depending on the situation; the professional will explain its purpose and obtain your consent. Additional tests, such as pelvic imaging, are sometimes used to investigate other possible causes. Whether these are necessary depends on the evaluation.

When should you consult a physiotherapist for pudendal neuralgia?

You may want to see a physical therapist if perineal pain persists, limits your activities, or makes sitting difficult. A medical evaluation is also helpful in determining the cause. The urgent symptoms listed below require immediate medical attention; do not wait for a physical therapy appointment.

• Persistent perineal pain
• Pain that limits your daily activities
• Difficulty staying seated to work
• The pain is worse when sitting and less severe when standing or lying down

Allez à l’urgence sans attendre si vous avez un engourdissement autour des organes génitaux ou de l’anus, une difficulté nouvelle à commencer à uriner, une impossibilité d’uriner, une perte inhabituelle de contrôle de l’urine ou des selles, ou si vous ne sentez plus le besoin d’aller à la selle. Une douleur qui descend des fesses vers les deux jambes, ou une faiblesse ou un engourdissement important ou qui s’aggrave dans les deux jambes, demande aussi cette évaluation. Ces signes peuvent correspondre à une compression de nerfs dans le bas du dos.⁷ La page du NHS, le service public de santé britannique, sur les signes neurologiques urgents décrit ces alertes⁸. Appelez le 911 si vous avez besoin d’une ambulance.

Une douleur dans le bas du ventre exige aussi une évaluation médicale urgente si elle est intense, s’aggrave ou augmente au mouvement ou au toucher, ou si elle s’accompagne d’une sensation de perdre connaissance, d’un évanouissement, d’étourdissements, d’une douleur au bout de l’épaule, de difficultés respiratoires, d’un saignement vaginal abondant ou d’une confusion soudaine⁹. Allez à l’urgence; appelez le 911 si nécessaire.

If you experience lower abdominal pain along with difficulty urinating or having a bowel movement, blood in your urine or stool, unusual vaginal discharge or bleeding, pain when urinating, or more frequent urination, seek medical attention immediately. Also seek medical advice if lower abdominal pain is accompanied by a very high fever, a sensation of feeling hot or cold or chills, vomiting with diarrhea or nausea, or if pregnancy is a possibility. If you are pregnant, contact your healthcare team. These symptoms should not automatically be attributed to the pudendal nerve.

Signs of serious illness are evaluated as a whole and in context, as noted in the clinical framework for spinal disorders. ⁷ This nuance does not justify delaying action in the face of the warning signs described.

Au Québec, vous pouvez consulter un physiothérapeute en clinique privée sans prescription médicale, selon l’Ordre professionnel de la physiothérapie du Québec¹⁰. Votre physiothérapeute peut vous orienter vers un médecin ou un autre professionnel si votre situation le demande.

An expert consensus published in 2022 recommends reducing the wait time before treatment. ¹¹ Seeking medical advice helps clarify symptoms and available options. It does not guarantee a faster recovery or prevent the need for surgery.

How does physical therapy help manage pudendal neuralgia?

Physical therapy can help manage pudendal neuralgia through tailored exercises, guidance on daily activities, and exercises targeting the pelvic floor muscles that remain contracted. A consensus among experts supports its potential effectiveness, while emphasizing the need for robust comparative studies. ¹¹ The expected benefits should be discussed along with their limitations.

Une enquête en ligne auprès de 144 personnes ayant reçu de la physiothérapie du plancher pelvien rapportait une amélioration nulle ou minime chez 66 % d’entre elles. Environ 12 % déclaraient une aggravation et 22 % une amélioration importante ou très importante.¹² Les participants avaient répondu volontairement et décrivaient eux-mêmes leur évolution. Cette enquête sans groupe de comparaison ne permet pas d’attribuer toute l’évolution au traitement, ni de prédire votre résultat. Elle souligne néanmoins l’importance d’écouter les personnes qui vont moins bien et d’ajuster les soins.

During your first visit, your physiotherapist will conduct a comprehensive evaluation:

• Assessment of Your Posture and Movement Habits
• Assessment of the pelvic floor's resting tension and its ability to contract and then relax
• Assessment of your breathing
• Discussion about your lifestyle habits and activities

Your physical therapist will work with you to monitor your pain, the amount of time you spend sitting, and the activities you’re able to do again. If your symptoms worsen or you aren’t making progress, your treatment plan should be reevaluated. A lack of improvement does not mean you aren’t trying hard enough. You can discuss other options with your care team and adjust your at-home exercises.

What can you do at home to relieve pudendal neuralgia?

To manage pudendal neuralgia at home, you can change positions, limit activities that trigger pain, and try appropriate relaxation exercises. These measures can reduce uncomfortable pressure on the perineum and help you continue with activities that are tolerable. These tips are not a substitute for evaluating the urgent symptoms described above.

• Limit prolonged sitting
• Take frequent breaks to get up and change positions
• If it helps, alternate between sitting and standing while you work, rather than staying in one position for long periods of time
• Adjust your support if a hard surface makes your symptoms worse

• Try a U-shaped pillow or one with a central opening to reduce pressure on the painful area. Keep using it only if it helps you.
• If you sleep on your side, placing a pillow between your knees can make the position more comfortable. Adjust it to suit your needs.
• Reevaluate your saddle if it puts pressure on the painful area or causes numbness.

Ces mouvements sont utilisés pour apprendre à détendre le plancher pelvien. Ils ne constituent pas un programme prouvé pour toutes les névralgies pudendales. Les conseils des hôpitaux de Leicester recommandent d’arrêter un étirement qui fait mal ou aggrave les symptômes¹³. Votre physiothérapeute peut choisir les variantes et la quantité qui vous conviennent.

• Take a temporary break from cycling if symptoms are severe
• Try a saddle and setup that are tailored to your body. A center-cut saddle may be comfortable, but it isn't necessarily right for everyone.
• Padded cycling shorts can improve comfort, but they are no excuse to continue a ride despite numbness or pain.
• Have the bike's position and adjustments checked if riding triggers your symptoms.
• Reduce the duration of your rides

• A lukewarm bath can provide relief. If you prefer a cool compress, protect your skin and avoid extreme temperatures. Stop if it irritates the area. If you have reduced sensation, seek advice before using heat or cold. These methods are intended to provide relief but do not guarantee nerve repair.
• Avoid constipation by drinking enough water and eating fiber
• Look for ways to reduce stress if you notice that it makes your symptoms worse. Calm breathing or taking breaks can help; stress alone does not cause the pain.
• Avoid tight clothing around the pelvis

What is the recovery time for pudendal neuralgia?

La Pudendal Neuralgia n’a pas de délai de guérison unique établi : l’évolution peut prendre plusieurs mois et certains symptômes peuvent persister. Un chapitre clinique propose souvent un essai de physiothérapie sur six à douze semaines lorsque des muscles du plancher pelvien restent contractés². Cette durée sert à organiser et à réévaluer les soins; elle ne prédit pas la date de disparition de la douleur.

You may see gradual improvement, even if the pain does not go away completely. Your return to activities will be planned based on your symptoms and goals. If the treatment isn’t helping or is making you feel worse, let us know: we need to adjust the plan, not just ask you to wait longer.

Si les soins sans chirurgie ne suffisent pas, l’équipe peut discuter de médicaments contre la douleur nerveuse, d’un bloc du nerf pudendal, de neuromodulation ou d’une chirurgie. La neuromodulation utilise un dispositif qui envoie des impulsions électriques à proximité de nerfs; les études spécifiques à la Pudendal Neuralgia restent limitées. Une chirurgie de décompression cherche à réduire une pression sur le nerf et s’envisage chez des personnes sélectionnées. Les avantages, les risques et les Other options doivent être discutés avec un spécialiste, selon les options de soins du NHS¹⁵ et le chapitre clinique sur le traitement².

Sources

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Nos physiothérapeutes ont défini la stratégie de recherche, le plan et le contenu clinique de cet article. Un outil d’IA a soutenu la recherche documentaire et la révision du texte pour assurer une cohérence du contenu et du style d’écriture.