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.

The exact prevalence of pudendal neuralgia remains unclear. The reported cases often involve middle-aged or older adults, and women are overrepresented in several clinical series. According to the clinical chapter on pudendal neuralgia, these observations do not allow for an estimate of the prevalence in the general population.

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.

Compression can occur between the sacrotuberous and sacroepineal ligaments, two bands of tissue in the pelvis. This passage is distinct from Alcock’s canal, which is located within the fascia of a muscle on the side of the pelvis.¹ A study describing observations made during surgeries distinguishes between these sites; it does not measure their frequency among all individuals with perineal pain.

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 subject of debate.² The presence of this ligament alone is therefore not enough 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. Riding position and saddle type can affect this pressure, according to a review of perineal problems related to cycling.³ Pain or numbness while cycling warrants adjusting your 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 asurinary incontinence orfecal 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.⁴ 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

Go to the emergency room immediately if you experience numbness around your genitals or anus, new difficulty starting to urinate, an inability to urinate, unusual loss of bladder or bowel control, or if you no longer feel the urge to have a bowel movement. Pain that radiates from the buttocks down both legs, or significant weakness or numbness in both legs—or if these symptoms are getting worse—also requires evaluation. These signs may indicate nerve compression in the lower back.⁵The NHS (the UK’s public health service) page on urgent neurological signs describes these warning signs. Call 911 if you need an ambulance.

Lower abdominal pain also requires urgent medical evaluation if it is severe, worsens, or increases with movement or touch, or if it is accompanied by a feeling of fainting, fainting, dizziness, pain in the tip of the shoulder, difficulty breathing, heavy vaginal bleeding, or sudden confusion. Go to the emergency room; call 911 if necessary.

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 problems.⁵ This nuance does not justify delaying action when the described warning signs are present.

In Quebec, you can see a physical therapist at a private clinic without a doctor’s prescription, according tothe Quebec Professional Order of Physical Therapy. Your physical therapist can refer you to a doctor or another healthcare professional if your situation warrants it.

An expert consensus published in 2022 recommends reducing wait times for care.⁶ Seeking medical advice helps clarify symptoms and available options. It does not guarantee a faster recovery or that surgery can be avoided.

How does physical therapy help manage pudendal neuralgia?

Physical therapy can help manage pudendal neuralgia through tailored exercises, activity guidance, and work on the pelvic floor muscles that remain contracted. A consensus among experts supports its potential effectiveness, while emphasizing the need for robust comparative studies.⁶ The expected benefits should be discussed along with their limitations.

An online survey of 144 people who had received pelvic floor physical therapy reported no or minimal improvement in 66% of them. About 12% reported a worsening of their condition, and 22% reported significant or very significant improvement.⁷ Participants responded voluntarily and described their own progress. Since this survey lacked a comparison group, it is not possible to attribute all changes to the treatment or to predict your specific outcome. Nevertheless, it underscores the importance of listening to patients who are not feeling better and adjusting their care accordingly.

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.

These exercises are used to help you learn how to relax your pelvic floor. They are not a proven treatment for all cases of pudendal neuralgia. The Leicester hospitals advise stopping any stretch that causes pain or worsens your symptoms. Your physical therapist can help you choose the variations and frequency that are right for you.

• 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?

There is no established standard recovery time for pudendal neuralgia: the course of the condition can take several months, and some symptoms may persist. Clinical guidelines often recommend a six- to twelve-week course of physical therapy when the pelvic floor muscles remain contracted. This timeframe is intended to help organize and reassess care; it does not predict when the pain will subside.

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.

If non-surgical treatments are not sufficient, the team may discuss medications for nerve pain, a pudendal nerve block, neuromodulation, or surgery. Neuromodulation uses a device that sends electrical impulses near the nerves; studies specific to pudendal neuralgia remain limited. Decompression surgery aims to reduce pressure on the nerve and is considered for selected patients. The benefits, risks, and other options should be discussed with a specialist, in accordance with NHS care guidelines and the clinical chapter on treatment.

Sources

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1. Kaur J, Leslie SW, Singh P. Pudendal Nerve Entrapment Syndrome. [Updated February 15, 2026]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2026. (Back to sections: 1, 2, 3)
2. Aldabe D, Hammer N, Flack NAMS, Woodley SJ. A systematic review of the morphology and function of the sacrotuberous ligament. Clin Anat. 2019;32(3):396-407. (Back to section: 1)
3. Baran C, Mitchell GC, Hellstrom WJ. Cycling-Related Sexual Dysfunction in Men and Women: A Review. Sex Med Rev. 2014;2(3-4):93-101. (Back to section: 1)
4. Labat JJ, Riant T, Robert R, Amarenco G, Lefaucheur JP, Rigaud J. Diagnostic criteria for pudendal neuralgia caused by pudendal nerve entrapment (Nantes criteria). Neurourol Urodyn. 2008;27(4):306-10. (Back to section: 1)
5. Finucane LM, Downie A, Mercer C, Greenhalgh SM, Boissonnault WG, Pool-Goudzwaard AL, et al. International Framework for Red Flags for Potential Serious Spinal Pathologies. J Orthop Sports Phys Ther. 2020;50(7):350-372. (Back to sections: 1, 2)
6. Levesque A, Bautrant E, Quistrebert V, Valancogne G, Riant T, Beer Gabel M, et al. Recommendations on the management of pudendal nerve entrapment syndrome: A formalized expert consensus. Eur J Pain. 2022;26(1):7-17. (Back to sections: 1, 2)
7. Niedenfuehr JM, Stevens DM, King LM. Pelvic Floor Physical Therapy Is Self-Reported as a Minimally Effective—and Sometimes Harmful—Treatment for Pudendal Neuralgia: A Cross-Sectional Study. Int J Sex Health. 2024;36(4):627-635. (Back to section: 1)
8. Leslie SW, Antolak S, Feloney MP, Soon-Sutton TL. Pudendal Neuralgia. [Updated February 12, 2024]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024.