Pudendal Neuralgia

Other names for pudendal neuralgia

• Alcock's canal syndrome
• Pudendal nerve compression syndrome
• Perineal neuralgia

What is pudendal neuralgia?

Pudendal neuralgia is chronic pain in the perineum caused by irritation or compression of the pudendal nerve. This nerve originates in the sacrum and supplies the genital region, perineum, and anal area.

The pudendal nerve originates from the S2, S3, and S4 sacral roots at the base of your spine. It then passes through Alcock's canal (also called the pudendal canal) before reaching the perineum. This nerve plays a vital role: it allows you to feel sensations in the genital region and controls the contraction of the sphincters and pelvic floor muscles.

When this nerve becomes irritated or compressed, the signals it transmits are disrupted. This can cause pain, changes in sensation, and difficulties with certain normal functions.

Pudendal neuralgia affects approximately 1 to 3% of the population. It generally appears between the ages of 50 and 70 and affects slightly more women than men.

What are the causes of pudendal neuralgia?

Pudendal neuralgia is often caused by compression of the nerve along its path in the pelvis. Key causes include prolonged sitting, intense cycling, pelvic injuries, and muscle tension in the pelvic floor.

The pudendal nerve can be compressed at various points:

• In Alcock's canal, between the sacrospinous and sacrotuberous ligaments
• By surrounding muscles (internal obturator, piriformis)
• By scar tissue after surgery

• Office work involving sitting for more than 6 hours a day
• Intensive cycling (more than 3 rides per week)
• History of pelvic or gynecological surgery
• Difficult or instrument-assisted childbirth
• Chronic constipation with repeated straining

What are the symptoms of pudendal neuralgia?

The main symptom is a burning, tingling, or electric shock-like pain in the perineal region. The pain is typically worse when sitting and relieved when standing or lying down.

A burning sensation is the most common symptom, described by more than half of affected individuals. Others experience tingling, pins and needles, or electric shock-like sensations in the perineum, genital organs, or anal area.

• Urinary issues: frequent urge to urinate, burning during urination, urgency
• Bowel issues: constipation, pain during bowel movements
• Sexual issues: pain during intercourse, erectile dysfunction, pain after orgasm
• Abnormal sensations: feeling of a foreign object in the rectum or vagina, changes in sensitivity

These symptoms can affect many aspects of your daily life. If this description sounds familiar, please know that solutions are available.

How is pudendal neuralgia diagnosed?

Diagnosis primarily relies on a clinical examination and your symptom history. Your physiotherapist or doctor will assess your pain, its location, and the factors that worsen or relieve it.

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 are often used to confirm the diagnosis:

• Pain in the anatomical area of the pudendal nerve
• Pain worsened by sitting
• Pain that does not wake you up at night
• No objective loss of sensation during examination
• Improvement after a pudendal nerve block

Your physiotherapist will also assess your posture, movement habits, pelvic floor muscle tone, and breathing. This comprehensive evaluation helps identify factors contributing to your problem.

When should you consult a physiotherapist for pudendal neuralgia?

Consult a physiotherapist if you experience persistent perineal pain, especially if it worsens when sitting. You do not need a medical referral to consult.

• Perineal pain for more than 2 weeks
• Pain that limits your daily activities
• Difficulty staying seated to work
• Typical pattern: worse when sitting, better when standing or lying down

In Quebec, you can consult a physiotherapist directly without a medical referral. If your condition requires a medical evaluation, your physiotherapist will inform you and can refer you to the appropriate professional.

The prognosis is better when treatment starts early. Early intervention helps prevent the condition from becoming chronic and reduces the risk of needing more invasive treatments.

How does physiotherapy help pudendal neuralgia?

Perineal physiotherapy helps release tight pelvic floor muscles, improve nerve mobility, and correct postural imbalances. Treatment is personalized based on your evaluation results.

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

• Assessment of your posture and movement habits
• Assessment of your pelvic floor muscle tone and its ability to contract and relax
• Assessment of your breathing
• Discussion about your lifestyle habits and activities

Physiotherapy is recommended for 6 to 12 weeks before considering other treatment options. Visits are typically 1 to 2 times per week initially, progressing towards independent exercises at home.

What can you do at home to relieve pudendal neuralgia?

At home, avoid prolonged sitting and regularly change your positions. Breathing exercises and gentle stretches can help release tension in the pelvic floor.

• Limit prolonged sitting
• Take breaks to stand up every 30 to 45 minutes
• Use a standing desk if possible
• Avoid sitting on hard surfaces

• Use a U-shaped cushion or a coccyx cushion to reduce pressure on the perineum
• When sleeping on your side, place a pillow between your knees
• Avoid narrow bicycle seats

• Take a temporary break from cycling if symptoms are severe
• Choose a wide saddle with a central channel
• Wear quality padded cycling shorts
• Have your bicycle professionally fitted
• Reduce the duration of your rides

• Warm baths can help relax muscles
• Avoid constipation by drinking enough water and eating fiber
• Manage your stress, as it increases pelvic tension
• Avoid tight clothing around the pelvis

What is the recovery time for pudendal neuralgia?

With appropriate conservative treatment, 60 to 70% of people experience significant improvement. Recovery time varies depending on how long symptoms have been present and how well the treatment works.

The prognosis is generally favorable, especially with an early diagnosis. Most people respond well to conservative treatment, which combines physiotherapy, lifestyle changes, and home exercises.

Be patient with yourself. Improvement is usually gradual over several weeks or months. Some symptoms may persist but become more manageable. Returning to normal activities happens gradually.

If conservative treatment is not enough after several months, other options are available: infiltrations (pudendal nerve block), neuromodulation with TENS, or in refractory cases, decompression surgery. Your care team will guide you to the best options for your situation.

Sources

• Kaur J, Leslie SW, Singh P. Pudendal Neuralgia. StatPearls. 2024. https://www.ncbi.nlm.nih.gov/books/NBK562246/
• Hibner M, Desai N, Robertson LJ, Nour M. Pudendal Nerve Entrapment Syndrome. StatPearls. 2024. https://www.ncbi.nlm.nih.gov/books/NBK544272/