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 innervates the genital region, the perineum, and the anal area.

The pudendal nerve originates from the sacral roots S2, S3, and S4 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 an essential role: it allows you to feel sensations in the genital area 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 sensitivity, and difficulties with certain normal functions.

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

What causes pudendal neuralgia?

Pudendal neuralgia is often caused by compression of the nerve in its pelvic pathway. The main causes include prolonged sitting, intensive cycling, pelvic trauma, and pelvic floor muscle tension.

The pudendal nerve can be compressed in different places:

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

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

What are the symptoms of pudendal neuralgia?

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

Burning sensation is the most common symptom. More than half of those affected describe it. Others experience tingling, pins and needles, or electric shock sensations in the perineum, genitals, or anal area.

• Urinary problems: frequent urge to urinate, burning sensation when urinating, urgency
• Intestinal disorders: constipation, pain during bowel movements
• Sexual disorders: pain during intercourse, erectile dysfunction, pain after orgasm
• Abnormal sensations: feeling of a foreign body in the rectum or vagina, changes in sensitivity

These symptoms can affect many aspects of your daily life. If you recognize yourself in this description, know that there are solutions available.

How is pudendal neuralgia diagnosed?

The diagnosis is based primarily on clinical examination and symptom history. Your physical therapist or doctor will assess your pain, its location, and the factors that aggravate or relieve it.

The assessment 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 territory of the pudendal nerve
• Pain worsened by sitting
• Pain that doesn't wake you up at night
• No objective loss of sensitivity on examination
• Improvement after pudendal nerve block anesthesia

Your physical therapist will also assess your posture, movement patterns, pelvic floor tone, and breathing. This comprehensive assessment helps identify the factors contributing to your problem.

When should you seek physical therapy for pudendal neuralgia?

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

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

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

The prognosis is better when treatment begins early. Early management prevents the condition from becoming chronic and reduces the risk of needing more invasive treatments.

How does physical therapy help with pudendal neuralgia?

Perineal physiotherapy helps relax tense pelvic floor muscles, improve nerve mobility, and correct postural imbalances. Treatment is personalized based on the results of your assessment.

During your first visit, your physical therapist will conduct a comprehensive assessment:

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

Physical therapy is recommended for 6 to 12 weeks before considering other treatment options. The frequency of visits is usually 1 to 2 times per week at the beginning, progressing to independent exercises at home.

What can you do at home to relieve pudendal neuralgia?

At home, avoid sitting for long periods of time and vary your positions regularly. Breathing exercises and gentle stretching 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 pillow or a coccyx pillow that reduces pressure on the perineum.
• To sleep on your side, place a pillow between your knees.
• Avoid narrow bike seats

• Take a temporary break from cycling if the symptoms are severe.
• Choose a wide saddle with a central channel
• Wear high-quality padded cycling shorts.
• Have your bike adjusted by a professional
• Reduce the duration of your outings

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

What is the recovery time for pudendal neuralgia?

With appropriate conservative treatment, 60 to 70% of people see significant improvement. Recovery time varies depending on the duration of symptoms and response to treatment.

The prognosis is generally favorable, especially if diagnosed early. Most people respond well to conservative treatment combining physical therapy, lifestyle changes, and home exercises.

Be patient with yourself. Improvement is usually gradual, taking several weeks or months. Some symptoms may persist but become more manageable. The return to normal activities is gradual.

If conservative treatment is not sufficient after several months, other options are available: injections (pudendal nerve block), neuromodulation with TENS, or, in refractory cases, decompression surgery. Your healthcare team will guide you toward 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/