Treatments For Pudendal Neuralgia
Treatments for pudendal neuralgia include:
- avoiding things that make the pain worse, such as cycling, constipation or prolonged sitting it may help to use a special cushion with a gap down the middle when sitting and try constipation treatments
- medicines to alter the pain these will normally be special medicines for nerve pain, rather than ordinary painkillers like paracetamol
- physiotherapy a physiotherapist can teach you exercises to relax your pelvic floor muscles and other muscles that can irritate the pudendal nerve
- painkilling injections injections of local anaesthetic and steroid medication) may relieve the pain for a few months at a time
- if something is pressing on the pudendal nerve, such as a piece of tissue, surgery to move it away from the nerve may help improve your pain
- nerve stimulation a small device is surgically implanted under the skin to deliver mild electrical impulses to the nerve and interrupt pain signals sent to the brain
You may be referred to a specialist NHS pain management team or pain management programme for support and advice about treatment.
Not all of the possible treatments are widely available on the NHS.
What Are The Causes
Pudendal neuralgia can occur if the pudendal nerve is damaged, irritated or squashed .
Possible causes include:
- Compression of the pudendal nerve by nearby muscles or tissue. This is sometimes called pudendal nerve entrapment or Alcock canal syndrome
- Prolonged sitting, cycling, horse riding or constipation . This can cause repeated minor damage to the pelvic area
- Previous surgery to the pelvic area
- A break in one of the bones in the pelvis
- Damage to the pudendal nerve during childbirth this may improve after a few months
- A non-cancerous or cancerous growth pressing on the pudendal nerve
In some cases, a specific cause isnt identified.
Mri Findings Are Not/should Not Be The Determining Factor In Deciding On Surgery
We do not have normative data on MRIs for the pelvis or Pudendal Neuralgia. Many of us probably have scar tissue in our pelvis that does not cause symptoms. Without knowing what normal is, we cannot determine if someone needs surgery based solely on what is found on the MRI. We have often seen an MRI positive for scar tissue around the pudendal nerve on one side, but the patients symptoms were on the opposite side. We also see patients who have had 3 different MRIs from the best pudendal neuralgia MRI experts and received 3 different types of findings. MRIs CAN BE useful for ruling out other major issues such as a mass/tumor occupying space around the nerves.
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Support & Yoga For Pelvic Pain
As one of the worlds leading specialty centers for the holistic care of pudendal neuralgia, we can connect you with others with pudendal neuralgia.
Click here to see a list of our education evening talks to help keep our out of town members in touch. Topics focus on self-management techniques and new advances in pain management in relation to pudendal neuralgia, such as understanding persistent pain and discussing advances in neuromodulation.
Yoga for Pudendal Neuralgia and pelvic pain. If you are interested in the next yoga series in Sydney, please email Rebecca Shaw email@example.com
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Enhancing Healthcare Team Outcomes
Pudendal neuralgia due to PNE is a rare neuropathic condition. It causes a significant impairment of quality of life. It often does not get diagnosed promptly, and most patients get treated for other conditions. Thus Nantes diagnostic criteria were established and validated by an interprofessional team to aid in the diagnosis and further treatment of such patients. If the patient fulfills the Nantes criteria, no further investigation is required. However, if any of the criteria are not present, the patient should be further evaluated, and MRI is generally done to rule out other causes of chronic pain. Individualized treatment is necessary. It typically requires permanent lifestyle changes and physical therapy. The treatment options include pharmacological therapy, CT guided blocks, decompression surgery, and neuromodulation.
A well-coordinated interprofessional healthcare team comprised of a pain physician, surgeon, anesthesiologist, nurse, radiologist, and physiotherapist to help in physical rehabilitation is necessary to treat this challenging neuropathic syndrome. All these disciplines need to collaborate across interprofessional boundaries to optimize care and outcomes.
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Does Pudendal Neuralgia Go Away
Unfortunately there is no cure for pudendal neuralgia. Rather, pudendal neuralgia, as any chronic pain condition, is managed through a variety of measures involving everyday life, from work to leisure activity adjustments, as well as medical interventions. The crucial element in the process is that you, the patient, are the driver of this management plan.
Avoid or minimize specific physical activities that are known to irritate the pudendal nerve. Spending hours on a bicycle is an activity to avoid, as is horse riding. Other activities that may contribute to pudendal neuralgia are trampoline jumping, bench pressing and excessive core muscle exercises.
Manage your sitting: the aim is to avoid pressure on the perineum, which is the area inside the sit bones, as this could lead to compression of the nerve. Coccyx-cut-out memory foam cushions are available commercially. You can increase the size of the cut-out to accommodate your particular need.
When you sit, do not take any weight on the perineum, all the weight is on your bottom and sit bones. Decrease your sitting by standing at your desk for part of the day. You may need to adjust the height of your desk to allow this.
Bowel and bladder management strategies
Physiotherapy treatments aim to relax and/or stretch the often over-contracted pelvic floor muscles and thus decrease the pressure on the pudendal nerve.
When To Get Medical Advice
See your GP if you have persistent pelvic pain.
Do not delay seeking advice if the pain is causing problems. Pudendal neuralgia can continue to get worse if left untreated, and early treatment may be more effective.
The stress of living with pudendal neuralgia can also have a significant impact on your physical and mental health if it’s not treated.
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Treatments For Pudendal Neuralgia That You May Have Already Tried That Did Not Help
For some people, any one of these treatments may be enough to provide pain relief and an improvement in quality of life. Unfortunately, the people who have success with these treatments are not the people that we see in our offices. We see the people who continue to have problems.
Many doctors tell their patients that the most important aspect of treating pudendal nerve pain is to figure out what is causing it. This of course is something we all agree on. But what if you are looking in the wrong places? Likely if you look in the wrong places you will get the wrong treatment. Many doctors focus on treating the injured pudendal nerve. This may not be the best treatment plan if you do not treat the problems of pelvic instability and sacrum instability we discussed above. Else wise the pudendal nerve will remain or repeatedly become entrapped. This could be why you are not getting long-term results and have bounced from specialist to specialist.
The first options were conservative care, simply avoidance of those things that cause pain.
If You Have A Question About Pudendal Nerve Entrapment Syndrome Get Help And Information From Our Caring Medical Staff
1 Kaur J, Singh P. Pudendal Nerve Entrapment Syndrome. In: StatPearls. Treasure Island : StatPearls Publishing 2020. 2 Possover M, Forman A. Voiding Dysfunction Associated with Pudendal Nerve Entrapment. Current Bladder Dysfunction Reports. 2012 Dec 7:281. 3 Gohritz A, Dellon AL. Bladder Pain Syndrome/Interstitial Cystitis due to Pudendal Nerve Compression: Described in 1915-A Reminder for Treating Pelvic Pain a Century Later. J Brachial Plex Peripher Nerve Inj. 2020 15:e5-e8. Published 2020 Mar 6. doi:10.1055/s-0039-1700538 4 Soucy B, Luong DH, Michaud J, Boudier-Revéret M, Sobczak S. Accuracy of Ultrasound-Guided Pudendal Nerve Block in the Ischial Spine and Alcocks Canal Levels: A Cadaveric Study. Pain Medicine. 2020 May 25.
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Overview Of Pelvic Nerve Pain
Men and women alike are prone to chronic pelvic nerve pain, usually resulting from damage to one of the following four nerves:
These nerves are present either in the abdominal wall, in and around the pelvic cavity, and in the groin and perineal area. Damage to any of these nerves can lead to chronic pelvic nerve pain.
What Are The Symptoms Of Pudendal Nerve Pain
Pudendal nerve pain originates from the nerve itself. Thus, it can cause different pain sensations, ranging from burning, deep ache to electrical shock-like discomfort. The area may also be highly sensitive to pressure or have pronounced prolonged response to pain.
These symptoms may occur spontaneously or after doing things like sitting or straining.
Pudendal nerve pain is often embarrassing, not just for its location, but what the nerve inflammation can do to the bodys other functions, related to sex, urination, and bowel movements.
Pudendal nerve pain can often go together with by urination problems, like hesitancy, frequency and urgency. It can also cause constipation and painful bowel movements.
Because pudendal nerve is responsible for sensation in the genitals, there may be numbness in the penis or vagina, and men may experience problems achieving erection and ejaculation.
Sometimes the electrical shock-like sensations can also strike the genitals, leading to a odd and painful sensations, especially during sex.
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Anatomy Of The Pudendal Nerve
The Pudendal nerve is derived from anterior divisions of the ventral rami of the S2, S3 and S4 nerves of the sacral plexus. It accompanies the internal pudendal artery along the lateral wall of the ischiorectal fossa in the pudendal canal. The pudendal nerve carries sensory, motor, somatic and sympathetic innervation and innervates the external genitalia of both men and women , as well as the bladder and rectum.
It is considered the MAIN nerve of the perineum and chief sensory nerve of the external genitalia as it supplies the skin and muscles of the perineum, the external urethral sphincter and external anal sphincter. The pudendal nerve contains sympathetic fibers that innervate penile erectile tissue making its function crucial for intercourse.
Its course through the pelvic is complex and tortuous, yet predictable. The pudendal nerve originates in Onufs nucleus in the sacral region of the spinal cord, coursing through the pelvic region then exiting the pelvis through the greater sciatic notch between the piriformis and coccygeus muscles. It curves around the ischial spine and sacrospinous ligament and enters the perineum through the lesser sciatic foramen. Its branches include the inferior rectal nerves, perineal nerve, and it terminates as the posterior scrotal/labial nerves and dorsal nerve of the penis/clitoris.
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Weâre also big fans of the EndoFEMM therapy pad, which is like a warm and cosy hug for your pelvis.
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Diagnosis Of Pudendal Neuralgia
Pudendal neuralgia can be very difficult to diagnose, as no specific test exists.27 Therefore, diagnosis of this condition relies heavily on a proper history and physical examination.
History should first be directed at identifying symptoms of pudendal neuralgia . Then, an inciting event should be explored. It is very important to establish how and when the injury occurred, and whether symptomatology was immediate or gradual. Commonly, surgery, vaginal delivery, or pelvic trauma is identified. Pudendal nerve entrapment is rarely idiopathic. Therefore, if there is no identifiable event, causes other than pudendal nerve entrapment should be ruled out.
One of the greatest authorities in surgical decompression of the pudendal nerve, Professor Roger Robert from Nantes, France, published his own criteria to diagnose pudendal neuralgia in 2008 . These criteria have been validated27 and are based on the consensus of mostly European physicians with extensive experience treating pudendal neuralgia. The study showed that patients meeting all the required criteria have better outcomes from decompression surgery than patients who only partially meet them.
Table 2. Nantes criteria for the diagnosis of pudendal neuralgia
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What Causes Pudendal Nerve Entrapment
Pudendal nerve entrapment syndrome may be caused by:
- repeated minor damage from prolonged sitting, cycling, or horse riding
- straining related to chronic constipation
- trauma to the nerve through childbirth, although this often resolves itself
- trauma to the pelvic area from a broken pelvic bone
- nerve damage through surgical procedures in the pelvic or perineal regions
- lesions or growths pressing on the pudendal nerve
- peripheral neuropathy associated with diabetes or other vascular conditions
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Treatment For Pudendal Nerve Entrapment Syndrome
Most of the patients we see have already had a long history of testing and diagnosis elimination scans. This includes for women a vaginal examination, for men a rectal examination. The goal of these examinations is to palpitate or apply pressure to the branches of the pudendal nerve to reproduce a pain response of nerve sensation. Many will have already had an MRI or CT scan to document nerve compression. Some would have had nerve conduction studies to assess damage or compression of the pudendal nerve.
Many also had nerve blocks. A painkiller not only improves pain but isolates the cause of the problem on the pudendal nerve. If pain relief is achieved, even in the very short term, then there is confidence the problem is the pudendal nerve.
Because a nerve block does not work, for some, this should not rule out the pudendal nerve. In a May 2020 study in the journal Pain Medicine , researchers noted that two common methods of nerve blocks using ultrasound guidance, one injection is given at the ischial spine or the other option the injection is given at the Alcocks or Pudendal canal were on average 80% accurate for hitting their mark.
What Are The Symptoms Of Pudendal Neuralgia
There are many different symptoms but they are usually worse when sitting. The symptoms include:
- pain in the area of the pudendal nerve anywhere from the clitoris or penis back to the anal area. It may be on one side or both sides, near the front, or further back. This pain is usually a burning or sharp electric feeling.
- sexual problems with less feeling in the penis or clitoris
- difficulty opening your bowels
- numbness in the area affected
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** Bonus There Isnt An Exact Exercise Protocol For Pudendal Neuralgia
but there are some basic guidelines that are helpful. We look forward to sharing more about this topic and more in the future. Just remember that overall, movement is very important and exercise doesnt cause nerve damage typically. We see patients fear movement , which is not helpful at all for feeling better.
There are exercises that should likely be avoided. If these exercises seem to aggravate pudendal symptoms, stop them even if your orthopedic PT says they help most patients: Any type of squat or monster walks with squatting and theraband tend to aggravate symptoms. If you can complete exercises without discomfort during or after, you are NOT doing damage.
Loretta J. Robertson and Tracy Sher
There are many more tips to share and we look forward to imparting more pudendal and pelvic pain wisdom. Loretta J. Robertson, MS, PT and Tracy Sher, MPT, CSCS
Posterior Femoral Cutaneous Nerve
Although the pudendal nerve is predominantly responsible for pelvic and perineal innervation, the posterior femoral cutaneous nerve also supplies sensory innervation to the perineum.12 The PFCN arises from the ventral rami of S1S4 and courses with the pudendal nerve until it reaches the ischial tuberosity. At this level, the PFCN passes inferior to the ischial tuberosity to access the superficial fascia of the perineum. It then divides into the inferior cluneal and perineal nerve. The inferior cluneal nerve innervates the inferior buttock, while the perineal branch innervates the lateral perineum, proximal medial thigh, the posterior lateral aspect of the labium majus or scrotum, and the clitoris or penis. The perineal branch of the posterior femoral cutaneous nerve communicates with the inferior rectal nerve, and it is thought that this communication is the reason why sensory impairment is not seen with pudendal nerve entrapment.
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Pudendal Neuralgia: What In The World Is It
Neuralgia is just a fancy medical word for pain along the nerve distribution or path. Pudendal Neuralgia has to do with the Pudendal Nerve, the nerve that supplies the genital area in men and women. The Pudendal Nerve supplies sensory fibers to the penis, scrotum, vagina, labia, clitoris and rectal areas. It also provides motor fibers, which means it is responsible for muscle function in the muscles of the pelvic floor. These muscles are responsible for normal urinary, bowel, and sexual function as well as a key component of spine, hip and pelvic stability. If your pudendal nerve is having issues, you may struggle with bowel or bladder problems, you may have pain in any or all of these areas, or you may suffer from painful orgasm or inability to orgasm.
Nerves are vulnerable to injury:
- where it travels through tunnels or canals
- where they branch off, especially if they make sharp turns
- where they lie along hard surfaces like bone
- there the system is fixed leaving less room for movement of the nerve