Introduction to pudendal neuralgia
What is pudendal neuralgia?
Pudendal neuralgia is a condition that arises due to damage or irritation to the pudendal nerve, a critical nerve within the pelvis. This can lead to sensations of pain, discomfort or numbness in the pelvis and external genitalia. It is a chronic condition.
Pudendal neuralgia affects approximately 4% of all patients consulting for pain control therapies and has a higher prevalence in women [1].
What is the pudendal nerve?
The pudendal nerve arises from the sacral plexus, a network of nerve fibres located within the pelvis. The nerve is paired, meaning it is found bilaterally: one on the left side and one on the right side of the body. The pudendal nerve travels from deep within the pelvis, to the base of the vagina, where it branches off to form other nerves [2, 3].
The pudendal nerve has sensory, motor, and autonomic functions. In women, the pudendal nerve carries physical sensations from external genitalia to the brain. Branches of the pudendal nerve carry sensations from the clitoris, labia minora and majora, vaginal vestibule, lower portion of the vagina, and the anus. The nerve is also involved in the control of the muscles required for sexual function, urination, and defecation. As a result, damage or irritation to the pudendal nerve can result in various symptoms.
Causes
Causes of pudendal neuralgia
Pudendal neuralgia is caused by damage or irritation to the pudendal nerve and can arise in numerous ways.
Inflammation
Pudendal neuralgia is often caused by inflammation of tissue near the nerve [4]. This is often a result of trauma, such as a fall or physical injury, that can irritate or damage the pudendal nerve.
Compression
Compression and stretching are generally the most common causes of nerve injuries. This can be temporary or permanent and can be a result of:
- physical injury.
- childbirth.
- tumour or growths.
- sitting for prolonged periods of time.
- damage from a surgical procedure.
- activities that put pressure on the nerve (e.g., cycling, horseback riding).
Pudendal neuralgia can also be caused by nerve entrapment. Pudendal nerve entrapment can occur if the nerve becomes compressed or trapped between neighbouring tissue or structures. For example, the pudendal nerve can become trapped between the sacrotuberous and sacrospinalis ligaments within the pelvis [5].
In some cases, pudendal neuralgia can be a consequence of pelvic radiation therapy. Radiation can cause inflammation, compression or entrapment of the pudendal nerve, leading to sensations of pain, burning and numbness [6].
Pudendal neuralgia is typically a chronic condition, meaning it persists over time. However, the progression of the condition can vary significantly among individuals. Some people may experience periods of symptom improvement followed by flare-ups, while others may have constant pain. The progression of pudendal neuralgia can also be influenced by the underlying cause of the condition and the effectiveness of treatment strategies.
Symptoms
What are the symptoms of pudendal neuralgia?
Pain
The most common symptom of pudendal neuralgia is pain. Organs, muscles, and tissues that are innervated by the pudendal nerve can be affected. This pain can be experienced and described in different ways. Pudendal neuralgia pain often occurs within the pelvis and extends to the external genitalia [7]. This pain can be unilateral (one-sided) or bilateral (on both sides), depending on which pudendal nerve branches are affected.
The pain associated with pudendal neuralgia has been described as:
- Shooting, sharp or stabbing.
- Aching or burning.
- Tingling or numbing.
For some, the pain intensity is consistent, while for others, the intensity varies. This means that it can change and be better or worse at different times of the day.
Discomfort, numbness and increased sensitivity
Pudendal neuralgia can lead to general discomfort, numbness or increased sensitivity in the areas surrounding the nerve. This can lead to discomfort during activities like sitting or putting on clothing, as these actions put increased pressure on the pudendal nerve.
These sensations may also be felt beyond the regions directly innervated by the pudendal nerve. This can include pain, discomfort or numbness in the lower abdomen, inner thigh, and lower back.
Urinary and digestive symptoms
Pudendal neuralgia can lead to urinary and digestive symptoms, depending on which pudendal nerve branches are affected [8].
Urinary symptoms can include:
- Urinary hesitancy or difficulty with starting or stopping the flow of urine.
- Increased frequency or frequent need to urinate
- Increased urgency or sudden sensation to urinate.
Digestive symptoms can include:
- Constipation.
- Pain with defecation.
- Reduced control and awareness with defecation.
Sexual dysfunction symptoms
Pudendal neuralgia can lead to symptoms of sexual dysfunction.
Pudendal neuralgia can lead to physically altered sensations. In women, this includes pain, discomfort and numbness of the external genitalia. These sensations can become intolerable with sexual activity. Dyspareunia refers to pain with or following sexual intercourse. Individuals have reported difficulty with reaching orgasm. Pudendal neuralgia can also result in loss of libido or sexual desire, due to the physical and psychological changes associated with the condition [9].
Mental health symptoms
Pudendal neuralgia can interfere with daily activities and lead to psychological distress. Studies show that patients who experience chronic pain may develop symptoms of anxiety and depression [10]. Psychological interventions may be beneficial in managing the impact of pudendal neuralgia on mental health.
The symptoms of pudendal neuralgia can vary greatly between individuals. Speak to your healthcare provider about any symptoms you experience or changes to your health.
Diagnosis
Pudendal neuralgia is diagnosed through a physical exam and other tests [11]. It can present with symptoms similar to those of other conditions.
How is pudendal neuralgia diagnosed?
History and physical exam
Your healthcare provider will first take a personal history and note your symptoms. A detailed history is essential in ruling out other conditions.
Next, your healthcare provider will perform a pelvic exam. During the pelvic exam, the healthcare provider will likely insert a gloved finger into your vagina or rectum to put pressure directly on the pudendal nerve. This pressure can cause pain and discomfort.
Imaging tests
Imaging tests can provide a detailed image that gives your healthcare provider information about the structure of your pudendal nerve and surrounding tissues. Magnetic resonance imaging (MRI) is an example of an imaging test used.
The Nantes Criteria
Pudendal neuralgia can be clinically diagnosed using the Nantes Criteria. This includes:
- Pain in the pudendal nerve area.
- Pain that is worsened by sitting.
- No nighttime awakening due to pain; individuals may have trouble going to sleep because of pain.
- No sensory deficits.
- Confirmation with neurophysiological testing or a pudendal nerve block injection.
The Nantes Criteria was originally developed to diagnose pudendal neuralgia caused by pudendal nerve entrapment; therefore, further tests should be pursued if the criteria are not met or there are inconsistencies in symptoms [12].
Neurophysiology tests
Neurophysiology tests are useful in assessing the function of nerves.
Quantitative warm thermal threshold sensitivity testing is a commonly performed neurophysiology test for possible pudendal neuralgia. Compressed nerves typically lose the ability to transmit thermal and vibratory sensory information quickly; therefore, this test provides information about the pudendal nerve and its functioning.
Nerve block tests
Nerve block tests can assess nerve injury or damage. During this test, your healthcare provider will inject medication into your pelvis to numb the pudendal nerve and observe whether symptoms are impacted. Nerve block tests can support and confirm a pudendal neuralgia diagnosis. However, more research is needed on the effectiveness of this test and its use as a treatment [13].
Speak to your healthcare provider about the best diagnostic tests for your condition.
Treatment
Numerous treatment options are available to help manage the symptoms of pudendal neuralgia. Many will receive treatment that includes a combination of the following therapies.
Each experience is different. Speak to your healthcare provider to find the treatment option that is best for you.
What are the treatment options for pudendal neuralgia?
Lifestyle management
Lifestyle modifications can be beneficial in alleviating symptoms of pudendal neuralgia [14]. Certain activities can aggravate the pudendal nerve, leading to worsened pain.
The following activities should be modified or managed:
- Sitting for prolonged periods of time.
- Riding a bicycle or motorcycle.
- Horseback riding.
- Squatting with weights.
- Repeated hip flexion exercises (jogging, rowing, etc).
- Straining with defecation.
Be mindful of which activities cause your symptoms to worsen so you can make necessary modifications.
Some find it useful to use supportive cushions, like “sit-pads” or “doughnut pillows.” These cushions are protective in that they prevent direct pressure on the pudendal nerve.
Individuals with pudendal neuralgia typically experience relief of pain and symptoms when lying down or sleeping. Certain positions can help improve sleep quality with pudendal neuralgia.
Physical therapy
Physical therapy can provide relief from pudendal neuralgia symptoms, including pain. A physical therapist can teach you exercises for pudendal neuralgia to relax or stretch the pelvic floor muscles, which can alleviate pudendal nerve pain. A course of 6 to 12 weeks is commonly recommended.
Transcutaneous electrical nerve stimulation (TENS) has been used successfully for some pelvic pain syndromes; however, there is limited data on its use specifically for pudendal neuralgia [15].
Mental health therapy
Stress can aggravate the chronic pain associated with pudendal neuralgia [16]. Cognitive behavioural therapy can be recommended as a complementary or added therapy for patients with pudendal neuralgia. Speak to a psychologist or mental health counsellor for support as your treatment progresses.
Medication
Certain medications may provide relief from pain related to pudendal neuralgia. The recommended medications typically target pain or muscle activity associated with the pudendal nerve. Antiepileptics and antidepressants can also be prescribed [17].
Speak to your healthcare provider about medication options that will best fit your needs.
Common medication options for pudendal neuralgia include:
- Amitriptyline
- Duloxetine
- Gabapentin
- Pregabalin
- Clonidine
- Palmitoylethanolamide (PEA)
Pulsed radiofrequency
Pulsed radiofrequency (PRF) of the pudendal nerve is another treatment option for pudendal neuralgia. This treatment has been shown to improve sitting tolerance and reduce pain related to pudendal neuralgia [18]. More research on this treatment is needed.
Surgery
Surgical options for pudendal neuralgia include pudendal nerve decompression surgery, laparoscopic nerve decompression, and neuromodulation.
Pudendal nerve decompression surgery aims to release pressure from the nerve. Various approaches to the surgery are available. Decompression surgery can provide relief of symptoms for 60% to 80% of patients [19].
Laparoscopic nerve decompression has shown impressive results in terms of pain alleviation. It is a minimally invasive surgical approach that can treat pudendal nerve compression [20].
Neuromodulation techniques like sacral neuromodulation offer promising results for individuals with pudendal neuralgia. Sacral neuromodulation uses implanted leads and a battery pack to deliver low-amplitude electrical stimulation to specific nerves [21]. This treatment aims to modify nerve activity, relieve pain and return typical organ function.
If pain relief and improved quality of life are long-term goals, successful treatment of pudendal neuralgia and management of pudendal neuralgia is possible. Early and targeted management can provide long-term symptom control and relief and improve overall quality of life.
The effectiveness of these treatments can vary greatly. Speak to your healthcare provider about the best treatments for your symptoms and overall health condition.
Conclusion
Pudendal neuralgia is a painful and challenging condition with many impacts on well-being and quality of life. Pudendal neuralgia is an understudied condition. More research is needed to understand the causes of pudendal neuralgia and potential therapy options for the condition.
For more information about pudendal neuralgia, use MediSearch. Always consult a healthcare professional regarding your condition.