Pudendal Neuralgia

Original Editor - Sazia Queyam

Lead Editors

 

Introduction

Pudendal ( Latin pudenda, meaning “external genitals”, derived from pudendum, meaning "parts to be ashamed of".

Neuralgia (Greek neuron, "nerve" + algos, "pain") is pain in the distribution of a nerve or nerves.

Pudendal neuralgia is a chronic neuropathic pelvic pain that is often misdiagnosed and inappropriately treated by many practitioners.

The condition is sometimes referred to as cyclist syndrome because, historically, the first documented group of patients with symptoms of pudendal neuralgia was competitive cyclists. There is a misconception, however, that the condition only occurs in cyclists. In fact, pudendal neuralgia and pudendal nerve entrapment specifically may be caused by various forms of pelvic trauma, sitting for prolong duration, from vaginal delivery (with or without instrumentation) and heavy lifting or falls on the back or pelvis, to previous gynecologic surgery, such as hysterectomy, cystocele repair, and mesh procedures for prolapse and incontinence.

Clinically Relevant Anatomy

The pudendal nerve is paired, meaning there are two nerves, one on the left and one on the right side of the body.

The pudendal nerve is a sensory, autonomic, and motor nerve that carries signals to and from the genitals, anal area, and urethra.

There are slight differences in the nerve branches for each person but typically there are three branches of the nerve on each side of the body; a rectal branch, a perineal branch and a clitoral/penile branch.

Mechanism of Injury / Pathological Process

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Clinical Presentation

Clinical characteristics include pelvic pain with sitting which increases throughout the day and decreases with standing or lying down,

sexual dysfunction and difficult with urination and/or defecation. To confirm pudendal neuralgia, the Nantes criteria are recommended.

Treatment includes behavioral modifications, physiotherapy, analgesics and nerve block, surgical pudendal nerve decompression,

radiofrequency and spinal cord stimulation.[ Source: Management of pudendal neuralgia. F. R. Pérez-López, link: https://doi.org/10.3109/13697137.2014.912263]

In most cases, patients will describe neuropathic pain – a burning, tingling, or numbing pain – that is worse with sitting, and less severe or absent when standing or lying down.

Initially, pain may be present only with sitting, but with time pain becomes more constant and severely aggravated by sitting. Many of my patients cannot tolerate sitting at all. Interestingly, patients usually report less pain when sitting on a toilet seat, a phenomenon that we believe is associated with pressure being applied to the ischial tuberosities rather than to the pelvic floor muscles. Pain usually gets progressively worse through the day.

Diagnostic Procedures

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Outcome Measures

The McGill Pain Questionnaire, also known as McGill Pain Index, is a scale of rating pain developed at McGill University by Melzack and Torgerson in 1971. It is a self-report questionnaire that allows individuals to give their doctor a good description of the quality and intensity of pain that they are experiencing.

add links to outcome measures here (see Outcome Measures Database)

Management / Interventions

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Differential Diagnosis

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Resources

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