Pudendal neuralgia (PN) is a term meaning intense pain in the area in and around the pudendal nerve, which is located in the pelvic region and carries sensory and motor fibers. The pudendal nerve stems from the sacrum and runs through the pelvic area into the urethra, anus, rectum, perineum and genitalia. PN is caused by the entrapment, compression or dysfunction of the pudendal nerve.
This uncommon condition is the source of chronic pelvic pain. Referred to as pudendal nerve entrapment (PNE), it is also known as cyclist’s syndrome, pudendal canal syndrome, or Alcock’s syndrome. Although pudendal neuropathy (neuropathy means disease or dysfunction of the nerve) is technically another correct term for the condition, it is more commonly referred to as a general pain syndrome, thus pudendal neuralgia. Neuropathy is a specialty at The Institute for Advanced Reconstruction, thus we have extensive experience treating disorders like pudendal neuralgia.
According to The Pudendal Neuralgia Association, Inc., PN is a pain lasting three or more months. Acute pain is also experienced in the area surrounding the pudendal nerve, most commonly known as the “sitting area”.
Trauma to the area of the pudendal nerve caused by cycling, childbirth, surgeries, squatting exercises, bio-mechanical abnormalities (e.g., sacro-iliac joint dysfunction, pelvic floor dysfunction), chronic constipation, repetitive vaginal infections or falls on the tailbone are among the events that may trigger pudendal neuralgia. The pain can be further aggravated by sitting.
The International Pudendal Neuropathy Association estimates the incidence of this condition to be 1/100,000; however, most practitioners treating patients with this condition feel the actual rate of incidence may be significantly higher (Hibner et al, 2010). Pudendal neuralgia can occur in men or women although about two thirds of patients are women.
Without treatment, over time there may be a progressive worsening of symptoms starting with a small amount of perineal discomfort (the area in the pelvis and rectum) that develops into a chronic and constant state of pain that does not decrease even when standing or lying down.
Symptoms of Pudendal Neuralgia
Primary symptoms of pudendal neuralgia include:
- Burning, numbness, increased sensitivity, stabbing or aching pain, abnormal temperature sensations
Other symptoms may include:
- Pain in the area innervated by the pudendal nerves, with sitting intolerable. Skin in this area may be hypersensitive to touch or pressure
- Pain often not immediate but delayed and continuous and stays long after discontinuing the pain-causing activity (e.g. not sitting, cycling, sex)
- Less pain in the morning upon awakening and increasing throughout the day
- Loss of sensation, difficulty achieving orgasm or pain after orgasm; possible scrotum/testicular pain
- Strange feeling of uncomfortable arousal without sexual desire
- Friction and feeling of inflammation along the course of the nerve when walking for too long or running
- Constant pain even with standing or lying down
- Feeling of a lump or foreign body in the vagina or rectum
- Problem with urinary retention after urination; urethral burning with or after urination; urinary frequency
- Pain with bowel movement; constipation.
- Buttock sciatica including numbness, coldness, burning sensation in legs, feet, or buttock, often due to a reaction of the surrounding muscles to the pain in the pelvic region; can also be from “cross talk” of the nerves
- Low back pain resulting from radiation of the pain
- Complex regional pain syndrome and even post-traumatic stress disorder after prolonged or severe pain
Pudendal Neuralgia DiagnosisIt is important to note that pudendal neuralgia is largely a “rule out” condition. In other words, because its symptoms can indicate a number of other problems, extensive testing is required to ensure that a different condition is not the source.
Common conditions which are evaluated include coccygodynia (pain in or around the coccyx), piriformis syndrome, interstitial cystitis, chronic or non-bacterial prostatitis, prostatodynia (inflammation of the prostate), vulvodynia (pain, burning in vulval area), vestibulitis (pain in area surrounding entrance to the vagina), chronic pelvic pain syndrome, anorectal neuralgia, pelvic contracture syndrome/pelvic congestion, proctalgia (severe pain of pelvic floor muscle), or anorectal pain syndromes such as: proctalgia fugax or levator ani syndrome. It is also important to rule out other problems such as urinary tract infections, prostate infections, vaginal infections, or sexually transmitted diseases. Disorders that might cause peripheral neuralgia such as Lyme’s disease or multiple sclerosis should also be ruled out, as well as any colorectal cancers.
In addition to eliminating other conditions, it is important to determine if the pudendal pain is caused by a true nerve entrapment or other dysfunctions related to compression/tension. In almost all cases, pelvic floor dysfunction accompanies pudendal neuralgia. Testing overseen and conducted by The Institute for Advanced Reconstruction experts will help to determine if the symptoms are caused by a true nerve entrapment.
Some tests can be used to help diagnose pudendal neuropathy; however, a large part of diagnosis also relies on a methodical study of the symptoms and personal medical history. At The Institute of Advanced Reconstruction, we work closely with a number of specialists to both diagnose and treat pudendal neuropathy.
You will be asked your history, such as if you were exercising intensely, sitting long hours, or if you had been in an accident, vaginal delivery, or pelvic surgery. You will also be asked to pinpoint your pain, to determine if it is in the area innervated by the pudendal nerve.
Very often there are other painful areas in the surrounding region such as the piriformis muscle or tailbone pain. Most of the time this is a reaction to the nerve pain but in some cases the piriformis muscle could pinch the nerve and be the main cause. Since we are also experts in piriformis nerve entrapment, we are able to determine if this is the cause of the neuropathy, as well.
In addition to a physical exam, testing may be used, such as electromyography to measure the electrical activity of muscle tissue surrounding the pudendal nerve and magnetic resonance neurography (MRN) to image the relevant nerves. Image-guided pudendal nerve block, an injection with a local anesthetic performed by our experts, is the most important diagnostic test to determine if the condition is present.
The final diagnosis of pudendal neuralgia is based on a person having several or all of these criteria:
- Typical PN symptoms (see above)
- An abnormal electrophysiological test (MRN, MRI)
- Pain elicited upon pressing along the anatomy of the nerve
- Elimination of other diseases or conditions as the cause
- A positive response to the pudendal nerve block
Treatment for Pudendal Neuropathy
Pudendal Nerve Decompression Surgery
Pudendal neuropathy can be very complex and difficult to treat because of the location of the pudendal nerve and its functions. But at the Institute for Advanced Reconstruction, we are experts in complicated nerve procedures.
Pudendal nerve decompression surgery is an option that is usually considered after more conservative therapies fail. These therapies include such measures as lifestyle changes, pelvic floor physical therapy, medications and nerve blocks. Surgery is generally considered successful if there is at least a fifty percent reduction in pain and symptoms. Our experts will determine if you are an appropriate candidate for surgery, assist you to understand your options and assess the best course of action.
Using a minimally invasive procedure, Dr. Andrew Elkwood enters the pelvis through the skin in the area of the buttocks to decompress the pudendal and other associated nerve structures in an effort to alleviate the symptoms. In his experience, this technique is often highly effective, with many patients either symptom-free or with a significant relief of symptoms.
Following surgery, it is generally recommended that external physical therapy begin approximately one month following surgery that pelvic floor rehabilitation begins at three months.
Your Expert Surgeon for Pudendal Neuropathy
Dr. Andrew Elkwood of The Institute for Advanced Reconstruction is a renowned expert in nerve decompression surgery for a variety of conditions. In his nearly 20 years of medical practice, he has successfully treated countless patients with various nerve conditions and injuries, including the most complex cases. Dr. Elkwood is the founder and Chairman of the Center for the Treatment of Paralysis and Reconstructive Nerve Surgery at the Jersey Shore Medical Center, which was established to deal specifically with nerve injuries. Dr. Elkwood and his colleagues at The Institute for Advanced Reconstruction are among the few or only experts nationally and worldwide to perform all aspects of reconstructive procedures.
In addition to conducting both surgical procedures and research, Dr. Elkwood has applied his nerve decompression techniques to a variety of conditions, from pudendal neuropathy to those dealing with spinal cord injury and conditions resulting from stroke.
Sources & Resources
Health Organization for Pudendal Education http://www.pudendalhope.info/
Pudendal Neuralgia Association (PNA) http://pudendalassociation.org/