Do you have pelvic pain that is sharp, and bothers you when you sit?
Pudendal Neuralgia is sharp, shocking pain that follows the path of the pudendal nerve through the pelvis. It is different than neuropathy, which is damage to a nerve that results in loss of sensation or motor movement.
It may be caused by pudendal nerve entrapment, where the nerve shouts in pain because it's compressed or caught somewhere. However not all cases of Pudendal Neuralgia are due to pudendal entrapment.
What is the pudendal nerve?
The pudendal nerve is a mixed nerve that innervates the pelvic floor. A mixed nerve is one that sends both motor signals to your muscles to move, as well as sensory signals to your brain.
The pudendal nerve helps to regulate the tone of our pelvic floor. This is important to help us stay continent, as we both don't want to leak all day long nor do we have the time to constantly think about it.
The pudendal nerve splits into three branches within our pelvic floor.
The inferior rectal nerve branch helps to control our external anal sphincter (this is why you can hold in gas until it's an appropriate time to let it go). This nerve also allows us to experience sensation within the lower part of the rectum and skin surrounding.
The perineal nerve branch helps control a lot of the "main" muscles of the pelvic floor, as well as provides sensory information in that area such as the scrotum or labia.
The dorsal nerve branch of the clitoris or penis is responsible for clitoral or penile excitation, and the urge to urinate.
What causes Pudendal Neuralgia?
Pudendal Neuralgia (PN) can be caused by nerve entrapment, which means that the nerve is compressed or "stuck" along its pathway. Not all cases of PN are caused from entrapment, though.
Other frequent causes (not an exhaustive list):
Surgery -- especially surgery that includes mesh
Pregnancy and childbirth -- especially labor that includes perineal tearing and subsequent scar tissue.
Trauma to the pelvis (i.e. a fall, car accident, but also abuse)
Cycling
Prolonged sitting
Constipation
Anal intercourse
Excessive masturbation
How could my nerve get entrapped?
Pudendal nerve entrapment is not the same thing as pudendal neuralgia, although it can cause pudendal neuralgia. Essentially not all PN is caused by pudendal nerve entrapment . That being said:
Nerves weave in, out, and around most structures in the body to supply innervation and sensation. Nerves can commonly split muscles, weave around joints, and hang out in tight spaces. It's not uncommon for chronically tight muscles to place increased compression on a nerve and make them start shouting at you. The pudendal nerve tends to get trapped between the sacrospinous and sacrotuberous ligaments in the pelvis, for example. If you feel much better in a deep squat, then the nerve pain might be coming from that spot.
Nerves need to be able to freely move, just like our muscles. Cases where nerves can get entrapped in the pelvis include surgical sites, especially ones that have developed scar tissue. Scar tissue is like superglue, it is not flexible and does not allow the structures around it to move freely as needed, which can elicit quite a lot of pain. Even vaginal deliveries that require an episiotomy (a surgical cut to increase the birth canal) have been culprits of pudendal nerve entrapment.
What are the common symptoms?
Common signs and symptoms of PN include:
Pain anywhere along the nerve pathway. Nerve pain often is described as sharp, shooting, burning, tingling, stabbing.
Pain with sitting (due to compression), however sitting on the toilet may provide relief.
No pain during the night when sleeping.
Relief with a pudendal nerve block.
Intolerance to tight clothing.
Sensitivity to touch that wouldn't normally be bothersome (allodynia).
Pain worsens throughout the day.
Predominately one side is worse than the other.
Tenderness on the bony prominences of the pelvis (especially the ischial spine).
Pain is triggered with defecation / bowel movements, sometimes urination
Pain with intercourse or after intercourse.
Pain walking on an incline or hiking.
Note, you might not check all of these boxes and that's okay. Everyone experiences different symptoms, but these are the most common.
What might the pain be if it's not pudendal neuralgia?
Do the above symptoms not sound exactly like what you're going through? It can be hard to distinguish between pain and find an exact cause.
If you're experiencing pain elsewhere, these might be other causes:
Pain with intercourse can be spasming pelvic floor muscles, as well as vaginismus. Read our blog on vaginismus here.
Pain with urination that is frequently ruled out from being a UTI can be interstitial cystitis or a tight pelvic floor.
Pain with bowel movements can be a tight pelvic floor, hemorrhoids, or anal fissures.
Chronic constipation can be Aa prolapse, tight pelvic floor, or dyssynergic defecation.
Pain with sitting and sensitivity on the vulva can be vulvodynia, which is pain to non-painful stimuli. This is similar to pudendal neuralgia in that it is a nerve dysfunction, however the presentation and causes are different.
Pain with sitting around the tail bone can be a tight, spasming pelvic floor creating coccydynia.
Persistant genital arousal disorder is where the dorsal nerve to the clitoris is constantly compressed or stimulated. The dorsal nerve to the clitoris is a branch off the pudendal nerve.
Levator Ani Syndrome is pelvic pain created by muscle tension and spasms around the area of the pelvic floor.
Endometriosis is a systemic condition where cells that grow inappropriately outside the uterus create adhesions resulting in pain. This is a very simplified description of Endometriosis, however, and the scope of this blog isn't to cover Endo.
Lumbosacral radiculopathy is nerve pain coming from a nerve root in the lumbar or sacral spine.
This is not an exhaustive list, and not all of what is listed above could be the causes of your pain. The best plan of action is to speak with your medical provider about your signs and symptoms.
What should I do about Pudendal Neuralgia?
Pudendal Neuralgia can be treated with Physical Therapy, specifically Pelvic Floor Physical Therapy, as a first line of defense. You'll work with your therapist to identify the specific area of compression or pain, as well as the other variables that might be contributing, such as muscle spasms.
PN responds very well to manual therapy and dry needling provided by a Pelvic Floor Physical Therapist. Stretches and exercises work well to help keep tissues mobilized and pain free, but sometimes that extra bit of manual release is required to help you get the most out of your home routine.
Pelvic floor PT will also address over-activity of the pelvic floor muscles, or surrounding muscles of the hip and low back, if the underlying cause is coming from tension. Often times we have to relearn movement patterns and re-wire our natural resting tone when pain has become persistent.
If PN causes painful muscle spasms in the pelvic floor, or muscle spasms create nerve irritation, sometimes suppositories of medications can help create an environment of relief that allows you to benefit more from physical therapy. These suppositories can be valium or other muscle relaxants for example.
PN relief can also be found with nerve blocks, which are a key part of the diagnostic process, or botox. If you do get a nerve block from a physician, this should help make physical therapy even more successful by allowing the tissues to tolerate a bit more than they normally would. If your pain is 9/10 with physical touch, it can be difficult sometimes to tolerate the manual therapy needed.
If your pain does not improve, or it plateaus, then the next course of action may be injections and / or surgery. Surgery addresses mechanical entrapment of the pudendal nerve, which could be caused from prior surgeries or mesh placed. This obviously is not the only reason someone may have PN, so the good news is this isn't the road everyone has to go down to feel better.
Should I get an MRI to diagnose me?
The reality of an MRI, like all scans, is it has both pros and cons. MRI's cannot actually visualize nerves. When you are dealing with nerve pain, it is really hit or miss on why the nerve is in pain. Sometimes things can come up like tumors, disc herniations, or large amounts of scar tissue that may be the cause of nerve entrapment, therefore pain. If the nerve is in pain due to muscle spasms, though, the MRI will not be able to show that.
This is why an MRI result of "normal" may be very invalidating for those who are in pain and therefore do not feel normal.
Essentially this is a case by case basis to be discussed with your medical provider. However, an MRI should not be done unless you plateau with conservative treatment. Other medical procedures may also be more beneficial to try first, like a pudendal nerve block.
Is Pudendal Neuralgia a life-long diagnosis?
No! The good news is that PN can be treated by physical therapy, medication, injections, acupuncture, and in rare cases surgery. PN responds very well to treatment listed above, but if you have any further questions feel free to send us a message or comment below!
If chronic pain is also taking a toll on your mental well-being, as it undoubtably can, consider too how psychological care can play a huge roll in healing.
TLDR
Pudendal Neuralgia (PN) is nerve pain following the pathway of the pudendal nerve (throughout the pelvis). It can be caused by compression and entrapment, often times by surgery, cycling, or childbirth. PN may feel like stabbing, shooting, burning pain. Pudendal Neuralgia responds well to Physical Therapy, as well as movement in general.
About the Author:
Caroline Gamwell, DPT is a Doctor of Physical Therapy specializing in Women’s Health and Orthopedics. Dr. Gamwell earned her doctorate at Northwestern University in Chicago, IL with a focus on chronic pain rehabilitation. Dr. Gamwell owns Worth It PT, LLC, a boutique physical therapy practice based in Denver, CO focusing on all things Pelvic Health. She holds post-graduate certifications in Pelvic Floor Physical Therapy, as well as in treating pregnant and postpartum athletes. Her passions lie with helping others embrace body changes throughout the decades, whether it’s pregnancy and postpartum or simply aging well.