Pudendal neuralgia is a rare medical condition that causes discomfort, numbness, and pain in the pelvis or genitals. It is caused when the Pudendal nerve is compressed, damaged, or irritated. The areas in which it most commonly affects men are the penis and scrotum. For women, it affects the vagina, clitoris, and labia. For both men and women the areas of pain can include the anus, rectum, urethra, and perineum.
Two Thirds of all cases diagnosed are women, and over time it can cause issues with sitting down, sexual intercourse, or even using the bathroom. Many times, sitting down for prolonged periods of time can worsen symptoms, and exacerbate the pain. In many cases, the skin surrounding the affected area can also become hypersensitive to the touch, or to pressure. Clearly, this condition is nothing to fool around with, so let’s break down some of the major signs, symptoms, causes, and treatments of Pudendal neuralgia.
The most common symptom of Pudendal neuralgia is pain while sitting for long periods of time, but other symptoms include:
- Feeling a “lump” or something foreign in the body
- Painful intercourse
- Sexual dysfunction
- Straining or burning when urinating
- Pain and straining with bowel movements
- Increased sensitivity
It is common for Pudendal Neuralgia (PN for short) to be associated with musculoskeletal pain in other parts of the pelvis, such as the tailbone, sacroiliac joint, and certain muscles deep beneath the buttocks.
Without treatment, there is a significant possibility of symptoms becoming worse over time. What can start off as a little discomfort in the perineal area can become a constant long-term state of pain.
Causes of Pudendal Neuralgia
Some possible causes may include an autoimmune or inflammatory disease, tension on the PN nerve, an entrapped nerve (similar to carpal tunnel syndrome), frequent infections, exercise, childbirth, surgery, or even prolonged sitting. There is even a possibility that it could be hereditary due to a musculoskeletal predisposition.
Another common cause of PN is inflammation or trauma to the pudendal nerves. This pain may begin gradually with numbness, or tingling, in the area triggered by the pudendal nerve.
A common cause of the compression of the nerve can result from frequent long drives, or prolonged siting at work. Heavy weightlifting, which involves repeated hip bending, can also cause muscles or ligaments to strain, and enlarge, as to impinge on the nerve. Cycling has been shown to be a huge risk factor in developing PN, and it is commonly referred to as “cyclist syndrome”.
There is a theory that PN is hereditary, and can be triggered with a certain movement or action. For example, a person who is predisposed to PN, may develop PN, as a result from similar activities to someone who is not predisposed. There have been some doctors who noted that PN runs in families, with several family members reporting the condition across generations.
Constant friction on the nerve from tight muscles, or enlarged ligaments, can also be a cause due to pressure on the pelvis, which is why childbirth has been known to cause PN. In fact, many women have reported first symptoms of PN immediately after giving birth. These complaints often included severe clitoral/vaginal pain, and some minor pain around the tailbone. These sensations are often then followed by a feeling of “electric shocks”, which can grow in intensity over time.
Diagnosis of Pudendal Neuralgia
At this time, there is not a definitive test that can accurately diagnose PN. In most cases, diagnosis is based on the patient’s personal medical history, how their symptoms present, and after tests have been done to exclude any other diseases, or illnesses. Because it is a rare condition, it is often misdiagnosed, and some people have even undergone serious, unnecessary, surgical procedures. But rest assured, medical professionals do use an extensive series of procedures to make sure that a PN diagnosis is accurate. Below are the major steps in that procedure, as it applies to the majority of cases.
For women, this should include a pelvic exam. For men, it should include a digital rectal exam… sorry guys. This part of the process also includes a detailed medical history, as well as the patient’s habits leading to presentation of symptoms. Were they doing any heavy lifting? Were they in a car accident? Did they have an accident? Did they just give birth vaginally, or do they sit for long, extended periods of time? These are all common questions in the exam process, and they need to be answered truthfully, and completely, to ensure accuracy. A word of warning – during the physical exam, the doctor may also try to replicate the pain by pressing along the course of the nerve, via the rectum or vagina.
Eliminating Other Causes
Doctors will try and rule out other possible causes, such as UTIs (urinary tract infections), STDs (sexually transmitted diseases, and prostate, or vaginal infections. They will first prescribe medications to treat these infections, and if, after the course of the treatment the symptoms do not improve, they will then move onto the diagnosis of PN. They may also try and rule out Lyme disease and MS (multiple sclerosis).
MRI or CT Scan
Although these imaging procedures cannot see the nerves themselves, they are done in order to eliminate other issues, such as spinal abnormalities, or tumors.
Physical Therapy of the Pelvic Floor with Myofascial Release
Since PN and pelvic floor dysfunction (PFD) share some of the same symptoms, doctors may ask patients to undergo physical therapy. If there are no improvements, the likely cause of their pain is PN and not PFD.
Electro Physiological Testing
The PNMLT (pudendal nerve distal motor latency test) is an electro physiological exam that will measure the speed of nerve conduction. During the test, a neurologist will wear a special glove with electrodes that will stimulate the pudendal nerve inside the rectum, or vagina, at the ischial spine. If the nerve is slower than normal to react, it is a good indication that the nerve may be damaged, or entrapped. Though the PNMLT test cannot rate pain, it is done to test the motor function of the nerve.
A diagnosis block, more commonly known as a nerve block, is an injection that contains a local anesthetic, like lidocaine. The injection is given in the buttock to best reach the pudendal nerve at the ischial spine, where the nerve is likely entrapped. If the pain lessens as soon as it is administered, or if it is gone completely, this may be evidence that the nerve is damaged. The injection, though used for diagnostic purposes, can also be used as a treatment. If it’s used as a treatment, the injection will also contain an added steroid component.
Treatment for Pudendal Neuralgia
There can be numerous options for treatments of PN that include anything from lifestyle changes, to physical therapy. And, in more serious cases, surgery.
For lifestyle changes, the one thing that may need to be avoided above all else is sitting. Since sitting is the most common promoter of PN pain, doctors and therapists often tell their patients to try to stand, or kneel, as often as possible to avoid the pain.
With physical therapy, there are certain pudendal neuralgia exercises, and stretches, that people can do to help alleviate the pain. However, it should be noted that doing the wrong kind of stretches can make the pain worse. In some cases, strengthening the muscles is the key. Acupuncture is another common practice among PN patients, though the results are generally a mixed bag.
Certain medications can be prescribed to help treat PN, some of which include antidepressants, palmitoylethanolamides, and anti-epileptics. As mentioned before, anesthetic injections with an added steroid component can help with some pain relief. Sometimes, the injections can last long-term since the steroid helps with inflammation around the nerve, and can reduce pressure on the nerve itself. Success rate in patients using injections is 65-73%.
Pudendal neuralgia surgery as a treatment is considered to be the “last resort” and is still considered controversial. There are few surgeons, in a small number of countries, who actually perform this type of surgery, and only a handful of doctors will actually prescribe surgery. There are 3 types of PN decompression surgeries.
This is where an incision is made in the buttocks through the gluteal muscles on one or both sides. This type gives the surgeon the best visual access to the nerve, especially if it is caught in the ST (sacrotuberous) ligament, but it also leaves the biggest incision scar, and brings with it possible post-op pelvic instability from severed ligaments.
For men, the cut is made in the perineal area between the scrotum and the anus. For women, the cut is made half-way up the back of the vagina. This type leaves a smaller incision, and spares the ST ligament, but it gives the surgeon less visibility of the surgical area, and possibly no access to the ST ligament to free the nerve.
This is where the incision is made vertically in the perineum between the anus, and the sit bone, on one side, or both sides. This type is the least invasive and spares all ligaments, but it gives the surgeon the least visualization, and is extremely difficult to free the nerve from entanglement.
Pudendal neuralgia is a serious, but rare, long-term pelvic pain that develops from an irritated, or damaged pudendal nerve. The most common causes are believed to be over-exercise, compression of the nerve, childbirth, or sitting for an extended period of time, and there appears to be a potential genetic predisposition. Treatments, medications, and interventions are wide-ranging and vary in their invasiveness, so if you have any of the symptoms listed above, and are starting to think it might be PN, it’s best to seek medical attention right away, and not let the pain develop. Don’t let it get bad!
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