Pudendal Neuralgia and Pudendal Nerve Entrapment
Overview of Symptoms
The main symptom of pudendal neuralgia (PN) and pudendal nerve entrapment (PNE) is pain in one or more of the areas innervated by the pudendal nerve or one of its branches. These areas include the rectum, anus, urethra, perineum, and genital area. In women this includes the clitoris, mons pubis, vulva, lower 1/3 of the vagina, and labia. In men this includes the penis and scrotum. But often pain is referred to nearby areas in the pelvis. The symptoms can start suddenly or develop slowly over time. Typically pain gets worse as the day progresses and is worse with sitting. The pain can be on one or both sides and in any of the areas innervated by the pudendal nerve, depending on which nerve fibers and which nerve branches are affected. The skin in these areas may be hypersensitive to touch or pressure (hyperesthesia or allodynia).
Possible symptoms include burning, numbness, increased sensitivity, electric shock or stabbing pain, knife-like or aching pain, feeling of a lump or foreign body in the vagina or rectum, twisting or pinching, abnormal temperature sensations, hot poker sensation, constipation, pain and straining with bowel movements, straining or burning when urinating, painful intercourse, and sexual dysfunction – persistent genital arousal disorder (genital arousal without desire) or the opposite problem loss of sensation.
It is not uncommon for PN to be accompanied by musculoskeletal pain in other parts of the pelvis such as the sacroiliac joint, piriformis muscle, or coccyx. It is usually very difficult to distinguish between PN and pelvic floor dysfunction because they are frequently seen together. Some people refer to this condition as pelvic myoneuropathy which suggests both a neural and muscular component involving tense muscles in the pelvic floor.
Some tests can be used to help diagnose PN/PNE, as described in the diagnosis section
. However a large part of diagnosis relies on systematic study of the symptoms. This page is aimed at helping patients and doctors determine the strong possibility of PN/PNE from study of symptoms alone. History is also a factor in the diagnosis so it is important to consider possible causes as well as symptoms.
Without treatment, over time there may be a progressive worsening of symptoms starting with a small amount of perineal discomfort that develops into a chronic and constant state of pain that does not decrease even when standing or lying down.
Possible Causes of PN
There are numerous possible causes for pudendal neuropathy. Some of the possible causes are an inflammatory or autoimmune illness, frequent infections, tension on the nerve, a nerve entrapment similar to carpel tunnel syndrome, or trauma to the nerve from an accident/fall, exercise, childbirth, prolonged sitting, or surgery. Sometimes there is no apparent explanation and some doctors have theorized that the problem can be hereditary due to a musculoskeletal predisposition. Occasionally the problem originates in the spine or sacral area rather then the peripheral pudendal nerve.
Pudendal neuralgia can be caused by inflammation of the nerve or by mechanical damage/trauma to the nerve. Sometimes the pain develops slowly and is almost imperceptible at first, sometimes preceded by paresthesia in the area innervated by the pudendal nerve. Paresthesia is a “pins and needles” sensation or a feeling of prickling, numbness, and tingling.
Many people however recall one event in particular as the beginning of their symptoms. Some recall the feeling of a lightning electrical shock after a bad move. Some people report their symptoms started after direct shock like a fall on the buttock or a car accident. Others report pain after a sacral surgery such as a sacroiliac joint fusion resulting in a tilted pelvis or a pelvic surgery such as a sacrospinal fixation. Sometimes there is direct trauma to the nerve either from retractors or misplaced sutures. Pelvic surgery such as a hysterectomy may trigger pudendal neuralgia even though the nerve was not touched directly. One theory is that the nerve can undergo a stretch injury if the body is in a certain position for a long period of time during surgery. Sometimes women develop pudendal nerve pain immediately following childbirth and while often this eventually subsides, for some women the pain does not go away. Women with severe endometriosis may develop scarring or inflammation if the endometriosis settles on the nerve.
Prolonged sitting at work and frequent long drives are a common cause of compression to the nerve. Sports involving repetitive hip flexion like heavy weight lifting may cause enlarged or strained ligaments or enlarged muscles that impinge on the nerve. Some young athletes have been shown to have an elongated ischial spine, a bone that protrudes into the pelvis near the pudendal nerve. Cycling is a leading favorable risk factor for the development of the condition. In the sports medicine community it is sometimes called “cyclist syndrome”.
One hypothesis suggests that people who have PN were predisposed to have it and something occurred that triggered it. Other people who are predisposed may never develop the condition if they never engage in an activity or experience an incident that triggers it. For instance, someone who is predisposed to PN may take up weightlifting and consequently develop PN while another person who is predisposed but does not weight lift will not develop PN.
Tight muscles, tendons, or enlarged ligaments can lead to constant friction on the nerve or if the pelvis is out of alignment there may be undue pressure on the nerve. For some, the pudendal nerve can follow an irregular path or they may naturally have a tight space between the ligaments at the ischial spine or in the alcock’s canal. Some doctors have seen PN run in families, with several members in successive generations developing PN. Some people tend to form excessive scar tissue and this may lead to entrapment of the nerve. Certain autoimmune or inflammatory illnesses have been linked to pudendal neuralgia.
However, sometimes the cause remains unknown.
For more information on PN please visit Health Organization for Pudendal Education (HOPE)
Read More Here
Below is a list of Doctors who are up to date with the latest research on persistent pelvic pain, pudendal neuralgia and pudendal entrapment.
New South Wales:
Thierry Vancaillie MD (Belgium), FRANZCOG, PPFMANZCA
Gynaecologist and Pain Specialist
Director of the Womens Health and Research Institute of Australia
Level 12, 97-99 Bathurst Street – Sydney NSW 2000
Ph. 1300 722 206
Dr. Tim Pavy. Specialist Pain Medicine Physician
Suite 20, 2 McCourt Street. West Leederville
Western Australia 6007
Phone: +61 8 9468 5188
Fax: +61 8 9381 2006
Dr. Bernadette McElhinney
Suite 4, Level 1 Killowen House
Mercy Hospital Mount Lawley, Thirlmere Road
Mount Lawley, Western Australia 6050
Ph: +61 8 9370 9960 Fax: +61 9340 9826
Pelvic Pain Clinic
King Edward Memorial Hospital for Women
Subiaco, Perth, Western Australia
Tel: +61 8 9340 2222 (if outside Australia) 08 9340 2222 (within Australia)
Women’s Pelvic Pain Support Group
King Edward Memorial Hospital for Women
In GAIN demountable building (Corner of Bagot and Hensman Rds, Subiaco, Western Australia)
Informal chat over coffee 2nd Saturday of month 12-2pm
Ring Vanessa on Mob: 0437 498 917 or Catherine on Mob: 0406 333 735
Dr. Susan Evans
38 The Parade, Norwood, South Australia, 5067
Ph: +61 8 8363 2811 Fax: +61 8 8363 2911
Below is a list of physiotherapists who we know to be knowledgeable and up to date in pelvic pain issues.
Taken from the HOPE website.
New South Wales:
Stuart Baptist, B.Sc. (Hons), Physio RegPT
Sydney Men’s Health Physiotherapy
lvl1 139 Macquarie St
Sydney NSW 2000 Australia
Ph: +61 (02) 9252 5770
Clinical Specialist Pelvic Floor Physiotherapist
Conjoint Lecturer, UNSW
Womens Health and Research Institute of Australia (WHRIA)
Level 2 Royal Hospital for Women
Baker St. Randwick, Sydney, NSW 2031
Ph: (13) 0072 2206
Peter Dornan, Dip, Phty, FASMF
Mary Rose Saunders, MPT
13 Morley Street
4066 Toowong, QLD, Australia
Ph: (07) 3371 9155 Fax: (07) 3871 0301
Integrated Pelvic Physiotherapy
7 Maud Street
Nambour QLD, 4560 Australia
Ph: (07) 5441 4764
Unit 6., 294 Gt. Eastern Highway
Midland, Western Australia 6056
Ph: +61 (08) 9274 5666
Mens Health Physiotherapist Complete Physiotherapy
Ph: (08) 9203 7070 Carine Ph: (08) 9339 1932
Palmyra E-mail: email@example.com
Dr. Judith Thompson
Body Logic Physiotherapy
215 Nicholson Rd
Shenton Park, Western Australia 6008
Ph: +61 (08) 9381 7940