Pudendal neuralgia is chronic pain related to the pudendal nerve. Your pudendal nerve runs from your lower back, along your pelvic floor muscles, out to your perineum (the skin between your pubic bone and your tailbone).
It supplies the skin between the anus and the clitoris (or a man’s penis) as well as the muscles of the urethra and the anus.
Pudendal Nerve Neuralgia
The nerves throughout our bodies are usually supple and stretchy. They slide smoothly when we go about our everyday lives. Think about how far the nerves in your arms stretch when you reach above your head. We can also gently squash them for a while before they let us know, like the ‘dead arm’ feeling of pins and needles. They usually recover fairly quickly, too.
When nerves go through a large trauma (like a big fall onto a hard surface or a difficult labour) or lots of repetitive small trauma (like years of straining with constipation or repetitive heavy physical exercise) they can become irritated. Your nervous system can then become sensitised so that pain is triggered at a lower level, and the response is greater. It’s as though the volume is turned up for pain.
Pudendal neuralgia can come about when your pudendal nerve is exposed to traumas, the nerve is irritated, or compressed by bulky pelvic floor muscles or tight ligaments.
Symptoms of pudendal neuralgia
The main symptom of this problem is pain. This can be highly variable. You might feel burning, electric shock, shooting, aching, itch or a raw feeling in your clitoris, labia, vagina (penis in men), urethra, perineum, anus or rectum. You might find it difficult to sit because of your pain.You may also experience bladder and bowel irritation. Sometimes you can feel this irritation without feeling much pain. Occasionally there is a full sensation in vagina or rectum.
Sometimes pain can be felt into the buttocks, legs and feet. This is because the skin there is supplied by the same level of your spinal cord and your brain ‘perceives’ the pain in the skin of your buttocks, legs and feet.
You may also have associated bladder, bowel or sexual problems.
What causes pudendal neuralgia?
There is no one cause of pudendal neuralgia. It may be related to:- Childbirth trauma
- Gynaecological or colo-rectal surgery
- Cycling
- Excessive physical exercise
- Past pelvic or perineal trauma
- Injury
- Straining
- Musculoskeletal issues
- Posture
- Stress
We’ll conduct examinations and tests to work out whether you have pudendal neuralgia. None of these tests on its own is a diagnosis. Your doctor will assess your history, and the information from your physical examination and tests to come to a diagnosis – or to work out if your symptoms are caused by another problem. Then, they’ll discuss the best treatment plan with you.
Physical examination
When you first come in, you’ll have an initial physical examination with one of our doctors and an allied health professional. We’ll look at the neurological and musculoskeletal functions of your legs, pelvis and perineum by checking your muscles, joints, posture and reflexes.Pudendal nerve block
One of the next steps we might recommend is a pudendal nerve block. Under X-ray or ultrasound, your doctor will inject a local anaesthetic into the canal the nerve travels through.You should go temporarily numb – if your pain is eliminated or significantly reduced, it indicates that the pudendal nerve is an important element in your pain syndrome.
Pudendal nerve MRI
Another test your doctor might suggest is a pudendal nerve MRI. We’ll refer you to Dr Toos Sach, an expert in the interpretation of MRI images of the pudendal nerve. The MRI will give us information about the anatomic structures surrounding the nerve.Sonography of the sacroiliac joint and ligaments
Depending on what we found in your initial evaluation, we may suggest sonography (ultrasound) of the sacroiliac skeletal structures at the bottom of your spine. These structures are put under stress during pregnancy, a fall onto the buttocks, and intense sporting activities – so depending on your situation, it might be important to check them.Sonography of the pelvic floor muscles
Your doctor may recommend an ultrasound of your pelvic floor muscles. This test gives us information about the muscles around the vagina, the floor of your pelvis and the adductors of your leg – the muscle that brings your knee inwards to cross your legs.Management of pudendal neuralgia
Pudendal neuralgia, like any pain condition, is managed through adapting your everyday life. We’ll suggest adjustments to your work and home life, and your leisure activities. Your doctor might also suggest medical interventions.The crucial element in the process is that you are the driver of your management plan. Your physical, work, home and social goals are the main focus. We help you work towards them.
Remember there was a time when your pudendal nerve was much happier? With tailored management, we will help you regain that as much as possible.
Conservative Management
Depending on the factors involved in your pudendal neuralgia, your management plan might involve several different specialists, as well as your own self-management.The aim is to reduce the irritability of your pudendal nerve. As with any nerve irritability in the body, the nerve needs time to settle, even after you’ve made changes in your lifestyle.
Many people find that understanding what triggers their nerve pain and knowing how to modify their life around it makes it much easier to manage. With the right knowledge and tools, you can reduce your pain significantly and live a full and functional life.
Common lifestyle changes include:
Bowel and bladder management strategies: Try not to strain when emptying your bowels or passing urine, as this stretches the nerve. Avoid stimulant laxatives. Physiotherapy can help you develop a plan for good bladder and bowel habits that suit you.
Sitting modification: Avoiding pressure on the perineum (the area inside your ‘sit bones’) helps to prevent the nerve compressing. You can buy special coccyx-cut-out memory foam cushions and modify them to remove the section under your perineum, so that when you sit you won’t take any weight there. Decreasing your sitting can also help – try standing at your desk for part of the day using a laptop on a box or a portable desk raiser.
Avoiding physical activities that irritate the nerve: The biggest ones are spending hours on a pushbike and horse-riding. Other activities to minimise are trampoline jumping, bench pressing and excessive ‘core muscle’ exercises. Osteopathy and physiotherapy can help you identify movements specific to you that may need to be minimised for a period of time.
Adapting your sex life: Some people find sex can flare their pain. There are many options to keep your sex life going while avoiding pain. Your clinician can help you with this.
Physiotherapy
A physiotherapist can teach you how to relax and/ or stretch your pelvic floor muscles, which might be over-contracted. This can help to decrease the irritation of the nerve.You may also need to manage painful trigger points in your pelvic floor muscles. Your physiotherapist might recommend using TENS (trans-cutaneous electrical nerve stimulation) – the so-called ‘tingly machine’ – to help relieve your pain. You can use this machine for effective self-management – but ask the physiotherapist to help you place the electrodes correctly.
You may also benefit from specific external exercises and stretches and you may need to address your posture and activities that may flare your pain. Your physiotherapist will also encourage you in general cardio exercise to maintain your fitness and strength, both mental and physical.
A physiotherapist can also help you plan your daily bladder and bowel management routine.
The ligaments of the sacroiliac joints in the bottom of your spine are continuous with the ligaments that the pudendal nerve travels through. Tension at these joints may contribute to irritation of the pudendal nerve. Some of the muscles in your hips and buttocks can also irritate the nerve.
Osteopathy may help you to alleviate these pressures and tensions. Your osteopath will help you make changes to simple things like how smoothly you walk and move to reduce the irritability of your nerve, as well as the pain from muscles tightening in response to your pain.
Acupuncture
If you have recently developed symptoms – such as ongoing pain in the perineal area within a few months of a difficult birth – acupuncture can be a great alternative to traditional medical management and may mean you can avoid medication. Within the first one year is ideal, however you may still benefit from acupuncture at any time.If you have experienced significant side effects from the commonly prescribed medications for pudendal neuralgia, a traditional Chinese medicine approach is also a viable option.
