Pudendal Neuralgia and Physical Therapy

Introduction

Is it pain in the pelvis from pudendal neuralgia, or is it sciatica? Pudendal neuralgia is chronic pain along the pudendal nerve, which runs through the perineum (genital area). It can affect both men and women, though about two-thirds of patients are women. The pudendal nerve is the main nerve of the pelvis. It forms in the low back near the tailbone, then travels a winding path through the pelvis, branching off to different pelvic floor muscles along the way.

The nerve is particularly vulnerable to compression in two anatomical areas: Alcock's canal, and the "clamp" between the sacrotuberous and sacrospinous ligaments. Treating pudendal neuralgia successfully depends on targeting the underlying cause of the symptoms, which is discussed further in the physical therapy section below.

Other Names for Pudendal Neuralgia

• Pudendal canal syndrome
• Cyclist's syndrome
• Alcock's syndrome

Causes of Pudendal Neuralgia

• Nerve compression from ligamentous or fascial entrapment, such as from cycling, childbirth injury, or scarring
• Changes in bony alignment, such as from a sports injury
• Increased pelvic muscle tone, from fear or pain, which can compress the nerve
• Decreased pelvic and hip flexibility
• Surgeries and resulting scars in the pelvic area
• Chronic constipation, from repetitive, small trauma
• Recent weight loss, which decreases cushioning and can cause nerve compression

When nerves become chronically irritated, pain is perceived at a lower threshold and the pain response becomes greater.

Could It Be Pudendal Neuralgia?

If you answer yes to several of the following, it might be pudendal neuralgia:

• Do you have pain with sitting that's reduced when sitting on the toilet?
• Did your symptoms begin after biking for a long time?
• Did your symptoms begin after a fall on your tailbone (coccyx)?
• Do you have incontinence of stool, gas, or urine?
• Do you have pain during intercourse?
• Do you have pain after ejaculation?
• Do you experience sexual dysfunction?

Symptoms

• Pain is the main symptom, typically worsening as the day goes on, and relieved by sitting on the toilet
• Bladder, bowel, and sexual dysfunction may also occur
• Symptoms may start suddenly or progress gradually
• Symptoms may occur on one side or both sides of the perineum
• The skin of the perineum may be sensitive to touch

Location of Pain

Pain is usually felt in the perineum, and sometimes in the hip and pelvis as well, including in the labia, vulva, clitoris (or penis and scrotum in men), urethra, rectum, and anus.

Diagnosis

Pudendal neuralgia is rare and difficult to diagnose. It usually coexists with pelvic floor dysfunction, which can make diagnosis harder. In men, it's most commonly misdiagnosed as nonbacterial prostatitis. Neurologists and pain management doctors typically treat pudendal neuralgia. Tests used to help diagnose it include:

• Pudendal nerve motor latency test (PNMLT)
• EMG (electromyography)
• 3T MRI
• MRN (magnetic resonance neurography), which may show clear enough images to identify nerve entrapment
• Diagnostic nerve blocks (CT-guided)

A conclusive diagnosis generally depends on symptoms consistent with pudendal neuralgia, an abnormal test result, pain along the pathway of the nerve, and ruling out other possible causes, such as infection, prostatitis in men, or vaginal infections and STDs.

Treatment for Pudendal Neuralgia

Pudendal neuralgia is more likely to respond well to treatment when it's caught early. Treatment can be divided into conservative and surgical approaches.

Conservative treatment includes:

• A thorough physical exam and understanding of the symptoms
• Ruling out other causes of pain, such as coccydynia, interstitial cystitis, and prostatitis
• Testing to help confirm pudendal neuralgia
• Physical therapy
• Pudendal nerve blocks
• Medications, such as antidepressants
• Lifestyle modifications, such as avoiding prolonged pressure on the buttocks by limiting sitting and avoiding strenuous exercise
• Perineal suspension pads to help relieve pressure when sitting

Surgical treatment involves releasing the entrapped pudendal nerve, using one of three approaches: transperineal, transrectal, or trans-ischiorectal.

Physical Therapy for Pudendal Neuralgia

Physical therapy is a very important part of the conservative treatment of pudendal neuralgia, and it's most effective as part of a team approach. A plan of care depends on the findings from a thorough history and physical exam, so I create a custom plan for each patient based on their goals and the impairments I find. This may include:

• Trigger point release, when increased tone in the pelvic floor muscles and trigger points (hyperirritable spots in the muscle fibers that are painful with compression) are found. A more aggressive option is trigger point injections, usually performed by a physician.
• Relaxing and lengthening tight or shortened pelvic floor muscles when pelvic floor dysfunction is noted. Kegel exercises aren't appropriate in this case.
• Pudendal nerve gliding, when abnormal neural tension is noted
• Exercises to improve stability and restore function, when biomechanical and structural issues are found in the SI joint, hips, low back, or with joint hypermobility

Conclusion

• Pudendal neuralgia is a rare peripheral nerve disorder that can be very distressing
• It can be resolved, depending on the severity of nerve involvement
• Most pudendal neuralgia responds well to conservative treatment with physical therapy