Pudendal nerve irritation (neuralgia or nerve entrapment) is defined as pain in the distribution of the pudendal nerve, specifically the rectum, vagina, penis, perineum and mons pubis. It can refer to nearby areas in the pelvis, but the predominant area of pain is in the areas described above.
Pudendal nerve entrapment occurs when there is something physically compressing the pudendal nerve along its pathway. This can occur as a result of a traumatic injury to the pelvis, where the pudendal nerve can become entrapped between the sacrospinous and sacrotuberous ligaments, or anywhere else along its pathway. It can also occur after a traumatic childbirth, especially forceps delivery, or other instrumentation during the birthing process. The third scenario that could potentially result in pudendal nerve entrapment is post-surgical entrapment, where a stitch may have been inadvertently introduced into the path of the pudendal nerve.
If these criteria are not met, and the pain is predominately in the distribution of the pudendal nerve, then pudendal neuralgia is a more likely diagnosis.
Dr. Eric Bautrant presented at the ESSIC conference in Rome, Italy in September 2015 on Pudendal neuralgia and pudendal nerve entrapment as a differential diagnosis to Bladder Pain Syndrome/Interstitial Cystitis. According to Dr. Bautrant, the major criteria that need to be present for the diagnosis for pudendal neuralgia are:
- Pain in the territories of at least 2 out of the 3 terminal pudendal branches (there are three branches of the left pudendal nerve, and 3 branches of the right pudendal nerve; the three branches are the dorsal (clitoral or penile) branch, the perineal branch (middle branch) or the rectal branch.
- Positive tinel’s sign (tapping of the ischial spine internally which produces the patient’s typical pain)
- Sexual arousal syndrome (may only be present in some patients)
- Positive CT-guided pudendal nerve block; in other words, the pudendal nerve block temporarily abolished or significantly reduced the typical pain that the patient is complaining of
If the pudendal nerve is truly entrapped, the following criteria need to be met:
- The pain is experienced predominately while sitting
- The pain does NOT wake the patient up at night- this is a very important criteria
- The pain does not correlate with any objective sensory impairment (numbness)
- The pain is reduced by a pudendal nerve block (CT guided)
Dr. Bautraunt also clearly stated that if a patient has signs of central sensitization, the patient does not make a good surgical candidate. Scoring less than 40 on the Central Sensitization Inventory would indicate a better prognosis with surgery. Furthermore, patients who have other co-morbid conditions that are highly correlated with central sensitization would also not do as well with surgery, according to Dr. Bautrant. These concurrent conditions would include vulvodynia, endometriosis, BPS/IC, chronic prostatitis, idiopathic low back pain, fibromyalgia, tempro-mandibular joint pain and migraine headaches.
Pudendal neuralgia and pudendal nerve entrapment often involve a component of biomechanical dysfunction in the SI joint, Pelvic Floor Muscle Tightness and Connective Tissue Dysfunction. If you are going to consider a pudendal nerve block, you should see a Pelvic Floor Physiotherapist first to ensure that the “container” of the pudendal nerve (muscles, connective tissue and bony structures of the pelvis) are healthy so that the effect of the nerve block can be accurately assessed. If these structures are still tight, you will not likely get relief from the block, even though the pudendal nerve may be truly involved. Furthermore, neural tension of the pudendal nerve should be assessed and treated prior to and after a pudendal nerve block by a pelvic floor physiotherapist. Neural Tension exercises will help to ensure that the pudendal nerve is gliding smoothly within its container.
A research study, completed by Peter Doran and Michel Coppetiers, two physiotherapists in Australia, reported on a protocol for the treatment of the pelvic girdle for pudendal nerve involvement. They had good success with a small group of patients using externally driven techniques to mobilize the sacro-iliac joints, decreasing tension on the sacrotuberous and sacrospinous ligaments. This is a non-invasive approach that should be considered before more aggressive approaches be attempted. See article.
Pudendal Neuralgia, or Entrapment, has been compared to Complex Regional Pain Syndrome (CRPS), a sympathetically-mediated pain syndrome. There is significant central sensitization that occurs with these pain syndromes, and the Sensitive Nervous System must be addressed to get full resolution of these symptoms. The term “pinched nerve”, or nerve entrapment, can be very scary. Sometimes, the diagnosis itself can create its own set of problems. The more you learn about your protective nervous system, the better you will be able to restore the nerve to normal function again.