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5 Things to Know About Pudendal Neuralgia

If you have pudendal neuralgia — a condition that causes persistent and debilitating pain in the vulvar area — the simple act of sitting is likely to be excruciating, and even wearing underwear or yoga pants may cause an unbearable burning or shooting pain.

Pudendal neuralgia occurs when there is damage or irritation to the pudendal nerve. This essential pelvic nerve gives sensation and function to the pelvic floor area, including the skin, parts of the vulva, the anus, and the pelvic floor muscles. Pudendal neuralgia can lead to chronic pelvic pain and other frustrating symptoms that impact your bowel, bladder, and sexual function.

Adding to the distress is the alarming lack of understanding surrounding this condition. Similar to endometriosis — another pelvic health disorder notorious for being misunderstood and under-diagnosed — diagnosing pudendal neuralgia often involves a lengthy and frustrating journey to relief. It may take years of inconclusive medical examinations, consults with various specialists, and multiple failed interventions and medication trials, all while enduring persistent pelvic pain and dysfunction.

On the much brighter side, once pudendal neuralgia is accurately diagnosed, a range of treatment options becomes available to alleviate symptoms and address the underlying issues affecting the pudendal nerve. Among these options, pelvic floor physical therapy can help you to find the tools you need to finally experience some relief.

Understanding this condition is a critical first step to feeling better. Here are 5 facts it helps to know.

1. Pudendal neuralgia is a little known cause of vulvar pain.

Have you ever hit your funny bone, only to feel a searing, burning, tingling pain down your arm to your wrist, pinky and ring fingers? Now imagine that pain, but in your vulva whenever you sit.

Pudendal nerve pain is most often described as burning, shooting, or stabbing pain in the areas which the pudendal nerve provides sensation including the perineum, labia, anus, and clitoris.

2. There are many possible causes of pudendal neuralgia.

Neuralgia refers broadly to irritation or damage to a nerve. What a nerve is irritated or damaged, it screams out loudly — often in the form of pain and muscle dysfunction. With pudendal neuralgia, irritation or damage can be due to a number of causes including:

  • Chronic strain or compression to the pelvic floor, including chronic constipation, squatting activities, and prolonged sitting like can occur with cycling or horseback riding.
  • Pelvic floor injury including traumatic falls and vaginal childbirth.
  • Disorders of the surrounding anatomy including, pelvic tumors, bony abnormalities, nerve anatomy abnormalities.
  • Surgical or medical complications, including damage to the nerve after pelvic surgery or pelvic radiation therapy, or complications from pelvic infections including herpes zoster.

3. Pudendal neuralgia is like sciatica for your vulva.

You can think of pudendal neuralgia like the “sciatica of your pelvic floor”. You may know about, or have even experienced sciatica — the irritating, burning or aching nerve pain that runs down your butt and back of your leg caused by compression or irritation of the sciatic nerve. When irritated or injured, the pudendal nerve can lead to pain and dysfunction in all of the areas it innervates.

In addition to “nervy pain” in the area of your vulva and anus, symptoms of pudendal neuralgia most commonly include:

  • A sensation of ”something” in your rectum or vagina known as sympathalgia
  • Urinary frequency or pain with a full bladder
  • Pain with bowel movements
  • Referred pain including the buttocks, pubic bone, inner thighs, and even in the area of the sciatic nerve
  • Pain with sex
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4. There are no specific tests to confirm the diagnosis of pudendal neuralgia.

The diagnosis of pudendal neuralgia is known as a ‘clinical diagnosis.’ This means that rather than laboratory tests or imaging, diagnosis is confirmed through a person’s medical history and identifying the signs and symptoms. Often, the Nantes Criteria are used to guide this diagnosis.

Also, if pudendal neuralgia is suspected, a pelvic physical therapist will assess the pudendal nerve during the transvaginal pelvic floor muscle exam using what is known as Tinel’s Sign. The pudendal nerve is fairly superficial in the pelvis, and can be felt during the exam. Ordinarily tapping on this nerve is pain free, but if it is irritated or injured it may reproduce your pain.

5. The anatomy of the pudendal nerve makes it particularly vulnerable to injury.

As the pudendal nerve travels down to provide sensation and motor function to the pelvic floor area, it twists, turns, and dives in and out of the pelvis, slipping between bones, muscles and ligaments. It finally makes its way back out of your pelvis near your sit bones where its three branches (the clitoral, perineal, and rectal branches) head to your vulva. This “tortuous” path allows plenty of opportunity for irritation and compression.

If you have pudendal neuralgia or think you might have it, talk to your doctor about your pain and symptoms and ask about a referral to pelvic floor physical therapy. A pelvic floor PT can help you better understand your pain and how to get relief.

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Dr. Ashley Rawlins, PT, DPT

Dr. Rawlins is a physical therapist at Origin who specializes in the treatment of pelvic floor muscle dysfunctions including pelvic pain, sexual dysfunction, pregnancy related pain, postpartum recovery, and bowel and bladder dysfunction. In addition to being a practicing clinician, she is a passionate educator and author.

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