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Pudendal Neuralgia

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The Gist: What Is Pudendal Neuralgia?

Also known as: Pudendal neuropathy, pudendal nerve entrapment, Cyclist's Syndrome, Pudendal Canal Syndrome, Alcock's Syndrome

Pudendal neuralgia is a painful, chronic condition in which the pudendal nerve, which supplies innervation to the pelvis, is irritated or compromised either through compression, tension, bone remodeling, trauma, or surgical injury. Common symptoms of pudendal neuralgia include "nervy," "burning" or "sharp" pain in any of the areas innervated by the pudendal nerve. This can include the perineum, rectum or clitoris, the skin surrounding the pubic symphysis, the vulva, labia and vagina, as well as the sit bones of the pelvis.

Common activities that can reproduce or worsen these symptoms include intercourse, orgasm, bowel movements, pregnancy, sitting on hard surfaces, and bicycling. In some situations, symptoms can develop or worsen gradually, but in other instances, they can come on intensely and suddenly.

Who Gets Pudendal Neuralgia? When Does It Occur For Women?

Unfortunately, the prevalence and incidence of this condition is unknown, as it may be largely underreported, unrecognized, and potentially misdiagnosed. However, individuals who regularly bicycle or participate in spin classes, those with professions involving prolonged sitting, athletes who perform repetitive squatting or lunges, and those with a history of trauma to the pudendal nerve due vaginal surgeries or delivery, labral tears, and hip injuries are those most frequently diagnosed with pudendal neuralgia. In each of these scenarios, the nerve can be affected by traction, compression or increased inflammation surrounding the nerve.

Common complaints include pain that is worse later in the day, typically just inside the sit bones. Pain may occur on just one side, or both. Discomfort may occur in the perineum (the ares within the sit bones between the vagina and anus), the anus itself, or the clitoris. It is common for people to report a sensation of a foreign object in the vagina or rectum. Urinary, bowel or sexual dysfunction may also accompany discomfort.

The Origin Way: Physical Therapy For Pudendal Neuralgia

At Origin, treatment of pudendal neuralgia is addressed conservatively through a multidisciplinary approach, with physical therapy considered the first line of defense. Evidence shows that working with a pelvic floor Physical Therapist can help reduce symptoms through manual therapy to the muscles and tissue of the pelvic floor, stretches and exercises to address muscle imbalances of the core, hips and pelvic floor, as well as education and guided behavioral modifications to further manage symptoms.

Our Physical Therapists are experienced in working with individuals diagnosed with pudendal neuralgia. They are trained in neural mobilization and desensitization, myofascial release, trigger point release and soft tissue mobilization of the muscles and tissues surrounding the pelvic floor. Patient education is provided regarding activity modification and strategies to manage symptoms in order to reduce pain and improve your quality of life. This treatment will often coincide with medications prescribed by your physician to treat nerve pain and muscle spasms. Our Physical Therapists will work with you and your healthcare team to build an individualized plan of care that focuses on achieving your specific goals.

Should conservative treatment fail to fully resolve symptoms, a pudendal nerve block performed by a physician is another option that can provide positive outcomes for patients living with chronic pudendal nerve pain. Surgery is reserved for patients experiencing pudendal neuralgia due to entrapment.  Not all patients with pudendal neuralgia have pain due to entrapment. Unfortunately, the only way to definitively diagnose entrapment is through improvement in symptoms after surgical release of the surrounding tissue, often resulting in unnecessary surgeries.

If you have been diagnosed with pudendal neuralgia you might find groups like Pudendal Hope helpful.

Additional Reading & Sources

Hibner, Michael, et al. "Pudendal Neuralgia." Journal of Minimally Invasive Gynecology, vol. 17, no. 2, 2010, pp. 148–153., doi:10.1016/j.jmig.2009.11.003.

Khoder, Waseem, and Douglass Hale. "Pudendal Neuralgia." Obstetrics and Gynecology Clinics of North America, vol. 41, no. 3, 2014, pp. 443–452., doi:10.1016/j.ogc.2014.04.002.

Marvel, Richard P. "Pudendal Neuralgia: Making Sense of a Complex Condition." Current Sexual Health Reports, vol. 10, no. 4, 2018, pp. 237–245., doi:10.1007/s11930-018-0177-y.

Valovska, Assia. "What Is Pudendal Neuralgia?" The Pudendal  Association, Inc, 2019, pudendalassociation.org

Itza Santos F, Salina J., Zarza D et al.  Update in pudendal nerve entrapment syndrome:  an approach anatomic-surgical, diagnostic and therapeutic.  Actas Urol Esp. 2010 Jun; 34(6):500-9

Stav K, Dwyer PL, Roberts L.  Obstet Gynecol Surv  2009 Mar; 64 (3): 190-9

Labat, J. J., Riant, T., Robert, R., Amarenco, G., Lefaucheur, J. P., & Rigaud, J. (2008). Diagnostic criteria for pudendal neuralgia by pudendal nerve entrapment (Nantes criteria). Neurourology and urodynamics, 27(4), 306-310.

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