Pudendal neuralgia: Causes, Symptoms and Treatment

Pudendal neuralgia simply means a neuropathic pain in the area supplied by the pudendal nerve. The pudendal nerve runs through your pelvic region, including your genitals, urethra, anus, and perineum. This is also known as cyclist’s syndrome, Alcock’s syndrome, pudendal neuropathy, pudendal nerve entrapment or pudendal canal syndrome. This is a severely painful and disabling neuropathic condition that can affect both men and women. The pain in pudendal neuralgia is aggravated, especially when you sit. Men with pudendal neuralgia may have pain in the penis, scrotum, buttocks, and perineum. Women with pudendal neuralgia may have pain in their clitoris, vagina, vulva, urethra, buttocks, and perineum.

What causes Pudendal Neuralgia?

Pudendal neuralgia is causes due to the compression of pudendal nerve. The compression can be anywhere along the course of the pudendal nerve or its branches but most commonly between the space of sacrotuberous and sacrospinous ligaments. In few cases compression can be within the pudendal canal of Alcock.

Pudendal nerve entrapment or compression is caused by several factors, the most common causes may include

Prolonged sitting or bicycle riding for years
Damage to the pudendal nerve due to surgical procedures
Compression due to tumors in the pelvic region
Pelvic trauma (during childbirth)
Disease affecting the nerves (neuropathy, diabetic neuropathy, multiple sclerosis and others)
Constipation
Anal intercourse
Frequent use of anal devices
Excessive masturbation

Symptoms of Pudendal Neuralgia

The main symptoms of pudendal nerve neuralgia is pain which can be very severe, sharp, burning, stabbing, aching, pins and needle or knife-like, cramping and twisting. Irritation, numbness or hypersensitivity is also experienced by some. Some women may experience foreign body like sensation in the vagina or rectum. Some find sex very painful while some may have no sensation at all. Few may have sexual dysfunction leading to persistent genital arousal without desire. Sharp pain while urinating or defecation is also seen that can lead to dyschezia and urinary hesitancy. Pain usually starts in one place and progresses.

Other conditions that can be confused with Pudendal nerve neuralgia

Prostatodynia
Vulvodynia
Idiopathic proctalgia
vestibulitis
Idiopathic penile pain syndrome
Chronic pelvic pain syndrome
Anorectal neuralgia
Pelvic contracture syndrome
Pelvic congestion Syndrome
Levator ani syndrome
Idiopathic orchialgia
Chronic or nonbacterial prostatitis

Treatment of Pudendal Neuralgia

The mainstay of management of pudendal neuralgia is the treatment of neuropathic pain and the avoidance of injury and precipating factors. If pain is present with prolonged sitting, avoidance and lifestyle modification should be done. If it is the result of cycling or any other activities, it should be avoided. Neuropathic pain can be managed by medical therapy that includes gabapentin, pregabalin, duloxetine, and amitriptyline. Steroid injection and anesthetic nerve blocks to pudendal nerve are also useful therapy. Other options include physiotherapy, percutaneous posterior tibial nerve stimulation, osteopathy and short-term psychotherapy. When nothing works, surgical decompression is the treatment of choice in patients with pudendal neuralgia.