Chronic Pelvic Pain and the Pudendal Nerve

Pudendal nerve pain is a form of chronic pelvic pain that occurs when the pudendal nerve, which supplies sensation and motor control to the pelvic region, is irritated, compressed, or damaged. The pudendal nerve plays a crucial role in the functioning of the pelvic floor, anus, genitalia, and even the bladder. When it is compromised, it can result in a variety of symptoms. 

The pudendal nerve is a mixed nerve, meaning it has both sensory and motor components. It originates from the sacral plexus, which is located at the base of the spine. The nerve passes through several key anatomical structures on its journey to the pelvic region: 

1. Sacral Plexus: The pudendal nerve arises from the sacral plexus from the lower sacral and coccygeal nerves (S2-S4). 

2. Greater Sciatic Foramen: The pudendal nerve exits the pelvis through the greater sciatic foramen, which is an opening in the pelvic bone that allows nerves and blood vessels to pass from the pelvis to the lower limbs.   

3. Pudendal Canal: After passing through the greater sciatic foramen, the pudendal nerve travels through the pudendal canal, also known as Alcock’s canal, which runs along the inner surface of the ischial spine. 

4. Lesser Sciatic Foramen: The nerve then passes through the lesser sciatic foramen before it divides into several branches, including the perineal nerve and the dorsal nerve of the penis or clitoris. 

5. Sacrotuberous and sacrospinous ligaments:  These ligaments run across the sciatic foramen and create the lesser and greater foramens.  The pudendal nerve run between these two ligaments. 

The main function of the pudendal nerve is to provide both motor and sensory innervation to the pelvic floor and surrounding areas, including the anal canal, external genitalia, and external sphincters. The nerve plays a role in controlling the external anal sphincter, urethral sphincter, and transverse perineal muscles. 

The pelvic floor is a group of muscles and tissues that support the organs in the lower abdomen and pelvis, such as the bladder, uterus, and rectum. The pudendal nerve is responsible for controlling several of the muscles of the pelvic floor, allowing for essential functions like urination, defecation, and sexual activity. 

The external anal sphincter and external urethral sphincter are controlled by the pudendal nerve, which means that dysfunction or irritation of the nerve can lead to issues with bowel movements, urination, and sexual dysfunction. 

Pudendal neuralgia is a condition caused by damage or irritation to the pudendal nerve, resulting in chronic pain in the pelvic region. Some of the most common symptoms of pudendal neuralgia include: 

• Pelvic pain: This can range from mild discomfort to severe, burning, or stabbing pain in the perineum, vagina, penis, or anus. 

• Pain while sitting: Prolonged sitting can aggravate pudendal neuralgia, as it increases pressure on the nerve. 

• Pain during sexual activity: This can include pain during intercourse, a sensation of heaviness in the pelvic area, or loss of sensation. 

• Pain during urination or defecation: Irritation or compression of the pudendal nerve can lead to difficulty or pain while urinating or having a bowel movement. 

• Numbness or tingling: Loss of sensation or the sensation of “pins and needles” in the genital or anal regions can occur. 

• Incontinence: Dysfunction of the external sphincters can result in urinary or fecal incontinence. 

Pudendal nerve entrapment occurs when the pudendal nerve is compressed as it travels through the pelvis. This compression can happen due to a variety of reasons, including trauma, prolonged sitting, or repetitive activities such as horse riding, cycling, or any activity that places pressure on the pelvic floor. Entrapment may also occur due to anatomical variations or conditions like pelvic organ prolapse, where organs may press on the nerve, increased muscle tension, or sacral torsion. 

Certain activities or conditions increase the risk of pudendal nerve damage or irritation. These include: 

1. Sitting for long periods: Occupations or lifestyles that involve long periods of sitting (e.g., office workers, truck drivers) may put increased pressure on the pudendal nerve, leading to chronic pain. 

2. Repetitive trauma: Activities like horse riding, cycling, and weightlifting can contribute to nerve compression due to repetitive motion or direct pressure on the pelvic floor. 

3. Childbirth: Vaginal childbirth can cause trauma to the pelvic floor, resulting in stretching or injury to the pudendal nerve. 

4. Pelvic surgery: Surgeries involving the pelvis, such as hysterectomies or prostate surgeries, can sometimes result in nerve damage. 

Diagnosing pudendal neuralgia is challenging because its symptoms often overlap with other conditions, such as irritable bowel syndrome or interstitial cystitis. A thorough physical examination and detailed medical history are essential to identify potential causes of the pain. 

Specialized diagnostic techniques may be used to assess nerve function, such as: 

• Pudendal nerve block: This involves the injection of an anesthetic into the region around the pudendal nerve to see if the pain is temporarily relieved. A positive response to this test can indicate that the pudendal nerve is the source of the pain. 

• MRI or CT imaging: These scans can help rule out other conditions, such as tumors or anatomical abnormalities, that might be compressing the pudendal nerve. 

• Electromyography (EMG): This test measures the electrical activity of the muscles innervated by the pudendal nerve and can help assess nerve function. 

The treatment of pudendal nerve pain typically involves a combination of lifestyle changes, medications, and therapeutic interventions. Some options include: 

1. Nerve Block Injections: A pudendal nerve block involves injecting a local anesthetic or steroid near the nerve to reduce inflammation and provide temporary pain relief. In some cases, nerve block injections can provide long-lasting relief. 

2. Physical Therapy: Pelvic floor physical therapy can help address underlying issues with muscle dysfunction or tension in the pelvic region. It often involves techniques like rehabilitative ultrasound, manual therapy, and exercises to lengthen or strengthen the pelvic floor. 

3. Medications: Pain relief for pudendal neuralgia often involves medications like nonsteroidal anti-inflammatory drugs (NSAIDs), anticonvulsants (e.g., gabapentin), and tricyclic antidepressants (e.g., amitriptyline). These medications can help manage pain and nerve-related symptoms. 

Pudendal neuralgia can significantly impact daily life, but with proper treatment and management, many people can find relief from their symptoms. Avoiding activities that put pressure on the pelvic floor (such as sitting for extended periods or engaging in high-impact exercise) is essential for managing pain. Additionally, seeking professional help for diagnosis and treatment is crucial to effectively manage the condition and improve quality of life. 

Pudendal nerve pain and pudendal neuralgia are complex conditions that can cause significant discomfort and interfere with daily activities. Early recognition, accurate diagnosis, and an individualized treatment approach are essential in helping patients manage the symptoms and regain control over their pelvic health. 

---

Disclaimer: This blog is here for your help. It is the opinion of a Licensed Physical Therapist. If you experience the symptoms addressed you should seek the help of a medical professional who can diagnose and develop a treatment plan that is individualized for you.