Pudendal Neuralgia

What is Pudendal Neuralgia?
Pudendal neuralgia is pain caused by the nerve that supplies the skin between your pubic bone and your tail bone.
The pudendal nerve carries the sensations of touch and pain from the skin between the anus and the clitoris, as well as the sphincters (muscles that keep the openings of the bladder and bowel closed).

What are the signs and symptoms of Pudendal Neuralgia?
The most common complaint is pain with sitting, which gets worse as the day goes on. However, as the nerve is also involved with bladder and bowel function, other problems, such as bladder frequency, feeling of a bladder infection, pain with intercourse and the sensation of an urgent need to open the bowels, can also occur.

Typically, the pain resolves during the night or when lying down. Pudendal neuralgia can be related to intense physical exercise involving the pelvic floor and neighbouring muscles. The exercises that are most commonly associated are: ‘Kegel’ exercises (exercises to strengthen the pelvic floor muscles), cycling and weight lifting/ bench pressing.

The most common association however is with childbirth. During vaginal delivery, the pudendal nerve is slightly stretched and may therefore malfunction and cause symptoms. This resolves spontaneously in most cases within a few weeks. Some women, however, will continue to suffer pain for longer periods of time, or the pain may come back months or years after the delivery.

Some types of surgery can lead to persistent postoperative pain. This surgery might have been a simple cut for the removal of a cyst or following childbirth (episiotomy) or a more complicated procedure, such as for correction of prolapse, for example. We do not have any way of predicting who will develop chronic pudendal pain after surgery.

Pain after surgery is not necessarily the result of incorrectly performed surgery.

How is Pudendal Neuralgia diagnosed?

History and physical examination
Most women with pudendal neuralgia have a ‘typical story’ to tell; they experience pain with sitting that usually starts around midday, worsens as the day goes on, and then resolves during the night.
The examination by a doctor aims to define how sensitive the skin of the perineum is and to reproduce the pain by feeling the nerve. This examination of the nerve requires a vaginal examination.

Pudendal nerve block
Local anaesthetic is injected into the canal through which the nerve travels. The perineal skin should go numb and, while you are numb, we would expect your pain to be eliminated or significantly decreased.

Other tests may be requested to rule out other problems. These tests include special scans (ultrasound or MRI) of the joints, ligaments and muscles of the pelvis.

How is Pudendal Neuralgia treated?

We do not use the term ‘cure’ for treatment of pudendal neuralgia. Rather, pudendal neuralgia, as any chronic pain condition, is ‘managed’ through a variety of measures involving everyday life, from work to leisure activity adjustments, as well as medical interventions. The crucial element in the process is that you, the patient, are the driver of this management plan.

Lifestyle changes
Avoid or minimise specific physical activities that are known to irritate the pudendal nerve. Spending hours on a bicycle is an activity to avoid, as is horse riding. Other activities that may contribute to pudendal neuralgia are trampoline jumping, bench pressing and excessive ‘core muscle’ exercises.

Manage your sitting: the aim is to avoid pressure on the perineum, which is the area inside the ‘sit bones’, as this could lead to compression of the nerve. Coccyx-cut-out memory foam cushions are available commercially. You can increase the size of the cut-out to accommodate your particular need.

When you sit, do not take any weight on the perineum, all the weight is on your bottom and ‘sit’ bones. Decrease your sitting by standing at your desk for part of the day. You may need to adjust the height of your desk to allow this. 

Bowel and bladder management strategies
To minimise constipation and straining, increase your intake of foods high in fibre, such as fresh fruit, vegetables, bran and wholemeal breads, and drink plenty of water. Place your feet on a stool when sitting on the toilet. This should make bowel movements easier and less painful. It is advisable to avoid straining when emptying your bladder or bowels, as this could possibly stretch the nerve. 

hysiotherapy treatments aim to relax and/or stretch the often overcontracted pelvic floor muscles and thus decrease the pressure on the nerve.

TENS (Trans-epithelial Nerve Stimulation), the so-called ‘tingly machine’ may also help relieve pain. It is important to ask the physiotherapist for guidance in correctly placing the electrodes, which are taped to the bare skin.

Medical management of pudendal neuralgia involves the same medications as for any other chronic pain condition. In addition, direct application of creams and ointments provide an alternative with fewer side effects than oral medications. The most commonly prescribed topical treatment involves the drug amitriptyline. This is a low-dose antidepressant, although you do not have to be depressed to gain benefit from the use of this drug.

When the pain is acute, for instance within a few weeks or months after childbirth, acupuncture can be a great alternative to traditional medical management.

DISCLAIMER: This information is intended to be used as a guide of general nature, having regard to general circumstances. The information presented should not be relied on as a substitute for medical advice, independent judgement or proper assessment by a doctor, with consideration of the particular circumstances of each case and individual needs. This information reflects information available at the time of its preparation, but its currency should be determined having regard to other available information. RANZCOG disclaims all liability to users of the information provided.