Pudendal Neuralgia

What is Pudendal Neuralgia?

Pudendal neuralgia is persistent pain related to the pudendal nerve. Your pudendal nerve runs from your lower back, along your pelvic floor muscles, out to the skin between your pubic bone and your tailbone  (perineum).

It signals when the skin between the anus and the clitoris (or penis) is touched, and contracts the muscles of the urethra and the anus (see light green area below) and some of the pelvic floor muscles.

The nerves throughout our bodies are supple and stretchy. They slide smoothly when we go about our everyday lives. Think about how far the nerves in your arms stretch when you reach above your head. We can also gently squash them for a while before they let us know, like the ‘dead arm’ feeling of pins and needles. They usually recover fairly quickly, too.

Nerve pain can occur with an actual injury (like a big fall onto a hard surface or a long, difficult labour) or a potential injury – eg. our brain registers the possibility of injury/ danger with lots of repetitive small insults (like years of straining with constipation or repetitive heavy physical exercise) they can become more sensitive. Your nervous system can become sensitised so that pain is triggered at a lower level, and the response is greater. It’s as though the volume is turned up for pain.

Pudendal nerve pain can be triggered when your pudendal nerve is exposed to injury, the nerve is irritated, or lightly compressed by bulky pelvic floor muscles or tight ligaments.

Symptoms of pudendal neuralgia

The main symptom of this problem is pain. This can be highly variable. You might feel burning, electric shock, shooting, aching, itch or a raw feeling in your clitoris, labia, vagina (penis in men), urethra, perineum, anus or rectum. You might find it difficult to sit because of your pain.

You may also experience bladder and bowel irritation. Sometimes you can feel this irritation without feeling much pain. You may to urinate frequently, especially during the night. Occasionally there is a full sensation in vagina or rectum.

Sometimes pain can be felt into the buttocks, legs and feet. This is because the skin there is supplied by the same level of your spinal cord and your brain ‘perceives’ the pain in the skin of your buttocks, legs and feet.

 You may also have associated bladder, bowel or sexual problems.

What causes pudendal neuralgia?

There is usually no one cause of pudendal neuralgia. It is often due to a combination of different factors, over many years. A big life stressor may be associated with a worsening or triggering of the pain. Life factors may include:

Sometimes there is no obvious link to any specific factor, but there are always options for treatment.

We’ll conduct examinations and tests to work out whether you have pudendal neuralgia. None of these tests on its own is a diagnosis, as pudendal neuralgia is mainly a ‘clinical diagnosis’ as nerve pain can not be ‘seen’ on any test. Your doctor will ask about your medical, social and trauma history. The information from your physical examination and tests are discussed with you and we come to a diagnosis – the likely reason for your symptoms. Then, we discuss the best treatment plan with you for your recovery.

Physical examination

When you first come in, you’ll have an initial physical examination with one of our doctors and an allied health professional. We’ll look at the neurological and musculoskeletal functions of your whole body including pelvis and perineum by checking your muscles, joints, posture and reflexes. 

Pudendal nerve block

One of the next steps we might recommend is a pudendal nerve block. Under X-ray or ultrasound, your doctor will inject a local anaesthetic into the canal the nerve travels through. You should go temporarily numb – if your pain is eliminated or significantly reduced, it indicates that the pudendal nerve is an important element in your pain syndrome. Click on Health Information (in the green section at the very bottom of this page) for a downloadable sheet with full details about this procedure. You will also need to fill in the form to measure your pain before and after the nerve block and bring with you to your next appointment. You can download and print a Health Information sheet and the pudendal nerve block form from our Health Information section.

Pudendal nerve MRI

Another test your doctor might suggest is a pudendal nerve MRI. We’ll refer you to Dr Toos Sach, an expert in the interpretation of MRI images of the pudendal nerve. The MRI can provide information about the anatomic structures surrounding the nerve. It is important to note that you can have pudendal nerve pain and a perfectly normal MRI; conversely, it is also possible to have nerve ‘compression’ on MRI and no pain –  and seen on cadaver studies. We will always listen to your clinical symptoms and put the whole story together.

Sonography of the sacroiliac joint and ligaments

Depending on what we found in your initial evaluation, we may suggest sonography (ultrasound) of the sacroiliac skeletal structures at the bottom of your spine. These structures are put under stress during pregnancy, a fall onto the buttocks, and intense sporting activities – so depending on your situation, it might be important to check them.

Sonography of the pelvic floor muscles

Your doctor may recommend an ultrasound of your pelvic floor muscles. This test gives us information about the muscles around the vagina, the floor of your pelvis and the adductors of your leg – the muscle that brings your knee inwards to cross your legs.

Management of pudendal neuralgia

Pudendal neuralgia, like any pain condition, is managed through adapting your everyday life. Understanding your pain is one of the first steps on the path to recovery. We’ll suggest adjustments to your work and home life, and your leisure activities. Your doctor might also suggest medical interventions.

The crucial element in the process is that you are the driver of your management plan. Your physical, work, home and social goals are the main focus. We help you work towards them. We use the Explain Pain resources and the Peripheral Nerve videos to explain how nerve pain can change and how you can help this process. 

Remember there was a time when your pudendal nerve was much happier? With tailored management, we will help you regain that as much as possible, as everyone’s nervous system is capable of change, everyday. 

Conservative Management

Depending on the factors involved in your pudendal neuralgia, your management plan might involve several different specialists, as well as your own self-management.

The aim is to reduce the irritability of your pudendal nerve. As with any nerve irritability in the body, the nerve needs time to settle, even after you’ve made changes in your lifestyle.

Many people find that understanding what triggers their nerve pain and knowing how to modify their life around it makes it much easier to manage. With the right knowledge and tools, you can reduce your pain significantly and live a full and functional life.

Common lifestyle changes include:

• Bowel and bladder management strategies: Try not to strain when emptying your bowels or passing urine, as this can trigger pain. Avoid stimulant laxatives (eg. senna). Physiotherapy can help you develop a plan for good bladder and bowel habits that suit you.
• Sitting modification: A split cushion reduces contact with the skin that is supplied by the pudendal nerve – this helps reduce the input via the pudendal nerve – like a ‘holiday’ while the senstivity reduces.  Loose clothing and underwear can also help. You can buy special coccyx-cut-out memory foam cushions and modify them to remove the section from your pubic bone to coccyx. Decreasing your sitting time can also help – try standing at your desk for part of the day using a laptop on a box or a portable desk raiser.
• Reducing physical activities that irritate the nerve: The biggest ones are spending hours on a pushbike and horse-riding. Other activities to minimise are trampoline jumping, bench pressing and excessive ‘core muscle’ exercises. Osteopathy and physiotherapy can help you identify movements specific to you that may need to be minimised or modified for a period of time.
• Adapting your sex life: Some people find sex can flare their pain. There are many options to keep your sex life going while avoiding pain. Your clinician can help you with this.
• For more information on what you can do and how this affects your nervous system to help reduce your pain, see the poster below

Physiotherapy

A physiotherapist can teach you how to relax and/ or stretch your pelvic floor muscles, which might be over-contracted. This can help to decrease the irritation of the nerve.

You may also need to manage painful trigger points in your pelvic floor muscles. Your physiotherapist might recommend using TENS (trans-cutaneous electrical nerve stimulation) – the so-called ‘tingly machine’ – to help relieve your pain. You can use this machine for effective self-management – but ask the physiotherapist to help you place the electrodes correctly.

You may also benefit from specific external exercises and stretches and you may need to address your posture and activities that may flare your pain. Your physiotherapist will also encourage you in general cardio exercise to maintain your fitness and strength, both mental and physical.

A physiotherapist can also help you plan your daily bladder and bowel management routine.

Osteopathy

Seeing an osteopath may help you to reduce the sensitivity of your pudendal nerve, via relaxing the ligaments, muscles and soft tissues of the pelvis and lower back to get you moving without pain.

The ligaments of the sacroiliac joints in the bottom of your spine are continuous with the ligaments that the pudendal nerve travels through. Tension at these joints may contribute to irritation of the pudendal nerve. Some of the muscles in your hips and buttocks can also irritate the nerve.

Osteopathy may help you to alleviate these pressures and tensions. Your osteopath will help you make changes to simple things like how smoothly you walk to reduce the sensitivity of the nervous system, improve the natural movement of the nervous system as you walk and reduce the pain from muscles tightening in response to nerve pain.

Psychology & Hypnotherapy

Having good mental health is extremely important in coping with chronic pain, especially perineal pain, which involves three vital functions – urinary, intestinal and sexual function, as well as enjoying sitting down.

You might want to try cognitive behaviour therapy, meditation, or mindfulness and relaxation exercises. Self-hypnosis has also become a well researched and important option for dealing with pelvic and perineal pain. WHRIA’s psychologist Tanya Wollstein offers this service via Telehealth, phone or in-person consultation.

WHRIA offers regular Visualisation for Relaxation evenings with Leititia Colautti, to help you practice relaxation for pain relief as well as meet others in a similar situation. Contact us at support@whria.com.au to register for the next visualisation evening. Read more about Psychology & Hypnotherapy available at WHRIA in ‘ Our Services’ section of our website, or ask your doctor for advice.

Acupuncture

If you have recently developed symptoms – such as ongoing pain in the perineal area within a few months of a difficult birth – acupuncture can be a great alternative to traditional medical management and may mean you can avoid medication. Within the first one year is ideal, however you may still benefit from acupuncture at any time.

If you have experienced significant side effects from the commonly prescribed medications for pudendal neuralgia, a traditional Chinese medicine approach is also a viable option. Our team can suggest an acupuncturist near you.

Medication

Daily medication – like topical creams and oral medications – may help calm your nervous system. Human nervous tissue is very sensitive. If you have had pain for a while, it is normal for the nervous system to become more sensitive, and cause your pain to flare with seemingly small activities or stresses. But this sensitivity can change. Your doctor may prescribe you medication to help you to manage your pain, with fewer flare-ups. For more information about medicines see the NPS MedicineWise website. We now know that long term opioid use can increase the sensitivity of the nervous system, and is not ideal for long-term use.

Support & Yoga for Pelvic Pain

As one of the world’s leading specialty centers for the holistic care of pudendal neuralgia, we can connect you with others with pudendal neuralgia.

Click here to see a list of our education evening talks to help keep our out of town members in touch. Topics focus on self-management techniques and new advances in pain management in relation to pudendal neuralgia, such as understanding persistent pain and discussing advances in neuromodulation.

Join our mailing list below for newsletters and more details.

Interventional management options

You can find out more about interventional treatment options, such as surgery and injections, by downloading our Health Information sheets (click on this link):

• Cortisone injections: near a nerve, into a joint, tendon or tender point where inflammation is present
• Hyaluronic acid injections near the nerve to help with healing (often added to the diagnostic pudendal nerve block injection)
• Botox / Botulinum toxin Type A injections: for overly tight muscles
• Activated platelet extract injections (PRP platelet-rich plasma): to activate healing
• Pulsed radio-frequency treatment of the pudendal nerve, sacral nerve roots or sacroiliac joints: for pain modulation
• Pudendal nerve release surgery
• Neuro-modulation with implantable electrodes

Further information

If you’d like more information you can view our Health Information page.