Without doubt, one of the least talked about pain is pudendal nerve pain.

Pudendal nerve defined: Pudendal nerve pain results from injury or irritation to the pudendal nerve, which originates from the sacral plexus and innervates the pelvic region, affecting bowel and bladder control as well as genital sensation.

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Symptoms: The condition manifests as burning, aching, or shock-like discomfort in areas such as the perineum, genitals, or rectum. It may also lead to urinary issues, constipation, and sexual dysfunction, including numbness and pain during intercourse.

Common causes: Pudendal nerve pain can arise from activities or conditions that exert pressure, trauma, or swelling in the pelvic area. Common causes include prolonged cycling, childbirth, pelvic surgeries, and accidents leading to pelvic fractures.

Treatment Options: Management strategies range from conservative approaches like physical therapy and lifestyle modifications to pharmaceutical interventions, including medications such as gabapentin and pregabalin. In certain cases, surgical decompression may be considered when other treatments have not provided relief.

This short guide for pudendal neuralgia includes a discussion of the role of chiropractic care, and the potential relationship between the neck and the pelvic floor.

(Read one man’s experienced with pudendal nerve pain in our upper cervical office.)

There is an expanded version of this guide found in the following articles:

• What is pudendal neuralgia? Is it the same thing as pelvic floor pain in men?
• What are my treatment options for pelvic floor pain from pudendal neuralgia or pudendal nerve entrapment?

Pudendal Nerve Pain defined

Pudendal nerve pain is caused by injury to the pudendal nerve, which is located in the pelvic area. This condition has varied symptoms and has several causes, and can happen in both women and men. It’s sometimes called pudendal neuralgia. Neuralgia meaning “nerve inflammation and pain.”

Depending on the cause, treatment for pudendal nerve pain can range from conservative measures to surgery. We will get into what that means in the treatment section below.

What is Pudendal Nerve Pain?

Pudendal nerve pain is the term for discomfort or pain caused by issues in the pudendal nerve. The pudendal nerve is a branch off of the bottom of your nerve system called the sacral plexus.

The pelvic region has two branches of the pudendal nerve. They control muscles responsible for bowel movement and urination, and sensation in the genitals and perineum. The two, smaller branches have other names. To keep it simple let’s just call it all pudendal.

The perineum is the region between the base of genitalia and the opening of the anus.

Most women who have been pregnant and given birth will be very familiar with the perineum. But many men will not, unless they have this sort of pain. Or they have ever ridden a bicycle or motorcycle long distance.

Any kind of compression, swelling or trauma to the pudendal nerve can elicit pain. Sometimes this can be called pudendal nerve entrapment. And it happens when the nerve is compressed by adjacent structures.

(This video discusses the successful resolution of pelvic floor pain in three different male patients.)

What are the symptoms of pudendal nerve pain?

Pudendal nerve pain originates from the nerve itself. Thus, it can cause different pain sensations, ranging from burning, deep ache to electrical shock-like discomfort. The area may also be highly sensitive to pressure or have pronounced prolonged response to pain.

These symptoms may occur spontaneously or after doing things like sitting or straining.

Pudendal nerve pain is often embarrassing. And not just for its location, but what the nerve inflammation can do to the body’s other functions, related to sex, urination, and bowel movements.

Pudendal nerve pain can often go together with by urination problems, like hesitancy, frequency and urgency. It can also cause constipation and painful bowel movements.

Because the pudendal nerve is responsible for sensation in the genitals, there may be numbness in the penis or vagina, and men may experience problems achieving erection and ejaculation.

Sometimes the electrical shock-like sensations can also strike the genitals, leading to a odd and painful sensations, especially during sex.

What is believed to cause pudendal nerve issues?

Conditions that cause pressure, trauma or swelling in the pelvic area can cause symptoms of pudendal nerve pain. This explains why pudendal nerve pain is common among cyclists and pregnant women.

Among cyclists, crotch pain associated with riding bicycles is actually a symptom of pudendal nerve pain. Accidents that cause trauma to the pelvic region also causes pudendal nerve pain, like a pelvic fracture for example.

Pudendal nerve pain can also be caused by surgery in the pelvic area. Sometimes, surgical operation cause swelling, or rarely, unintended trauma to the pudendal nerve and cause symptoms.

Diagnosis is complex

Diagnosis can be a bit tricky with this form of nerve pain because there are several conditions that have similar symptoms.

Identification of muscle, nerve, and spine problems are complex by nature. And many physicians don’t have enough training to identify the issue with confidence. Specialists rely on imaging which can be helpful in some situations, but can also create frustration because they

• May identify a “problem” that isn’t causing the pain – leading to a disease chase that doesn’t actually help the patient get what he or she wants
• May be “medically normal” – which gives the patient the impression there is nothing wrong when the doctor isn’t actually looking for a mechanical problem

Any condition that happens in the pelvis often has multiple symptoms that overlap with other conditions. Because the pelvis is large and has a range of different organs and tissue, many people with pudendal nerve pain even struggle to get a name for what they are experiencing.

Usually if no other culprit can be found for the pain, then pudendal nerve pain may be the diagnosis.

As in, you have a pelvic pain that doesn’t go away? Pudendal nerve pain.

Occasionally this form of pain in females will be diagnosed as a vulvodynia – or pain of the female genitals – again, often without a real cause identified.

In some cases a true source of pelvic pain may never be found unless the patient has surgery.

Lifestyle modifications

All conservative treatments are going to attempt to relieve the mechanical pressure on the pudendal nerve. For most that will start with lifestyle modifications.

So for some instances of pudendal pain, it’s just a temporary inconvenience that’s resolved by purchasing a new bicycle saddle, or waiting until the pregnancy is over.

Other doctors may advise using ergonomic devices like specialized bike saddles, and avoiding prolonged periods of sitting, especially on the toilet.

Avoiding straining when urinating or opening the bowels can help reduce exacerbation of symptoms – so supplements or over the counter approaches to making bowel movements easier may be recommended.

Pharmaceutical choices and pudendal nerve pain

Depending on the cause, the doctor may prescribe medicines to address pudendal nerve pain such as gabapentin and pregabalin.

Antidepressants like amitriptyline and anticonvulsants such as carbamazepine and sodium valproate also work to relieve nerve pain. If pudendal nerve pain is caused by pressure, the doctor may inject steroids in an attempt relieve inflammation.

Surgery is considered the last option for pudendal nerve pain because it requires general anesthesia and may not always produce intended results. Especially if the source of the pudendal nerve compression is never identified before the surgery.

Some people just have an aversion to taking medications long term, or doing exploratory surgery, so they may want to consider some other kinds of care.

The other conservative options in resolving pudendal nerve pain

The following options are based on the idea that a lot of nerve pain has a mechanical cause. Taking medications without addressing the mechanical cause is an exercise in futility for many patients.

If fixing mechanical problems in the pelvis can lead to less sciatica pain, for example, then why not pudendal pain? True, it’s a smaller nerve in a different location, but the principle still applies.

Chiropractic and upper cervical care

Chiropractic care aims to relieve the mechanical distortion created by misalignment in the spinal column, including misalignment of the pelvis.

There are several known and trusted chiropractic approaches to examining the pelvis that can be helpful in pudendal nerve pain and other pains of the hips and pelvis.

I recommend chiropractors who actually take an x-ray of the pelvis and draw lines on what they are seeing. Indiscriminate manual manipulation of the pelvis may not be helpful for tough cases of sciatica and pudendal nerve pain.

Chiropractic corrections of pelvic imbalance can take pressure off the nerve roots of the sacral plexus – allowing relief to flow further down the chain into the pudendal nerve.

That said, there is a fact of physiology that must be addressed in many cases. Some pelvic problems may not resolve without correcting the unhealthy alignment of the neck. It is counter-intuitive, but the short reason is that posture control centers are in the neck, and the pelvis may never full relax and take pressure off the pudendal nerve until the neck is corrected.

(If you need to see “proof” of the relationship between your neck and your pelvis, then please take a look at these articles:

• Sciatica resolved through correction of the neck
• Resolution of stomach pain and headaches through correction of the neck

I find that upper cervical chiropractors who have significant post graduate education in one of the several upper cervical techniques are the best place to get upper cervical corrections.

Physical therapy and rehabilitation of the pelvic floor muscles

The kind of physical therapy that is focused on strengthening muscles may not be helpful in the first phase of addressing pudendal nerve pain. Strengthening your core is great for the long term but not necessarily helpful in freeing a trapped pudendal nerve.

Instead, seek a physical therapist who has advanced training and certification in pelvic floor rehabilitation and release. In other words, you will be getting more muscle trigger point work and less exercise therapy, or a different kind of exercise rehabilitation depending on if the muscles of the pelvis floor are more or less tight.

Most of the people practicing physical therapy this way are physical therapists, but some chiropractors practice this way as well, depending on regulations in their state.

Keep in mind that this form of rehabilitation often requires muscular release of muscles at the bottom of the pelvis using the practitioners fingers. Sometimes this requires the practitioner to access the muscle by pressing through the the wall of the vagina or the rectum. (Chiropractors in Michigan cannot perform these procedures, but physical therapists can.)

In other words, it’s not surgery but it can feel invasive for some. So, ask for someone with advanced training in the pelvic floor if you are going to seek physical therapy. As that practitioner will be able to do the necessary internal work through the vagina walls or through the rectum with less discomfort.

Other forms of body work

Some other forms of body work may also unlock the pelvis in a way that helps or relieves pudendal nerve pain, including cranial sacral therapy.

Most license body workers (like licensed massage therapists, or physical therapy assistants) will not have a clearance that allows them to release the muscles internally – so if that is necessary – you may have to pair therapeutic massage with pelvic floor physical therapy.

How would I do it as an upper cervical chiropractor?

I am an upper cervical chiropractor who has seen major improvement in pelvic nerve issues, including sciatica and pudendal nerve pain. Through correcting the neck alone. Even in patients who did not respond to regular chiropractic care, physical therapy, and massage…So my experience come from what I know.

If I was facing pudendal nerve pain, here is how I would handle it.

• Get the neck corrected from an upper cervical chiropractor to allow the pelvis to relax, and take mechanical stress of the nerve system
• Clean up any issues in the pelvis with pelvic chiropractic adjustments and do internal and external muscle rehabilitation with physical therapy
• Support long term musculature on the outside with therapeutic massage and cranial sacral work from a body worker

Finally, keep in mind any pain and problems related to the digestive tract and sexual organs can and will have an emotional component as well and complete healing may not be possible without a process that takes into account feelings of fear, safety, sexuality, and violations around these issues.

If you’re in the Detroit-Metro area and you want a second opinion on the structural issues that may lead to pudendal nerve pain, then please contact me via this website to set up a 15 minute conversation about your concerns.

Reference:

Leslie SW, Antolak S, Feloney MP, et al. Pudendal Neuralgia. [Updated 2024 Feb 12]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK562246/