The challenge of treating pudendal neuralgia comes from the difficulty of recognizing it. It’s common for male patients to consult with multiple doctors only to be (potentially mis) diagnosed with a with a prostate problem. Currently there is no definitive “gold-standard” imaging or other kind of diagnostic tests for pudendal neuralgia in women or men other than assessment of trigger points and muscle restrictions around the nerve itself. Symptoms are the only clue we have. If a case is secondary to actual pudendal nerve entrapment, then many physicians will rely on the Nantes criteria to decide if the nerve is entrapped.
We will cover
- pharmaceutical treatments
- physical therapy and pelvic floor rehab
- and discuss a case of resolved pudendal pain using chiropractic care
The focus will be largely on the male patient’s experience.
See our article in this series: What is pudendal neurgalgia? Is that the same as pelvic floor pain (in men)?
Is it just pelvic floor pain? Is it pelvic floor pain due to the pudendal nerve? And is the nerve actually entrapped?
As we saw in our previous article, the terms pudendal neuralgia and pelvic floor pain are often used synonymously in men. However, the situation is about to get more complicated as pudendal neuralgia and pudendal nerve entrapment also can be used synonymously – even though they are not identical.
In short, if you have pudendal nerve entrapment you will have pudendal neuralgia (pudendal nerve pain). If you have pudendal neuralgia you will experience pelvic floor pain. But if you have pudendal neuralgia, it doesn’t necessarily mean that the pudendal nerve is trapped. And if you have pelvic floor pain, it doesn’t mean that the pain is directly related to a nerve inflammation of the pudendal nerve.
(For a similar situation, we can look to the hand and inflammation of the medial nerve. Carpal Tunnel Syndrome or chronic inflammation of the median nerve near the wrist will cause hand pain. But not all hand pain is caused by Carpal Tunnel Syndrome. Sometimes health care providers will speak of hand pain, Carpal Tunnel, and median nerve entrapment/neuralgia as if they were all the same, when sometimes they aren’t.Pudendal issues and pelvic floor issues are similarly confused.)
What entraps the pudendal nerve?
In a case of actual inflammation to the pudendal nerve, what causes the inflammation?
There are different underlying causes for this neuropathy. It could be due to local nerve irritation, vascular compression (swollen veins or arterial beds), pelvic floor muscle spasms, or other musculoskeletal problems (pelvic distortion).
For a more comprehensive discussion of causes of pelvic floor pain, read here.
French researchers Roger Robert and colleagues developed the Nantes Criteria for diagnosing pudendal nerve entrapment in men. The inclusion criteria are as follows:
- Pain in the distribution of the pudendal nerve (from the anus to the penis)
- Pain is relieved by pudendal block
- Pain does not arouse the patient from sleep
- There is no objective sensory impairment
- Pain is often experienced while sitting
Simply put, if your pelvic floor pain follows the route of the pudendal nerve, and it matches the above description, then it will most likely be diagnosed as a pudendal nerve entrapment.
Surgical decompression may be the treatment of choice for an actual pudendal nerve entrapment, but it is better to opt for a conservative approach for the initial treatment. It’s my opinion that surgery should only be considered if all treatment strategies have failed to provide significant relief.
Current treatments for pudendal neuralgia pain
Activity avoidance
If your condition is caused by repetitive trauma to the pudendal nerve (cycling, gymnastics, climbing, or any forms of exercise) avoidance of these painful activities will be the most common medical strategy to relieve pudendal neuralgia symptoms.
Some patients who stop these activities may experience improvement without further intervention. However, the symptoms may return once activity resumes without addressing any structural problems.
A chiropractic, physical therapy, or manual therapy approach may suggest that you stop these activities temporarily until the structural problem is actually addressed.
Pharmaceutical solutions for pudendal neuralgia
Medications – muscle relaxants are the first line pharmacologic treatment for pudendal neuralgia. Anticonvulsants (Lyrica Gabepentin) and analgesics are also considered beneficial. Vaginal or rectal suppositories are considered more effective than oral pain meds. Zanaflex (tizanidine hydrochloride) is a popular prescription for this kind if of pain. Like many chronic pain syndromes, I have personally met pelvic floor pain patients who were also prescribed anti-depressants.
Botulinum toxin (Botox) injection – may be administered to patients with significant muscle spasm. It aids in muscle relaxation and helps differentiate between pain caused by nerve injury or pain caused by muscle spasm and pudendal nerve injury.
Pudendal block – or CT-guided injections of the nerve is typically used to diagnose pudendal nerve entrapment but it can also provide therapeutic benefits. A second and third injection can be performed to administer more steroid and anesthetic into the Alcock canal in patients who responded to the first injection. (The Alcock canal is a major passageway of the pudendal nerve.)
Internal manual therapies (pelvic floor physical therapy)
Pelvic floor physical therapy has been found to be beneficial for patients with pelvic floor pain, including pudendal neuralgia. The therapist will elicit relaxation of the pelvic floor muscles while addressing spasms, connective tissue problems, and other dysfunctions. Digital (manual) release of musculature (trigger points) of the pelvic floor is accomplished through the rectal or vaginal wall in women, and the rectal wall in men. Here the differing anatomy of men and women obviously allow some approaches for women that are not available to men.
The patient will also be guided in certain muscle contractions and relaxation techniques that will aim to bring internal balance to the muscles.
Other uses of rehabilitation that are pelvis related
Pelvic floor physical therapy has applications outside of pudendal neuralgia and pelvic floor pain. Pelvic and abdominal rehabilitation are a specific discipline within the physical therapy profession that treat women with specific problems such as bowel and bladder incontinence, chronic pain due to surgery adhesions, support in the case of prolapse of the organs of the pelvis, and diastasis recti, which is the spreading apart of the abdominal muscles, typically after pregnancy.
Chiropractic care, pelvic floor pain, and other pelvic floor symptoms
Chiropractic and physical therapy licensures vary by state, and the kinds of procedures each profession can perform has some variety. In some states chiropractors are licensed to manipulate tissue within a body cavity, and in those states chiropractors may perform some kinds of pelvic floor rehabilitation as described above.
That said, most help for pelvic floor pain, pudendal pain, pudendal neuralgia, or even an potential pudendal nerve entrapment will come from working with the spine and pelvis outside of the body.
Most chiropractors will likely work directly with the pelvis and lower spine when addressing an issue of the pelvic floor. The problems can include:
- rotation and/or unleveling of the illia
- fixation or weakness of the sacroilliac joint
- loss of motion at the sacrococcyx joint
- calming chronic illiopsoas spasm
The nerve roots that make up the nerve plexus of the lower pelvis also travel through the lumbar spine, so rotational malposition and locking of the lumbar vertebrae (chiropractic subluxation) and chronic spasm in the surrounding tissues may also contribute to pelvic floor pain.
Structural chiropractors who look at the spine as an integrated whole may decide to focus exclusively on, or also include the patient’s neck (cervical spine). This concept will be explored in the next article on the body’s three dimensional tension system and the suffering pelvic floor.
Can chiropractors help with pelvic floor pain?
Yes. I have personally seen improvement in pelvic floor cases in my practice. (Like this one for example.) We will look at my perspective on the pelvic floor in another article. For now, let’s look to the following case study, published by Parker College of Chiropractic, which has one of the best descriptions of pelvic floor pain and its difficulties in a male patient.
A 24-year-old male sought chiropractic care for persistent left-sided medial gluteal [butt] pain and associated proximal thigh and genital paresthesia. This began after a period of intensive physical activity, specifically squatting, and had lasted for greater than 3 years.
At rest, he described his left-sided gluteal pain as dull. He rated the pain at 3/10 on the Visual Analogue Scale (VAS). He described frequency as continuous with an occurrence 80%- 100% of the time.
The report states that the following made his symptoms worse (pain and paresthesia in the back of his medial thigh):
- straining/lifting,
- ejaculation,
- bowel movements,
- and sustained sitting.
He was unresponsive to the following treatments:
- antibiotics
- conventional physical therapy,
- pelvic floor therapy,
- and activity modification.
The report also states:
He reported regular use of a donut pillow and heating modalities for relief. Physical activity had been limited due to increased symptoms mirroring activity levels. He denied use of current medication, past medical and surgical histories.
How did the patient with pudendal neuralgia respond to care?
He was treated conservatively 2x/week for the first 2 weeks, and 1x/week for the next 3 weeks for a total treatment period of 5 weeks and 7 visits.
Initial treatment consisted of myofascial therapy [trigger point release of the muscle] to the left obturator internus and surrounding musculature and spinal manipulative therapy [chiropractic adjustments] of the lumbopelvic [low back] region.
Incorporation of nerve flossing techniques were provided at the third visit and cupping was added on the fifth date of service.
After the initial visit, he reported exacerbation of buttock, penile, and proximal medial thigh pain for a period of 3 days. After 4 days, his symptoms began to improve over the course of the week.
What’s important to note about this is that that the patient’s response to initial care was a temporary worsening of symptoms. This is a classic response to a true healing experience, and isn’t necessarily indicating that the treatment is not working. Unfortunately some patients will feel this worsening and will quit care before being helped.
Once over this initial worsening of symptoms, he begins to respond with quick improvement.
The report continues:
At the second visit, he further indicated that there were times in which he even felt as if he were normal again. There was diminished irritation with sitting and physical straining.
Over the next 3 weeks, myofascial therapy continued, in addition to incorporation of cupping of the posterior gluteal musculature over the ischial tuberosity and into the proximal hamstring.
He was encouraged to engage in physical activity over this time period.
Upon the final visit, he reported experiencing no pain or paresthesia at rest or with activity. He reported continued mild symptoms into his penis but now associated only with bowel movements.
He continued crossfriction massage over the obturator internus location mirroring myofascial release procedures, which he reported provided prophylactic relief. He was discharged at this time.
A follow-up conversation 1.5 months later revealed he had completely resolved all symptoms at rest and during straining. He reported a full restoration of function without pain or paresthesia.
My personal approach to pelvic floor pain
The combination of pelvic floor rehabilitation and physical therapy, combined with chiropractic work that seeks to balance the tension of the spine in the lumbar and pelvic area, is my personal recommendation for most men and women seeking helping with a non-emergency pelvic floor issue, including pudendal neuralgia.
I believe this approach is sound and helpful for cases other than pudendal neuralgia or pain, including bladder and bowel incontinence issues due to effect that chiropractic work can have on vagal tone which can influence the sphincters in the pelvis.
In our next article we will go over the concept of the suffering pelvic floor, and how it can be released and move towards correction with structural chiropractic care.
Gaspari, A., Sileri, P., & Toma, G. D. (2016). Pelvic floor disorders: Surgical approach. Milan: Springer.
Hibner, M. (2019, January 02). Pudendal Neuralgia. Retrieved from https://www.mdedge.com/obgyn/article/52441/pudendal-neuralgia/page/0/3
Valovska, A. T. (2016). Pelvic Pain Management. New York: Oxford University Press.
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