Pudendal nerve pain (or pudendal neuralgia) is a painful condition of the pelvic floor that both men and women may experience. The focus of this article series will be focused on the symptoms and treatment of pelvic floor pain primarily in men.
What is pudendal nerve pain?
Some doctors and therapists may use pudendal neuralgia and pelvic floor pain interchangably, particularly when dealing with male anatomy. In technical terms it could be said that pudendal neuralgia will involve pelvic floor pain, but not all pelvic floor pain is necessarily inflammation of the pudendal nerve.
For example, inflammation of the prostate gland in males can result in pelvic floor pain without necessarily involving the pudendal nerve. The prostate gland and the bladder will be the first places that doctors look when a male complains of pain in the pelvic floor. Only after a problem in the bladder or prostate are ruled out will the problem be considered one of possible musculoskeletal origin.
So it is very possible to have a diagnosis of pelvic floor pain, without having a diagnosis of pudendal neuralgia. And there are pros and cons to this situation. An official diagnosis of pudendal neuralgia may be helpful for focusing medical treatment. However, like many chronic pain syndromes, there is no gold standard test for pudendal neuralgia that offers a definitive diagnosis. Sometimes receiving a pudendal neuralgia diagnosis deters some patients from seeking alternative treatment options for their pelvic floor pain that may be necessary for a full or partial resolution of pain.
What about pelvic floor pain and pudendal nerve pain in women versus men?
Due to the fact that a female pelvis has much of its genitalia inside of the pelvic area, and the female genitourinary system is more complicated in general, the average female case of pelvic floor pain may be seen as more complicated than the male pelvis.
Female pelvic floor pain may be less likely to be diagnosed as pudendal neuralgia because of this.
This article and the following articles will largely focus on the experience of pudedal nerve pain or pelvic floor pain in men. I personally have have had far more men in my practice with pelvic floor pain than women even though pelvic floor pain and pelvic issues are very common in women.
What does pudendal neuralgia feel like?
Pudendal neuralgia is a characterized by severe, sharp, or shooting pain along the course of the pudendal nerve or its branches—from the muscles of the buttocks and into the perineum (the pelvic region that touches the seat of a bicycle)—which is made worse with sitting. In males, the perineal pain extends from the anus to the penis. This condition is also known as:
- Pudendal nerve neuropathy
- Pudendal canal syndrome
- Pudendal nerve entrapment
- Alcock canal syndrome
Pudendal neuralgia has been poorly defined for a long time and is often misdiagnosed as prostatitis or inflammation of the prostate gland. It was first described in 1882 by British obstetrician Dr. Edward John Tilt and was later called “the cyclist syndrome” by French psychiatrist Gerard Amarenco in 1987 due to its prevalence among competitive cyclists.
In general, the term refers to a chronic pain secondary to pudendal nerve injury (i.e. entrapment or compression). If there’s no obvious injury to the pudendal nerve, it is referred to as pudendal pain syndrome.
It’s estimated that only 1 out of 100,000 have pudendal neuralgia, although many clinicians believe that the condition is much more common.
It is difficult to distinguish pudendal neuralgia from other chronic pain at the base of the penis/anus region without a thorough understanding of the anatomy and physiology of the pelvic floor region. And even with this proper understanding, it is still difficult to distinguish pain in the organs of the genitourinary system (prostate and bladder in men) from an actual irritation to the pudendal nerve or musculature of the pelvic floor.
This is why some doctors are reluctant to blame pelvic floor pain on a direct irritation to the pudendal nerve, or simply speak of pelvic floor pain and pudendal neuralgia syndrome interchangeably, especially in men.
What are the symptoms of Pudendal Neuralgia
Just like chronic prostatitis (inflammation of the prostate), pelvic pain is the main symptom of pudendal neuralgia and has the following characteristics:
- The pain is in the penis, perineum, scrotum, and anorectal region
- The pain is exacerbated by sitting
- The pain is relieved by standing, lying down, and sitting on the toilet seat
- The pain tends to worsen over the course of the day
- The pain may be unilateral (predominant one sided) or bilateral pain (both sides)
- There is pain with bowel movements
Other symptoms may include:
- Foreign body sensation in the anus or rectum (sympathalgia)
- Exaggerated pain from non-painful stimuli (allodynia or hyperpathia)
- Gnawing, crawling, or prickling sensations
- Erectile dysfunction
- Frequent urination
- Pain after ejaculation
When the pain:
- Mostly resides in the region of the perineum and does not extend into the scrotum or penis
- And occurs with few of the secondary symptoms
Then a generic diagnosis of pelvic floor pain and not pudendal neuralgia may be more likely.
What are the causes of pudendal neuralgia?
There is no single definitive cause of pudendal neuralgia. It is often seen a combination of a few different factors.
- Pelvic trauma (heavy lifting, fall on the pelvis)
- Previous pelvic surgery
- Frequent straining due to constipation
- Excessive exercise (routine cycling)
- Musculoskeletal problems
- Orthopedic fractures
While the exact cause of pudendal neuralgia is not always clear, the patient’s history may reveal what has brought the problem to the surface. The usual cause is repetitive microtrauma to the saddle area of the pelvis. Prolonged sitting or cycling, straining with constipation, and certain fitness exercises, such as squats, kickboxing, and weight lifting can stretch or compress the pudendal nerve and lead to neuropathy.
The connection between pudendal neuralgia and the autonomic nervous system
Patients suffering from pudendal neuralgia or pudendal nerve entrapment may also experience disturbing secondary symptoms when the pain spikes. These symptoms include an increased heart rate, sweating, anxiety, and a sudden rise in blood pressure. This is due to the autonomic fibers of the pudendal nerve that innervate structures that are beyond our voluntary control. Painful stimulation to the pudendal nerve will also activate the autonomic nervous system causing these symptoms.
Global body posture and the suffering of the pelvic floor
Many ongoing chronic pain syndromes in the body’s musculoskeletal system are from lasting distortions to the body’s frame from memorable traumas (like car accidents), and repetitive daily trauma.
While direct compression or stretch to the pudendal nerve is possible, it is more likely in the patient who experiences substantial pelvic distortion such as: rotation and/or unleveling of the illia, fixation of the sacroilliac joint, loss of motion at the sacrococcyx, and chronic illiopsoas spasm, among other musculoskeletal problems. As the nerve roots that make up the nerve plexus of the lower pelvis also travel through the lumbar spine, rotational malposition and locking of the lumbar vertebrae and chronic spasm in the surrounding tissues may also contribute to pelvic floor pain.
We will explore the potential link between global body posture and the suffering pelvic floor in an upcoming post.
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Labat, J., Riant, T., Robert, R., Amarenco, G., Lefaucheur, J., & Rigaud, J. (2008). Diagnostic criteria for pudendal neuralgia by pudendal nerve entrapment (Nantes criteria). Neurourology and Urodynamics,27(4), 306-310. doi:10.1002/nau.20505
Ünlü, Z., Yentur, A., & Çakil, N. (2015). Pudendal Nerve Neuropathy: An Unknown-Rare Cause of Pelvic Pain. Archives of rheumatology, 31(1), 102–103. doi:10.5606/ArchRheumatol.2016.5727
Valovska, A. T. (2016). Pelvic Pain Management. New York: Oxford University Press.