Pudendal neuralgia

The pudendal nerve is one of the main nerves in the pelvis, supplying areas such as the:

• lower buttocks
• area between the buttocks and genitals (perineum)
• area around the back passage (rectum)
• vulva, labia, and clitoris in women
• scrotum and penis in men

Pudendal neuralgia can be very uncomfortable and distressing, but help is available and there are several treatments that can be tried.

Symptoms of pudendal neuralgia

The main symptom of pudendal neuralgia is

The pain may:

• feel like a burning, crushing, shooting or prickling sensation
• develop gradually or suddenly
• be constant – but worse at some times and better at others
• be worse when sitting down and improve when standing or lying down

Other symptoms can include:

• numbness and
  pins and needles
  in the pelvic area
• increased sensitivity to pain – you may find just a light touch or wearing clothes uncomfortable
• feeling as though there's swelling or an object in your perineum – often described as feeling like a golf or tennis ball
• needing to go the toilet frequently or suddenly
• pain during sex, difficulty reaching orgasm, and
  erectile dysfunction
  in men

When to get medical advice

See your doctor if you have persistent pelvic pain.

Don't delay seeking advice if the pain is causing problems. Pudendal neuralgia can continue to get worse if left untreated, and early treatment may be more effective.

The stress of living with the condition can also have a significant impact on your physical and mental health if it's not treated.

Tests for pudendal neuralgia

Your doctor will ask about your symptoms and may carry out an examination of the area to check for any obvious causes of your pain.

If they think you could have pudendal neuralgia, or they're not sure what's causing your pain, they may refer you to a specialist for further tests.

These tests may include:

• a vaginal or rectal exam – to see if the pain occurs when your doctor applies pressure to the pudendal nerve with their finger
• a
  magnetic resonance imaging (MRI) scan
  – to check for problems such as entrapment (compression) of the pudendal nerve and rule out other possible causes of your pain
• nerve studies – a small device inserted into your rectum is used to stimulate nearby nerves with mild electrical impulses to check how well the nerves are working
• nerve block injections – painkilling medication is injected around the pudendal nerve to see if your pain improves

Treatments for pudendal neuralgia

Treatments for pudendal neuralgia include:

• avoiding things that make the pain worse, such as cycling,
  constipation
  or prolonged sitting – it may help to use a special cushion with a gap down the middle when sitting and try
  constipation treatments
• medications to alter the pain – these will normally be special medications for nerve pain, rather than ordinary painkillers like
  paracetamol
• physiotherapy
  – a physiotherapist can teach you exercises to relax your pelvic floor muscles (muscles used to control urination) and other muscles that can irritate the pudendal nerve
• painkilling injections – injections of
  local anaesthetic
  and
  steroid medication
  may relieve the pain for a few months at a time
• decompression surgery – if something is pressing on the pudendal nerve, such as a piece of tissue, surgery to reposition it away from the nerve may help improve your pain
• nerve stimulation – a special device is surgically implanted under the skin to deliver mild electrical impulses to the nerve and interrupt pain signals sent to the brain

You may be referred to a specialist NHS pain management team or pain management programme for support and advice about treatment.

Not all of the possible treatments are widely available on the NHS.

Causes of pudendal neuralgia

Pudendal neuralgia can occur if the pudendal nerve is damaged, irritated or squashed (compressed).

Possible causes include:

• compression of the pudendal nerve by nearby muscles or tissue – sometimes called pudendal nerve entrapment or Alcock canal syndrome
• prolonged sitting, cycling, horse riding or constipation (usually for months or years) – this can cause repeated minor damage to the pelvic area
• previous surgery to the pelvic area
• a break in one of the bones in the pelvis
• damage to the pudendal nerve during childbirth – this may improve after a few months
• a non-cancerous or cancerous growth (tumour) pressing on the pudendal nerve

In some cases, a specific cause isn't identified.