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Pudendal Nerve and Neuralgia

Physical therapy has proven to be a very successful treatment option for pudendal neuralgia, pudendal nerve irritation and pudendal nerve entrapment. The pudendal nerve originates from the lumbo-sacral plexus (L4-S4). It consists of both sensory fibers (80%) and motor fibers (20%).

The pudendal nerve branches into 3 smaller nerves:

• Inferior rectal nerve: supplies the anal canal, peri-anal skin, rectum, and external anal sphincter.
• Perineal nerve: supplies the perineum, vagina, urethra, male scrotum, labia, transverse perineal muscle, and urethral sphincter.
• Dorsal nerve of the clitoris or penis: supplies skin of the clitoris/penis, bulbocavernosus, and ischiocavernosus muscles.

Irritation of the pudendal nerve (severe pain in the distribution of the nerve), i.e. pudendal neuralgia, may result in sensory symptoms in any or all areas it supplies and spasms of the muscles supplied by it. A common site for pudendal nerve irritation may be at the Alcock’s Canal, the region between the sacrospinous and sacrotuberous ligaments, and/or at the obturator internus muscle.

The sensory symptoms could manifest as itching, burning, tingling, cold sensations, and/or burning and shooting pain. The sensory symptoms may extend into the groin, abdomen, legs, and buttocks. The pudendal nerve is the only peripheral nerve that has both somatic and autonomic fibers. Thus, a person can experience increased heart rate and blood pressure, decreased motility of the colon, decreased blood flow, and perspiration with pudendal nerve stimulation.

Signs and symptoms may include the following, but they vary between individuals:

• Pelvic pain with sitting, but improvement with standing or sitting on a toilet seat.
• Discomfort with tight clothing.
• Bladder and/or bowel symptoms (hesitancy, frequency, urgency, retention, constipation, pain
• Dyspareunia
• Genital pain
• Anal pain
• Abnormal pudendal nerve motor latency test
• Pudendal nerve block may decrease symptoms

Physical Therapy Treatment may consist of:

• rehabilitation of the pelvic floor, abdominal, gluteal, lumbosacral and hip rotator muscles
• pudendal nerve mobilization, connective tissue mobilization and myofascial trigger point release of the surrounding muscles and tissues.
• range of motion and strengthening of certain muscles to improve core and lower extremity balance and stability

Surgical Management of the Pudendal Nerve

Surgery for pudendal nerve entrapment should be considered your last option, because it is an extensive surgery. We advise that you try physical therapy two to three times/week, including a home exercise program and relaxation techniques, for a minimum of 6 months before considering surgery. Trigger point injections and pudendal nerve blocks, also compliment the physical therapy treatment, but are not always necessary. If you experience an improvement in your symptoms, even if it is only 25% during that 6 months, then we recommend that you continue PT for another 6 months, prior to considering surgery. Fortunately, we have not had to send any of our patients for surgery.

An entrapped pudendal nerve can be approached through 3 different types of surgeries:

1. Trans-ischio-rectal (TIR)
2. Trans-gluteal (TG)
3. Trans-perineal (TP)

In some cases, patients may experience post-operative pain. In this situation, physical therapy plays a big role in recovery. With the TIR surgery, men may have pain at the incision site and women may have vaginal scarring. Sacro-iliac joint dysfunction may also be present. In the TG approach, the gluteal muscle is severed and sciatic neural tension may occur.

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