Pudendal Neuralgia
Another important cause of pelvic pain, and missdiagnosed, along with endometriosis/adenomyosis, is represented by pudendal neuralgia (external pubic nerve).
This delay in diagnostic happens because there is still no well-established specialty for this pathology (a few exceptions). I am convinced that until recently (about a year ago), attributing the presence of pelvic pain to endometriosis/adenomyosis, I ‘missed’ this diagnosis many times. However, the pain in this pathology is different from that caused by pelvic endometriosis/adenomyosis from many points of view. That is why the discussion/dialogue with the patient and the clinical examination are extremely important.
Pudendal nerve is a sensitive somatic nerve located deep in the pelvis, medial to the sciatic nerve. It has a very interesting path, leaving the pelvis at the level of the sciatic spine to innervate (sensitive) the perineal region. At this level (sciatic spine) it can be compressed by muscle fibers, dilated veins or fibrotic scar tissue (traumas, surgeries). It has an extremely important role in the physiology of the urinary, lower digestive and external genital systems.
Pudendal neuralgia causes long-term pelvic pain that originates from damage/irritation of the external pudendal nerve (an important sensorial nerve in the pelvic region)
The regions innervated by this nerve are:
- lower gluteal region
- the perineal region (very frequently affected)
- the perianal and perivulvar region
- vulva, labia and clitoris in women (scrotum and penis in men)
Pudendal neuralgia can be very uncomfortable and annoying, especially due to the fact that the patients are very young and this pathology severely affects the sexual life.
The main symptoms of pudendal neuralgia (PN) are pelvic pain and perineal pain (any of the above areas can be affected).
As a type of pain, PN pain can be felt as a burning, stabbing, shooting, crushing, twisting sensation, etc. This pain can appear suddenly or gradually increase throughout the day. Usually the pain intensifies during the day (better in the morning, worse in the evening) and when patients has multiple lower limbs activity. The region/regions may be more painful in the ‘sitting’ position compared to the clinostatism position (lying down) or the orthostatism position (standing).
Other symptoms of PN can be:
- -numbness/paresthesias in the pelvic area, increased sensitivity to pain (sometimes a gentle touch can be felt as pain)
- a very frequent need to urinate – differential diagnosis with urinary infections or interstitial cystitis – not confirmed at cystoscopy
- feeling of constant pressure at the perineal level (often described as feeling like a golf or tennis ball at this level)
- the need to go to the toilet (pass stool) frequently or suddenly – sometimes symptoms similar to those of pelvic endometriosis (PN is also often associated with endometriosis)
- pain during sexual intercourse, lack of sexual pleasure (often this causes serious problems for the couple)
Over time, pain (PN) can worsen if it is not treated properly, and early treatment can avoid serious physical and mental health problems. As it worsens, this pathology is even more difficult to treat. Therefore, the intervention (surgical or conservative treatment) should not be postponed very much in these cases. Unfortunately, the diagnosis is not very easy, the painful symptoms can be confused with pain due to other pelvic pathologies: endometriosis, adenomyosis, infectious gynecological pathology, colorectal pathologies, urinary pathologies and other neuropathies.
Diagnosis of pudendal neuralgia
The doctor (neurologist, gynecologist, urologist) must know the possibility of the existence of this pathology and should ask the appropriate questions – specific symptoms of PN; he can also examine the area to check for any other obvious causes of pelvic pain (gynecologist).
There are some diagnostic tests for PN:
- vaginal or rectal examination – to see if pain occurs when the doctor applies pressure on the external pubic nerve
- MRI exam – to exclude other pelvic pathologies; sometimes it can highlight a cause of compression of the pudendal nerve: dilated veins, tumors at this level, etc.
- *nerve studies – a device is inserted into the rectum is used to stimulate nearby nerves with mild electrical impulses to check how well the nerves are working
- one of the most sensitive diagnostic tests is anesthetic infiltration of the external pudendal nerve – anesthetic block – Alcock canal; this maneuver is invasive, but it can give a definite diagnosis of this pathology
Causes of pudendal neuralgia
Pudendal neuralgia can occur if the pudendal nerve is damaged/destroyed, irritated or compressed (most frequently in our medical practice).
The most common causes are:
- compression of the pudendal nerve by pelvic/perineal muscles or other tissues (tendons, fascia, fibrotic tissue) – called Alcock’s canal syndrome
- prolonged sitting (occupational disease), cycling, horse riding or chronic constipation (usually months or years) – these can cause repeated minor injuries to the pelvic area
- dilated veins – pelvic congestion syndrome – at the pelvic/perineal level – which can compress the nerve (very delicate/sensitive)
- surgical interventions (multiple) in the pelvic area – we encountered this pathology innour practice especially after hysterectomy
- fractures of the pelvic bones
- trauma to the pudendal nerve during vaginal birth
- tumor that can compress the pudendal nerve
*In some cases, a specific cause cannot be identified.
Treatment of pudendal neuralgia
This can be conservative or interventional/surgical.
- avoiding things that make the pain worse, such as cycling, constipation or prolonged sitting
- symptomatic treatment: antialgic medication – reduce pain – these are special drugs for neuropathic pain (neurological/psychiatric medication), not usual painkillers (non-steroidal anti-inflammatory drugs)
- physiotherapy – a physiotherapist specialized in this type of perineal/pelvic pain may help reduce the pain significantly, especially in the initial phases of the disease (exercises to relax the pelvic muscles, as well as other muscles that can irritate the external pubic nerve)
- local anesthetic infiltrations for pain relief – can relieve pain for several months at a time – unfortunately the anesthetic also has adverse effects (sensitivity reduction in the respective area – decrease in sexual pleasure, urinary difficulties)
- surgical intervention – decompression of the external pudendal nerve – radical intervention that most often involves sectioning of some muscle fibers, fascia, tendon of the coccygeus muscle; sometimes the nerve can be compressed by dilated pelvic veins; coagulation and sectioning determine the significant and immediate relief of pain at this level.
- *nerve stimulation – implanting a device under the skin to deliver mild electrical impulses to the nerve for desensitisation.
Together with the pain specialists (with whom we have a close collaboration), we started to diagnose and treat correctly this very frequent and underdiagnosed condition. We are proud to be first gynecological surgery center in the country that practices this type of laparoscopic surgery (peripheral pelvic nerve surgery) with spectacular results a few days after surgery.
Dr. Gabriel Mitroi
Obstetrician – Gynecologist
Endometriosis Surgeon
