Pudendal Neuralgia

What is Pudendal Neuralgia?

Pudendal neuralgia is a chronic and painful condition that occurs in both men and women, although studies reveal that about two-thirds of those with the disease are women. The primary symptom is pain in the genitals or the anal-rectal area and the immense discomfort is usually worse when sitting.

What are the causes?

The most common causes for pudendal nerve entrapment syndrome include:

  • Repeated mechanical injury (eg, sitting on bicycle seats for prolonged periods over many years or months)
  • Trauma to the pelvic area, for example during childbirth
  • Damage to the nerve during surgical procedures in the pelvic or perineal regions
  • Compression from lesions or tumors arising in the pelvis
  • Any cause for the development of peripheral neuropathy (eg, diabetes or vasculitis).

What are the symptoms?

The symptoms of pudendal nerve entrapment syndrome arise from changes in nerve function and structural changes in the nerve that arise from the mechanical effects of compression. These changes give rise to so-called “neuropathic” pain in the perineum, genital and ano-rectal areas.

Neuropathic pain has many manifestations, most commonly spontaneous or evoked burning pain (also called “dysaesthesia”) with or without a component of severe lancinating (sudden, ‘electric shock-like’) pain. Other manifestations of “neuropathic pain” include a deep aching pain/sensation, increased appreciation of a sensation to any physical stimulus (“hyperaesthesia”), exaggerated sensation of pain for a given stimulus (“hyperalgesia”), pain sensation occurring with stimulation which doesn’t normally cause pain (“allodynia”) or an unpleasant, exaggerated prolonged pain response (“hyperpathia”).

The characteristic feature of pudendal nerve entrapment syndrome is aggravation of symptoms with assuming a sitting position, often after a short duration of sitting. Standing typically relieves symptoms and are usually absent when lying down or sitting on a toilet seat.

Various other symptoms may occur in some cases, for example urinary hesitancy (difficulty starting the flow of urine), frequency (frequent need to pass urine), urgency (sudden sensation to pass urine), constipation/painful bowel movements, reduced awareness of defecation (the process of passing bowel motions), sexual dysfunction, recurrent numbness of the penis and/or scrotum (or vulva in women) after prolonged cycling, altered sensation of ejaculation and impotence in men.

What are the treatments?

The condition may be amenable to treatment in a number of ways. General measures may include:

  • Avoid prolonged periods of sitting, particularly in cyclists who have this condition.
  • Use a foam ring-cushion so there is no pressure on the center when sitting
  • Avoid straining when passing urine or opening the bowels
  • See a physiotherapist to learn relaxation techniques for the pelvic floor

Various medical treatments may be tried to alleviate neuropathic pain including nerve stabilizing agents. These may include:

  • Tricyclic antidepressants such as amitriptyline
  • Anti-convulsants such as carbemazapine and sodium valproate
  • Nerve stabilizers such as gabapentin and pregabalin.

Where medical treatments are not successful in relieving symptoms, surgical treatments may be tried. Surgical treatments include local anaesthetic nerve blocks, botulinum toxin injections to relieve pelvic floor spasm, injections of corticosteroids to reduce swelling and inflammation, and surgical decompression of the pudendal nerve.
Surgical decompression of the nerve can be variably effective. Surgery may not be completely effective in all cases for various reasons, for example, irreversible damage to the nerve due to the effects of prolonged or severe nerve compression, processes which irreversible affect nerve function (such as longstanding poorly controlled diabetes mellitus), inadequate surgical decompression, surgical decompression of the incorrect site, and chronic pain syndromes.

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