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  • Pelvic pain
  • Pudendal neuropathy (PN)
  • Pudendal nerve entrapment (PNE)

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  • 353.8 Other nerve root and plexus disorders

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  • G54.8 Other nerve root and plexus disorders
  • R10.2 Pelvic and perineal pain

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Description

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  • Pain, burning, numbness, paresthesia in the gluteal, perineal, and/or genital area
  • Entrapment and injury to the pudendal nerve in Alcock’s canal
  • Alcock’s canal (musculo-osteo-aponeurotic tunnel) between sacrotuberous and sacrospinous ligaments, in the absence of organic disease

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Essentials of Diagnosis

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  • Nantes criteria2
  • Pain should be limited to the innervation territory of the pudendal nerve
  • Exclude any pain that is limited to the coccygeal, pelvic, or gluteal areas
  • Pain is predominantly experienced while sitting
  • Pain rarely awakens the patient at night
  • No objective sensory impairment can be found, even in the presence of paresthesia on clinical examination
    • Presence of a sensory defect should prompt investigations to exclude diseases of the sacral nerve roots and cauda equina syndrome
  • Pain should be relieved by anesthetic infiltration of the pudendal nerve
    • This is an essential criterion, but it lacks specificity as pain related to any perineal disease may be relieved by pudendal nerve block

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General Considerations

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  • Frequently misdiagnosed
  • Chronic pain condition
  • Urogenital pain disorders are frequently associated with pain and other musculoskeletal impairments in nearby body areas; especially back, pelvic, hip, and groin regions

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Demographics3

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  • Few epidemiologic data found in the literature
  • Mean time to diagnosis is 4 years, ranging from 1 to 15 years
  • More prevalent in women; 7 out of 10 patients are women

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Signs and Symptoms3

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  • Pain along pudendal nerve distribution
    • Perineal
    • Scrotal/testicular
    • Peri-anal
    • Suprapubic
    • Pain with ejaculation
    • Pain elicited with pressing along the course of the nerve
  • Pain aggravated by sitting, stair climbing
  • Pain relieved by standing or lying and with sitting on toilet
  • Associated symptoms
    • Voiding dysfunction: urinary hesitancy, frequency, urgency, obstructive voiding, painful voiding
    • Obstructive defecation: difficult and painful bowel movements
    • Sexual dysfunction: painful orgasms, persistent sexual arousal, erectile dysfunction
      • Autonomic dysfunction: sensation of dryness, itching, sweating

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Functional Implications

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  • Difficulty sitting for prolonged periods
  • Sexual dysfunction
    • May lead to unwanted sexual abstinence
  • Difficulty with urination and defecation
  • Pain during voiding
  • Decreased tolerance for exercise
  • Inability to work or attend school
  • Inability to maintain relationships

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Possible Contributing Causes

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  • Mechanical pudendal nerve: compression, tension, direct trauma
    • Identifiable trauma in athletes 15 to 25 years old
      • Cycling, weight lifting
      • Sitting: job, long travel
  • PFM dysfunction: TrP, connective tissue restriction
    • Myofascial entrapment along the course of the nerve
      • Sacrospinous and sacrotuberous ligaments
      • Alcock’s/pudendal canal
  • Surgery: multiple case reports in the literature of new onset pudendal neuropathy following surgeries for urinary incontinence
  • Sacral iliac dysfunction
  • ...

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