What is Pudendal Neuralgia?

 

Pudendal Neuralgia can be a debilitating condition that may cause urinary, bowel, sexual dysfunction and pelvic pain. The pudendal nerve is a mixed nerve containing autonomic, sensory and motor fibers arising from S2-S4. It follows a tortuous course through the pelvis to innervate the majority of the pelvic floor muscles, the urethral and anal sphincters, portions of the distal urethra and anal canal, and the skin of the clitoris and lower 2/3 of the labia in women, the dorsum of the penis and scrotum in men, and the skin of the perineum and anus in both sexes.

 Pudendal Nerve Sensory Distribution: male and female

The pudendal nerve is anatomically vulnerable to compression and tension as it travels through the pelvic floor, the space between the sacrospinous and sacroutuberous ligaments, Alcock’s Canal (formed by fascia and the Obturator Internus muscle), and around unyielding interfaces such as the ischial spine. The pudendal nerve has three primary branches: the perineal branch, the dorsal penile or clitoral branch, and the inferior rectal branch.

Pudendal Nerve, Alcock’s Canal, Obturator Internus

 

If a person describes pain in any of the above-mentioned areas that is sharp/stabbing/shooting their symptoms fit the description of Pudendal Neuralgia (PN). Pudendal Neuralgia may be classified as a myofascial pelvic pain syndrome, thereby explaining it’s associated with numerous other symptoms. In addition to the pain that is often worsened with sitting and may be (but not always) alleviated by standing, patients suffer a myriad of other symptoms. The pudendal nerve is intimately related to the pelvic floor and even more closely related to the Obturator Internus muscle. These muscles are almost always tender, hypertonic, and have trigger points in patients with PN. This muscular dysfunction can create symptoms of urinary frequency, urgency, hesitancy, and burning, constipation, pain with intercourse, aorgasmia, pain with orgasm, and as already mentions, pain anywhere in the territory of the nerve.

 

It is not uncommon for patients to suffer from additional symptoms such as sciatica, sacro-iliac joint and low pain, lower extremity heaviness and tightness and pain in their feet. The pelvic region may be hypersensitive, making underwear and clothing seem unbearable.

Pudendal, Posterior Femoral Cutaneous, and Sciatic nerves

Finally, the pudendal nerve is unusual because it not only has sensory fibers (to innervate the skin) and motor fibers (that innervate the muscles) but also autonomic fibers. The Autonomic Nervous System is responsible for controlling functions such as heart rate, blood pressure, goose bumps, and the flight-or-fight response. When the PN is involved, unfortunately patients may experience symptoms of a racing heart, anxiety, and temperature deregulation. They often feel like they are going crazy and they most certainly are not crazy. The symptoms are caused by the physiology of this complicated nerve.