What is Pudendal Neuralgia?
The condition where a person experiences chronic pain related to the pudendal nerve is known as Pudendal Neuralgia. The pudendal nerve travels from the lower back, along the muscles of the pelvic floor and towards the perineum, which is the skin between the tailbone and the pubic bone. Pudendal nerve supplies the skin between the clitoris (penis in males), the anus, the muscles of the anus and urethra.
The nerves present in our bodies are commonly stretchy and quite supple. They have the ability to smoothly slide as we go about our daily lives. For example, when we lift our arms above our head, the nerves also stretch the same length. We also tend to squash our nerves a bit before realizing it through indications, such as the 'dead arm' feeling which is a sensation of pins and needles. A person also recovers quickly from such type of sensation. Irritation of the nerves occurs when our body incurs large trauma, such as landing on a hard surface or going through a difficult labor. Other repetitive, chronic small traumas, such as repetitive heavy physical exercises, straining from constipation etc., can also cause irritation of the nerves. This increases the sensitivity of the nervous system due to which pain can be felt even when the stimulus is less with greater intensity. It is as if the volume is turned up for pain. So, when the pudendal nerve suffers from any trauma, it results in pudendal neuralgia. The pudendal nerve can also get compressed or irritated due to bulky muscles of the pelvic floor or from tight ligaments.
Causes of Pudendal Neuralgia
There are multiple causes for pudendal neuralgia and include:
- Colo-rectal or gynecological surgery.
- Trauma incurred during labor/ childbirth.
- Excessive physical exercise.
- Previous trauma to the pelvic or perineal region.
- Problems related to the musculoskeletal system.
- Bad posture.
Pudendal neuralgia is commonly caused by a combination of some of the above factors. In some cases, a specific cause cannot be found; however, Pudendal neuralgia is treatable.
Signs & Symptoms of Pudendal Neuralgia
- Pain is the primary symptom of Pudendal Neuralgia.
- The symptoms of pain in pudendal neuralgia varies and can be of different nature, such as can be felt as an electric shock, burning, shooting, itchy and achy type of pain.
- Symptoms of Pudendal Neuralgia can also be felt as a raw feeling in the clitoris, vagina, labia, and for males, in the penis.
- Pain is also felt in the urethra, perineum, rectum or anus.
- Patient can also feel bladder and bowel irritation. This irritation can also be felt without any acute pain.
- There can also be difficulty in sitting because of the pain from Pudendal Neuralgia.
- There can be a feeling of fullness in the rectum or the vagina.
- Pain can also radiate into the buttocks, legs and feet.
- Other than this, patient can also have associated bowel, bladder and sexual problems.
Diagnosis of Pudendal Neuralgia
There are different examinations and tests done to confirm the diagnosis of pudendal neuralgia. Physical examination and medical history of the patient is taken to arrive at a correct diagnosis and according to the diagnosis, a treatment plan is chalked out for the patient.
- In physical examination, the musculoskeletal and neurological function of the legs, pelvis and perineum is assessed by checking the joints, muscles, posture and reflexes.
- Pudendal nerve block is a procedure where a local anesthetic is injected into the canal where the nerve passes. This causes numbness and if there is any decrease in the pain or if the pain is completely gone, then it means that the pudendal nerve is involved in the pain syndrome and its pudendal neuralgia.
- Pudendal nerve MRI is another test, which can be done for diagnosis of pudendal neuralgia and helps in giving detailed information regarding the anatomic structures which surround the pudendal nerve.
- Ultrasound of the sacroiliac ligaments and joints can be done to arrive at a diagnosis. A lot of stress s placed on these structures under certain circumstances, such as falling onto the buttocks, during pregnancy, extreme physical activities etc., so an ultrasound helps in detecting the root cause of the pain.
- Ultrasound of the pelvic floor muscles helps in giving information about the vaginal muscles, pelvic floor muscles and the adductor muscle of the leg.
Treatment for Pudendal Neuralgia
Treatment for pudendal neuralgia comprises of medications, physiotherapy, and making lifestyle changes. Some of the common treatments for Pudendal Neuralgia include:
Conservative Treatment of Pudendal Neuralgia
Conservative Treatment is very beneficial in reducing the pain of pudendal neuralgia. Self management is important and consultation with different specialists may also be needed. The main focus of the treatment in pudendal neuralgia is to reduce the irritability of the pudendal nerve. Making some changes in daily life helps in achieving this. Even after making lifestyle changes, the nerve takes time to settle down and heal. Understanding and avoiding the triggering factor of the nerve pain helps in managing pudendal neuralgia. Learning how to modify one's life around the pain makes it easier to cope with this condition. Armed with the right knowledge, significant reduction can be achieved of the pain from pudendal neuralgia and patient can live a normal and functional life.
Some of the lifestyle changes which need to be made include:
- Bowel and Bladder Management in Pudendal Neuralgia: This can be achieved by avoiding straining when passing urine or emptying the bowels as straining stretches and puts unnecessary stress on the pudendal nerve. Stimulant laxatives should also be avoided. Physiotherapy also helps in developing good bowel and bladder habits.
- Altering physical activities for Pudendal Neuralgia by avoiding activities which irritate the pudendal nerve should be done, such as spending excessive time on horse-riding or on a pushbike should be avoided. Other activities which should be avoided or cut down are: bench pressing, trampoline jumping and excessive core muscle exercises. Physiotherapy and osteopathy help in identifying specific movements which need to be reduced for some period of time for relief from the pain of pudendal neuralgia.
- Modifications in sitting, such as avoiding putting pressure on the perineum helps in preventing compression of the pudendal nerve. A special coccyx-cut-out foam cushion can be used when sitting down which helps prevent any pressure or weight on the perineum when sitting. Decreasing the amount of time we sit also helps. This can be done by periodically getting up and standing at the desk and working by keeping the laptop on a portable desk raiser.
- Making changes in the sex life also helps, as in some patients, sex can increase pudendal neuralgia. Consult your physician on how to go about this.
Medications to Treat Pudendal Neuralgia
Oral medications or topical creams, which calm the nervous system, help in managing pudendal neuralgia. The nervous tissue is extremely sensitive. Chronic pain further increases the sensitivity of the nervous system and triggers or exacerbates pain with even very mild or small activities. Pain killers are prescribed to help relieve pain.
Osteopathy to Treat Pudendal Neuralgia
An osteopath can help in reducing the pressure exerted on the pudendal nerve. Any tension or stress on the ligaments of the sacroiliac joints can put pressure on the pudendal nerve. Some muscles of the buttocks and the hips can put compression on the nerve. Osteopathy helps in relieving the tension and pressure on the pudendal nerve by teaching how to make changes in walking, posture, footwear, so as to reduce the load on the pelvic structures thus reducing the irritation caused on the pudendal nerve and the ensuing pain of pudendal neuralgia.
Physiotherapy for Pudendal Neuralgia
Physiotherapy is beneficial in pudendal neuralgia, as it can help in stretching and relaxing the muscles of the pelvic floor thus reducing the tension in them. This also helps in decreasing the pressure on the pudendal nerve. The painful trigger points in the muscles of the pelvic floor also need to be soothed. This can be done by using a TENS unit, which is a trans-cutaneous electrical nerve stimulation. It helps in relieving the pain from pudendal neuralgia. Physiotherapy comprising of specific stretches and exercises, which correct the posture and avoiding activities which trigger the pain are also beneficial. Physiotherapy also helps in managing and cultivating good bowel and bladder habits.
Acupuncture for Pudendal Neuralgia
Acupuncture can also help with persistent pain in the perineal region due to pudendal neuralgia, especially the pain occurring from a difficult birth. Acupuncture is especially a good alternative for patients who are having significant side effects from the medications and other treatment for pudendal neuralgia.
Along with good physical health, having good mental health is also extremely important, especially in managing chronic pain, such as perineal pain occurring in pudendal neuralgia. Cognitive behavior therapy, mindfulness, meditation and relaxation exercises help a great deal in managing not only the pain of pudendal neuralgia, but also any type of pain.