Pudendal Neuralgia

What is pudendal neuralgia?

Pudendal neuralgia (or pudendal nerve entrapment) is when you experience chronic pelvic pain from damage or irritation to your pudendal nerve. If you have pudendal neuralgia, this nerve is injured or compressed and causes stabbing, burning or shooting pain. The pain can be felt in your buttocks, perineum and genital region, and is more severe when sitting.

Where is the pudendal nerve?

The pudendal nerve runs from the back of your pelvis to all the muscles and skin between your legs. Think of all the areas that touch the seat while riding a bike. That entire area may be affected by pudendal nerve damage. Your pudendal nerve controls movement and feeling in your genitals and anus. It also controls the sphincter muscles that help you pee and poop.

What does the pudendal nerve do?

The pudendal nerve provides sensory information about touch, pleasure, pain and temperature to your:

• Penis and scrotum (part of the male reproductive system).
• Vagina, labia and vulva (part of the female reproductive system).
• Perineum (the area between your anus and your vagina or penis).
• Anal canal and anus (part of your digestive system).
• Urethra (the tube that allows pee to exit your body).

How common is this condition?

Pudendal neuralgia is rare, but anyone can get it. An estimated 30,000 to 200,000 people have pudendal neuralgia in the United States. It’s most common in adults older than 19.

What are the symptoms of pudendal nerve damage?

The biggest symptom of pudendal neuralgia is pain. Any organs or muscles served by the pudendal nerve can be affected. You may feel pudendal nerve pain in your clitoris, labia, vagina, penis, scrotum, anus or rectum.

Some people describe the pain as:

• Shooting, aching, burning or stabbing.
• Tingling, prickling or numbing.
• Hurting worse in the evening and feeling better in morning.
• Varying degrees of intensity (sometimes worse than other times).
• Hurting most when sitting and improving when standing or lying down.

Other symptoms include:

• Increased sensitivity such as pain when putting on underwear.
• Feeling swollen in your perineal area (like there’s an object in your anus).
• Feeling an urgent need to pee.
• Painful bowel movements.
• Painful sex.
• Trouble reaching orgasm.
• Erectile dysfunction.
• General numbness, coldness or loss of sensation in your legs, feet and buttocks.

There are three branches of your pudendal nerve: a rectal branch, a perineal branch and a clitoral/penile branch. Your symptoms will vary depending on which branches and nerves are affected.

What causes pudendal neuralgia to flare up?

Pudendal neuralgia can occur when the pudendal nerve is damaged (by pressure or other irritation) or compressed, often by surrounding tissues or muscles. Some causes include:

• Activities that place constant strain on the pelvic area. Cycling, squatting exercises, horseback writing or chronic constipation are examples of constant or prolonged strain that could damage your pelvis.
• Prolonged sitting.
• Tension on the nerve from surrounding muscles and ligaments.
• Complications from surgeries like prostatectomy.
• A broken bone in the pelvis.
• Trauma during childbirth.
• Certain infections or diseases.
• A benign (noncancerous) growth or lesion.
• Neuropathy associated with diabetes or other conditions.

How is pudendal neuralgia diagnosed?

Healthcare providers diagnose pudendal neuralgia with a physical exam and other tests. They’ll ask you to describe your symptoms and the location of your pain. Often, they’ll rule out other conditions that cause similar pain first.

Some of the tests providers use include:

• Vaginal or rectal exam: Providers insert a gloved finger into your rectum or vagina to put pressure directly on your pudendal nerve.
• Magnetic resonance imaging (MRI): A powerful imaging test that can check your pudendal nerve and the structures around it to identify issues.
• Electromyography (EMG): Providers use a small device to stimulate your pudendal nerve with electrical impulses to see how well it’s functioning and responding to the stimulation.
• Nerve blockers:Providers inject pain medication into your pelvis to numb your pudendal nerve to see if your pain goes away. If your pain improves, it may be a sign that the pain is coming from your pudendal nerve.

Other conditions associated with pudendal neuralgia

Pudendal neuralgia and many other conditions have similar symptoms, such as pain and incontinence. Your provider may run tests or ask questions to rule out other issues. Some of these other conditions are:

• Vulvodynia (pain in your vulva).
• Coccygodynia (tailbone pain).
• Prostatitis (conditions affecting your prostate gland).
• Sciatica (injury to your sciatic nerve, which causes pain in your low back and leg).
• Pelvic floor dysfunction (damage to your pelvic floor muscles that may interfere with your ability to poop or hold your pee).

How is pudendal neuralgia treated?

Physical therapy, medication, lifestyle changes or surgery are possible treatments for pudendal neuralgia. Providers may combine treatments for quicker relief from symptoms.

Physical therapy

A physical therapist can teach you exercises to relax or stretch the muscles causing your pudendal nerve pain. They may also recommend using a TENS (transcutaneous electrical nerve stimulation) machine to reduce nerve pain.

Lifestyle changes

Certain things make pudendal nerve pain worse. Avoiding or modifying these activities can be beneficial. Some examples include:

• Prolonged sitting.
• Riding a bike.
• Squatting with weights.
• Horseback riding.
• Straining to poop if you’re constipated.

Using a donut or U-shaped pillow when you sit. These pillows have a hole in the center and take pressure off your pelvic floor muscles and perineum. If you find yourself chronically constipated, try increasing your fiber intake or using a stool softener, so you’re able to poop without straining.

Medication

Some people find pain relief through medications like painkillers or steroids. Specific medications for pudendal neuralgia include:

• Pain medication.
• Nerve stabilizing or antiseizure medications like gabapentin.
• Injections of local anesthetics (to block nerve pain) or corticosteroids to reduce inflammation.
• Tricyclic antidepressants such as amitriptyline.
• Botox injections to help relax the muscles around your pudendal nerve.

Surgery

Surgery is usually the last treatment option. Pudendal nerve decompression is a surgery that removes muscle or tissues away from your pudendal nerve. Surgeons make an incision in your gluteal muscles (buttocks) or perineal muscles to access your pudendal nerve. Pain relief from decompression surgery may take months or years and isn’t instantaneous relief.

Can you massage the pudendal nerve?

Massage therapy isn’t one of the recognized treatments for pudendal neuralgia. Some healthcare providers recommend massaging the muscle tissue around your pudendal nerve to release tension and tightness. This can offer temporary relief to a compressed or trapped pudendal nerve.

How can I reduce my risk of pudendal neuralgia?

It may be hard to reduce your risk of pudendal neuralgia if the cause is due to childbirth, trauma or surgery. However, certain activities can aggravate your pudendal nerve.

Some of the things you can do to help reduce your risk of pudendal nerve pain include:

• Avoid horseback riding or cycling.
• Alternate sitting with standing so you’re not sitting for long periods.
• Use a donut-shaped pillow when seated to take pressure off your pelvis.
• Don’t strain when you’re pooping or peeing.

Can pudendal neuralgia be cured?

No, there isn’t a cure. The goal of treatment is to minimize symptoms, but symptoms may never go away entirely.

How do I manage daily life with pudendal nerve pain?

Chronic nerve pain can interfere with your daily life. It affects your relationships, activities and general wellness. Seek help from a healthcare provider if you have pelvic pain or experience sexual dysfunction, incontinence or depressive thoughts. They can help you find relief for your pain and determine if your pudendal nerve is the cause.

When should I see my healthcare provider?

Contact a healthcare provider if you have pain in your pelvic or genital region. When left untreated, your pain may intensify and limit your activities. Some symptoms you should watch for include:

• Feeling “pins and needles” on your pelvis, buttocks or genitals.
• Feeling like there’s an object stuck in your anus.
• Painful urination or frequent need to pee.
• Sexual dysfunction.

A note from Cleveland Clinic

If you have chronic pelvic pain and a possible diagnosis of pudendal neuralgia, you’re not alone. While relatively rare, pudendal nerve pain can be debilitating and affect your lifestyle, relationships and daily activities. Discuss your symptoms with your healthcare provider. They can determine which type of treatment will be best based on the severity and location of your pain. Remember, pain relief is available and within your reach if you seek help from your provider.