Monday, 31 December 2018

Pudendal Neuralgia

This blog is going to focus on pudendal neuralgia in men, what are the signs and symptoms, diagnostic criteria and treatment from a physiotherapy perspective.

Pudendal neuralgia, also known as pudendal nerve entrapment is mostly a clinical syndrome (1). What this means is that there is no clear “test” that says you have it. The doctor will look at a number of criteria and features and determine whether or not it is likely that you have it. 

This can be a frustrating experience for clients as they go from test to test to rule out more serious conditions to often times hearing that the “tests” come back normal. Which on one hand is great because you don’t have a serious illness/disease but not so great because it leaves you wondering, “what is going on with me.”

Another problem with diagnosis is that some doctors may default to this diagnosis whenever there is someone presenting with perineal, buttock or pelvic pain (1).

Let’s look more closely at the diagnostic criteria in the research.

There are 5 criteria that must all be present to conclude a diagnosis of pudendal neuralgia (1).

  1. Pain must be in the area of the pudendal nerve region, anus to base of penis. The scrotum may be involved but does not include the testes, epididymis or vas deferens. The pain may be at the surface or deeper in the anorectal region.
  2. Pain is predominantly with sitting. It is not a positional problem but a compression problem. What this means is that sitting on a toilet should decrease pain, while sitting on a regular chair should produce symptoms.
  3. Next criteria is that the pain should not wake the individual while sleeping. Someone with pudendal neuralgia may have pain at night that makes falling asleep challenging or may wake up needing to urinate but should not be woken up due to perineal pain.
  4. There should be no sensory deficits in the perineal area. Meaning you should feel and sense your perineal area when touched, if not then it may indicate a different problem.
  5. Lastly the pain is relieved by diagnostic pudendal nerve block. It’s really important that the nerve block is done in the right place and close to the deeper nerve root.

Here are some additional diagnostic symptoms that may or may not be present with pudendal neuralgia(1), such as,
  1. Burning, stabbing, numbing or shooting pain
  2. A painful response to pressure/touch that normally would not be painful such as tight clothing or underwear
  3. The feeling of something being present in the rectum. Some might describe this feeling as a ball inside or a lump or heaviness.
  4. Pain gets worse as the day progresses
  5. One sided pain
  6. Pain with bowel movements
Here are some symptoms that are not associated with pudendal neuralgia (1).

  1. Buttocks, pubic or tailbone pain
  2. Skin rashes
  3. Shooting pains down the legs
  4. Abnormalities seen on imaging
  5. Buttock pain with sitting
  6. Sciatic type pain
  7. Urinary frequency or pain with a full bladder
  8. Pain after ejaculation
  9. Pain during and after sex
  10. Erectile dysfunction

Physiotherapy treatment

Firstly you want to seek out a pelvic floor physiotherapist, as they have received additional training in pelvic floor anatomy, assessment and treatment.

The physiotherapist will start with a thorough assessment and treatment which may include but is not limited to pain education, breathing and relaxation techniques, sleep hygiene and lifestyle changes. Manual therapy to address muscle imbalances and restricted tissues, such as fascia (also known as connective tissue). You may receive postural correction exercises, range of motion exercises and stretches where appropriate (2). The home exercise program is very important for maintaining gains made in therapy and to ensure resolution of symptoms.

 The Pelvic Health Lady

  1.    Labat et al. 2007. Diagnostic Criteria for Pudendal Neuralgia by Pudendal Nerve Entrapemnt (Nates Criteria). Neurourology and Urodynamics.
  2.  Hibner et al. 2010. Pudendal Neuralgia. The Journal of Minimally Invasive Gynecology V 17: 148-153.