Pudendal Neuralgia or Back Pain?

Pudendal Neuralgia

Pudendal neuralgia, also called pudendal nerve entrapment, is a pelvic pain syndrome often confused with various lower back pain manifestations. Symptoms exist in and around the sacrum, in the pelvis and in some of the most sensitive parts of the anatomy, including the rectal region, the perineum and in the genitals.  

Pudendal nerve entrapment is a hotly debated diagnosis, since like many other lower back and buttock based neuralgias, there are many theories as to the actual causation, a diversity of diagnostic tests that often produce no definitive results and an array of potential treatments that demonstrate a mixed bag of possible outcomes for patients. In essence, like back pain, it seems that pudendal nerve pain is greatly misunderstood by the very doctors who diagnose and treat it.

This focused essay examines a diagnosis on the rise: pudendal nerve pain. We will discuss possible causes for pudendal neuralgia to occur, the range of symptoms often associated with the diagnosis and some of the more popular and effective treatment options utilized to battle this terribly affective disorder. We will also take a detail look at the possibility that pudendal nerve syndromes are yet another diagnosis that can be categorized in the modern epidemic of mindbody pain syndromes.

Pudendal Neuralgia Defined

Neuralgia is a medical term that signifies nerve pain and other related symptoms, such as paresthesia, weakness or other functional deficit.  The pudendal nerve is a major neurological conductor located in the pelvis, serving the motor, sensory and autonomic needs of three vital areas of the anatomy: the anus and rectum, the perineum and the genitals. This neurological tissue is formed by the joining of branches of the S2, S3 and S4 sacral spinal nerve roots. Therefore, pudendal nerve entrapment is a condition that entails marked pain and dysfunction in these regions, as well as in the general area of the pelvis, where the branches of the nerve travel to their respective destinations.

Pudendal neuralgia syndromes affect women more than men by a margin of about 3 to 1. The condition also tends to affect people in the prime of their lives, affecting mostly working-age people in what may be called the “ages of responsibility” (30 to 60). This is certainly one factor that makes a mindbody cause very plausible, since this is the same age range that is actively victimized by virtually all psychologically-induced pain syndromes.

Nerve symptoms affecting the pudendal tissues can be caused by a wide range of suspected factors, although many patients do not demonstrate a history or anatomical propensity towards any of the most often accepted structural explanations. Some of the typically blamed causes of pudendal entrapment include pregnancy and childbirth, pharmaceutical product side effect, excessive participation in cycling sports and other dynamic seated activities, localized or spinal injury, autoimmune disease, surgical complication, musculoskeletal disease, demyelinating condition, lower spinal cord injury or anatomical structural irregularity. Lesser blamed factors include bodybuilding and serious weightlifting, general vigorous exercise participation, as well as excessive sitting in combination with obesity and a sedentary lifestyle.

It is obvious that many very different factors have been equated with pudendal nerve pain and it is also no surprise that many enlightened mindbody medicine practitioners have added this neuropathy diagnosis into their ever-growing list of possibly psychogenic pain syndromes. The mechanism for mindbody variants can involve direct oxygen deprivation of the nerve itself, or any of its branches, as well as structural compression of the nerve caused by ischemia of surrounding soft tissues, such as the piriformis muscle or the sacrospinous and sacrotuberous ligaments.

Pudendal Neuralgia Symptoms

Pudendal neuralgia symptoms can take many forms and may affect large areas of the lower body, including some of its most sensitive regions. Symptoms blamed on compression of the nerve often do not correlate by location or by duration, since many diagnosed patients experience lasting pain when continuing compression should cause numbness and functional loss. Below are listed the most common symptomatic expressions associated with pudendal nerve syndromes:

Pain is the main complaint for most patients. This pain might affect the general sacral and pelvic regions or specific areas of the lower anatomy, including the buttocks, hips, anus, perineum, as well as the internal or external genitals. General pelvic floor pain may accompany symptoms in both genders. Pain is often positionally-dependent or based on particular ranges of movement or activities.

Urinary or fecal incontinence is relatively common and might cause severe lifestyle restrictions and emotional consequences for the victim.

Sexual dysfunction is also commonplace, with patients reporting diminished sensations, exaggerated sensations, inability to climax, uncontrolled climax, pain upon sexual stimulation or inability to perform sexually. Some patients report persistent arousal even when not engaged in sexual thoughts or activities.

Constipation and/or the inability to urinate may replace incontinence or coexist, making for a double torment of opposing symptomologies.

Symptoms are typically worsened when sitting and relieved when standing, reclining or while seated on a surface that prevents contact with the central buttocks region, such as a donut cushion.

Diagnosis of Pudendal Neuralgia

Pudendal nerve entrapment is very often mistaken for another similar pain syndrome that may mirror many of the same symptoms and locations. Some of the more common erroneous diagnostic pronouncements include sacroiliac joint dysfunction, piriformis syndrome, general lower back pain, hip bursitis, pelvic floor dysfunction, urinary tract infection,  central spinal stenosis (since it is often coincidentally present), hemorrhoids, vulvodynia, prostatitis and various disease manifestations. In some cases, these diagnoses might also be correct and exist concurrently with the pudendal nerve pain.

Physicians have not set definitive diagnostic criteria for pudendal neuralgia, but can use a variety of procedures and tests to reach the conclusion in the absence of other explanations. Some of the most often utilized diagnostic evaluations include MRI studies, electromyography, various injection-based techniques and pudendal nerve motor latency testing. General symptomatic correlation with structural spinal or extra-spinal evidence will be completed and the results of a physical exam will be factored into the diagnosis, as well.

Very few patients will receive a diagnosis of any pudendal nerve condition immediately, but instead must typically endure several more general diagnostic suspicions and fruitless treatments before eventually gaining a more accurate explanation for their suffering.

Pudendal Neuralgia Therapy

Treatment for pudendal nerve symptoms depends greatly on the type of doctor consulted, the exact case-specific circumstances of the causative condition and many other individual factors. Some of the more commonly applied therapies include all of the following care approaches:

Surgery has gained tremendous ground as a leading treatment, despite its often poor results and common incidence of substitute symptomology even when primary symptoms are initially relieved. Surgical techniques vary greatly and usually entail some type of decompression procedure that is used to free the nerve from impingement by the piriformis muscle, compression between the sacrospinous and sacrotuberous ligaments, or general encroachment by some problem within the Alcock’s Canal, through which the nerve travels.

Drug therapies are often part of the causative process or the cure.  A variety of pharmaceuticals might be prescribed to provide symptomatic relief, but none of these products demonstrate any curative abilities for neuralgia. In some cases, existing drugs may be tapered off or ceased, since some pharmacological substances are known in increase neuralgia activity.

Exercise therapy is another treatment that is ironically often blamed as the cause, as well as cited as the potential cure for pudendal neuralgia. Many patients are told they must stop exercising so much, since this factor is suspected of creating the pain syndromes. Meanwhile, other patients are told to use exercise or physical therapy to treat existing neuralgia in the pudendal nerve region.  

Lifestyle modifications range greatly and might include prescriptions to eat differently, sit less, sit on a special cushion to reduce pressure on the pudendal nerve, participate in different fitness activities, cease cycling or other recommendations.

Injection therapies are common parts of the diagnostic process, using nerve blocks and the liberal application of anesthetics in an effort to clarify the exact tissues implicated in the pain condition. Injections are also a part of many therapy programs, with the similar anesthetics being used recurrently to provide short to moderate term relief. Alternately, prolotherapy might be used by some patients who adhere to natural and alternative care regimens. Botox has also demonstrated good results for many patients, especially those suspected of suffering from muscular compression of the pudendal nerve.

Knowledge therapy has proven itself to be highly effective for many patients with pudendal pain. Although this approach does not do anything to act on the anatomy, it helps resolve the underlying psychoemotional origins of the pain problem, eliminating the symptom imperative in the process.

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