Pudendal nerve entrapment
Management options include lifestyle adaptations, physical therapy, medications, long acting local anesthetic injections and others.
If the pain is chronic and poorly controlled, pudendal neuralgia can greatly affect a person's quality of life, causing depression.
[6][16] In over 50% of cases, the pain is in the perineum, but may be located in the genital areas (vulva, vagina, clitoris in females; glans penis, scrotum in males).
[9] The onset of pain symptoms is usually gradual without any single causative event,[15] although sometimes the condition may appear suddenly after some trauma, a long distance trip (cars, planes, etc.
[35] The nerve progresses between the piriformis and coccygeus muscles and exits the pelvis by passing through the greater sciatic foramen and enters the gluteal region.
[35] The pudendal canal is a fascial compartment located in the inferior (lower) border of the obturator internus fascia lining the lateral (side) wall of the ischiorectal fossa.
[17] This branch also supplies sensation to the anal canal, where it plays a role in maintaining continence and allows discrimination of the contents of the rectum (solid feces or gas / flatus).
[47] Heavy and prolonged cycling, especially if an inappropriately shaped or incorrectly positioned bicycle seat is used, may eventually thicken the sacrotuberous and/or sacrospinous ligaments and trap the nerve between them, resulting in PNE.
[15] Anatomic abnormalities can result in PNE due to the pudendal nerve being fused to different parts of the anatomy, or trapped between the sacrotuberous and sacrospinalis ligaments.
[15] Repetitive overuse of pelvic floor muscles may lead to remodeling of the bone in the region of the ischial spine and the inferior lateral angle of the sacrum.
[31] The diagnosis of pudendal nerve entrapment is based on the medical history, clinical examination and a positive result of the injection test.
[54] The Nantes group stated that they had deliberately created a limited list of simple diagnostic criteria in order to prevent other conditions being incorrectly diagnosed as pudendal nerve entrapment.
The group stated that the diagnostic criteria were therefore inevitably overly simplistic in nature, and would not cover all clinical situations as the condition is complex and symptoms are multiple and variable.
[16] As such, the expert consensus panel recommended physical therapy for pudendal nerve entrapment when it is associated with myofascial syndromes affecting levator ani, or the piriformis or obturator inturnus muscles.
[16] If there is hypertonia of levator ani (i.e., if the pelvic floor is "too tight"), endocavital maneuvers[clarification needed] were recommended by the expert consensus panel.
Strengthening exercises may also be recommended to relieve the excessive pressure caused by the entrapment, but there is currently limited evidence to support this choice of therapy.
Psychotherapy is especially indicated where there are associated psychological conditions such as depression, anxiety, catastrophism, feelings of injustice, kinesiophobia (the avoidance of movement because of fear of pain), post-traumatic stress disorder, perfectionism, hypervigilance, sexual dysfunction and lack of motivation for change.
[16] Based on many studies on the pharmaceutical management of neuropathic pain in general, the expert consensus recommended a low and progressive dose of a tricyclic antidepressant medication such as Amitriptyline, or a selective serotonin reuptake inhibitor such as Duloxetine, or an anti-epileptic such as Gabapentin.
[16] The expert consensus panel found no evidence for the use of pudendal nerve blocks as a treatment modality, either with corticosteroid or as local anesthetic alone.
[16] However, the panel stated that only patients for whom all 5 Nantes criteria were present, including the pudendal block injection test, should undergo surgery.
[4] Some advise that surgery should not be attempted unless pudendal neuralgia has been present for over 1 year,[62] thereby allowing sufficient time to try various non surgical options first.
[4] The transischiorectal fossa approach involves placing an incision halfway up in the back wall of the vagina (in females) or in the rectum (in males).
[10] In 2024 a systematic review which included reported outcomes of 810 patients who had undergone different surgical procedures for pudendal nerve entrapment was published.
There were no adverse events reported, but only bilateral stimulation of the pudendal nerve gave statistically significant reduction in pain 4 weeks after the procedure.
[61] Pulsed radiofrequency (PRF) is an invasive neuromodulation technique involving the brief delivery of an electrical field and controlled heat bursts to tissues via a catheter needle tip.
[64] In pulsed radiofrequency stimulation, the mechanism of action is not completely understood, but it is thought to involve inhibitory pain pathways and reduction of pro-inflammatory cytokines such as tumor necrosis factor-α and interleukin-6.
[64] In 2014, a study involving 30 patients with pudendal neuralgia and who had not achieved pain relief with other treatments underwent pulsed radiofrequency under computed tomography guidance.
Affected individuals may undergo various tests and investigations, and over time may seek treatment with multiple different medical specialists such as gynecologists, colorectal surgeons, and urologists.
[70] By 2005 some American doctors were publishing detailed theories about pudendal nerve entrapment, and treating the condition with block injections of local anesthetic and corticosteroids.
In 2019, a group named Convergences in Pelvic and Perineal Pain organized the development of consensus recommendations for the diagnosis and management of entrapment of the pudendal nerve.
