The pudendal nerve is one of the main neural structures of the pelvic floor: it originates from the sacral plexus, the complex network of peripheral nervous system nerves that emerge from the spinal column, and it runs bilaterally, passing through the pelvis until it reaches the perineum, the area between the genitals and the anus. Its function is both sensory and motor, as it contributes to the control of several structures involved in urination, defecation, and sexual function. When the nerve becomes trapped, compressed, irritated, or damaged along its anatomical course, pudendal neuralgia (also known as Pudendal neuropathy or Alcock’s canal syndrome) may occur. The resulting clinical picture is a chronic pelvic pain syndrome, with significant repercussions on the patient’s psychophysical well-being and quality of life.
What are the symptoms of pudendal neuralgia?
The clinical picture of pudendal nerve neuralgia is characterized by unilateral or bilateral perineal pain, which may variably radiate to the genital region, the anal area, or the entire perineal area. In some cases, it may be associated with sensory disturbances in the affected areas. Patients frequently describe the pain as a sensation of burning, stabbing, electric shocks, pressure, or a foreign body sensation. A characteristic feature of the condition is worsening of symptoms while sitting, whereas the pain tends to improve when standing or lying down. Associated functional disorders may also occur, such as pain or discomfort during urination, bowel movements, or sexual intercourse.
Possible causes and risk factors
Although the causes of pudendal neuralgia vary and the mechanism is not yet fully understood, the factors involved in the onset of the condition include:
- compression or entrapment of the nerve along its anatomical course (particularly beneath the piriformis muscle, between the sacrotuberous and sacrospinous ligaments, in Alcock’s canal, and in its terminal branches);
- trauma to the pelvis or perineum;
- surgical procedures in the pelvic region;
- sports activities involving prolonged pressure on the perineum (e.g., cycling);
- muscle tension of the pelvic floor;
- inflammatory or scar-related processes.
Diagnosis and its challenges
The diagnosis of pudendal neuralgia is a complex clinical challenge. The nonspecific symptoms may overlap with other pelvic conditions, making recognition difficult. Data from the “Survey on Pudendal Neuralgia” conducted in 2014 via an online questionnaire by AINPU (Italian Association of Pudendal Neuropathy) show how the diagnostic pathway can be long and difficult, characterized by multiple medical visits and misdiagnoses, as well as possible associations with mental disorders, stress, or depression. Although the study dates back over ten years, the described difficulties are still relevant today and consistent with clinical experience. In particular:
- 53.9% reported waiting between one and five years for a confirmed diagnosis.
- 17.5% waited between six and ten years.
- 9.9% experienced a diagnostic journey lasting more than ten years.
The diagnosis of pudendal neuralgia is primarily based on a clinical evaluation performed by a specialist experienced in pelvic floor disorders. The examination includes a careful medical history and a targeted manual examination, useful for assessing signs consistent with pudendal nerve involvement. Since there are no specific instrumental tests that can definitively confirm the condition, in 2006 Dr. Roger Robert proposed the so-called “Nantes Criteria”, which still represent an important clinical reference for guiding diagnosis and treatment. The criteria include five main elements:
- pain localized in the territory of pudendal nerve innervation;
- worsening of pain when sitting;
- absence of nocturnal awakening caused by pain;
- absence of superficial sensory deficits of the perineum;
- improvement of symptoms after anesthetic infiltration of the pudendal nerve (positive nerve block).
During the examination, specific clinical maneuvers may also be performed, such as the “Tinel sign”, which consists of stimulating the pudendal nerve through digital pressure via transrectal or transvaginal examination. Another test used is the “skin rolling test”, in which a fold of skin in the perineal region is lifted and rolled along the presumed course of the nerve: the onset of pain during these maneuvers may suggest involvement of the pudendal nerve.
Treatments: a multidisciplinary approach is required
To date, there is no single definitive treatment for pudendal neuropathy, and in most cases a multimodal and personalized therapeutic approach is required. Treatment strategies may include:
- lifestyle modifications, aimed at reducing activities or postures that may worsen symptoms, both in daily life and during sports;
- pharmacological therapy, which may include opioids, neuroleptics, muscle relaxants, analgesics, and antidepressants;
- physiotherapy and pelvic floor rehabilitation, sometimes combined with osteopathic techniques;
- interventional neuroradiology, with ultrasound-guided or CT-guided pudendal nerve infiltrations. In some cases, botulinum toxin injections or other selected infiltrative techniques may also be used;
- sacral neuromodulation;
- pulsed radiofrequency;
- surgical treatment, reserved for selected cases, which may include pudendal nerve decompression, neurolysis procedures, or implantation of neuromodulators.
An invisible disease
Pudendal neuralgia is one of those “invisible diseases”: poorly known, rarely discussed, insidious, and often responsible for delayed diagnosis. In the aforementioned A.I.N.P.U. questionnaire, participants were asked to provide any additional information useful for understanding the impact of the condition on daily life, as well as suggestions for improving medical care. What emerges is a bleak picture: a true cry for help from hundreds of people who every day live with difficulties not only physical but also relational, occupational, and economic. These are stories of daily pain that are not always heard, too often minimized, leaving those who suffer in a condition of profound isolation.
BIBLIOGRAPHY
- www.ainpu.it (A.I.N.P.U. Italian Association of Pudendal Neuropathy – ONLUS)
- www.nataleursino.com
- www.fisioterapiaitalia.com
