What is pudendal neuralgia?
It is a rare and very painful disease; the discomfort is constant and may worsen in certain positions.
Nerve pain is extremely severe pain and can become unbearable, such as in trigeminal neuralgia , intercostal pain , sciatica , carpal tunnel syndrome , etc.
The course of the pubic nerve includes the perineal, genital and anal regions, so symptoms appear in this area.
The majority of patients are women.
What Are the Causes of Pudendal Neuralgia?
This neuropathy can be triggered during sports activities, trauma, in rare cases during sexual intercourse, childbirth, proctological-urological-gynecological operations or pelvic endoscopy, but it can also occur without any apparent reason.
The cause of this neuralgia is not yet clear; the most plausible assumption is that the nerve is being compressed because the symptoms are neural in nature and follow the course of the pubic nerve.
Die Anatomie des Pudendus-Nervs
The pudendal nerve (pudendal nerve) arises from the spinal cord at the level of the sacrum, more precisely from the nerve roots that emerge from the intervertebral foramina S2-S3-S4. From here it runs along the back and passes through the large ischial foramen (foramen ischiadicum majus) behind the pear muscle (musculus piriformis). Below it, it is divided into two branches: the perineal nerve (Nervus perinealis) and the dorsal nerve of the penis (Nervus dorsalis penis), which continue to the penis or the labia majora.
The pubic nerve is both sensory and motor, innervating the region of the anal sphincter, genitals, and the intervening skin area.
What Are the Symptoms of Pudendal Neuralgia?
The symptoms can be of different kinds; the pains are felt in the pelvic area, between the anus and genitals; neuralgia can be unilateral or bilateral
Those who suffer from pudendal neuralgia experience severe pain when sitting for long periods; he may need to use a seat ring; This is an air-filled ring, similar to a swim ring, that transfers body weight to the outer buttocks and thighs, relieving the mid-perineal area.
Standing for a long time is also uncomfortable; in bed, on the other hand, the symptoms decrease or disappear completely. Discomfort with urination, bowel movements and sexual intercourse can occur, and erection problems are also possible in men.
In addition to unbearable pain, the patient often complains of:
- Foreign body sensation in the rectus
The stabbing pain occurs when sitting in a chair or in a car and usually during sexual activity .
The patient cannot bear tight-fitting clothing because it presses directly on the perineal region.
Symptoms worsen with exercise.
During the day, the patient usually chooses the standing position or sits on a seat ring so as not to stress the affected area. There may be a loss of sensation in the area supplied by the pubic nerve, in the genitals, and in the gluteus maximus.
Symptoms can affect the bladder and cause incontinence, a feeling of not being able to empty the bladder and an urgency to urinate.
Pain may occur during and after defecation, the patient may also suffer from constipation , fecal incontinence or hemorrhoids . Sexual intercourse is painful and the feeling persists afterwards.
This neuralgia tends to become chronic because it does not respond to common painkillers.
Diagnosis of pudendal neuralgia
A medical examination is usually sufficient for the diagnosis, since imaging examination methods such as magnetic resonance bring negative results.
Often this neuralgia is confused with other diseases; the patient often visits many specialists before the actual problem is identified and he is exposed to sometimes invasive procedures that could have been avoided.
The region affected by the symptoms is within the competence of gynaecologists, urologists, proctologists, gastrointestinal specialists, neurologists, etc.
Doctors must differentiate this syndrome from other diseases such as:
- vaginal inflammation
- urinary tract infection
- testicle pain
- coccyx pain
- Pain of a neurological peripheral or medullary nature, etc.
The GP or urologist will prescribe an abdominal ultrasound to evaluate the perineum and testicles: in this case, only the prostate and bladder will be analyzed.
To get a more complete picture, an ultrasound scan of the scrotum (scrotum) and groin area must be done, using a different probe.
This ultrasound makes other body structures visible and can show a broken testicle (scrotal hernia) that you might not otherwise notice.
To diagnose pudendal neuralgia, hyposensitivity of the perineum must be noted, as well as loss of anal reflex, pain and burning along the course of the pubic nerve, discomfort in the external anal sphincter. If pressure is applied to the anus, this will produce pain in the sciatic region.
Electromyography to evaluate the innervation of the anal sphincter and the bulbospongiosus muscle is positive in patients with pudendal neuralgia. Another useful instrumental study is the PNTML, pudendal nerve latency study, which measures the nerve’s motor output and conduction velocity.
Anorectal manometry can also be done to diagnose conditions such as rectal spasms, constipation , fecal incontinence, anal fissures, difficulty passing stool , anal prolapse , and hemorrhoids .
What can you do? Which therapy is suitable?
Anyone suffering from pudendal neuralgia often visits many specialists, undergoes a wide variety of therapies and, last but not least, surgery.
Anti-inflammatory drugs usually don’t solve the problem. Physical therapies of physical therapy can relieve symptoms, but the most effective treatments are the manual and surgical forms of therapy. A commonly used form of treatment is the injection of anesthetic, which has a great pain-relieving effect, but is not permanent.
Manual therapy dissolves adherences in the connective tissue caused by trauma , operations, etc. have arisen and are now interfering with the nerve, causing pain.
Doctors usually prescribeanti-inflammatory drugs, cortisone drugs (Medrol), antidepressants and drugs for neuropathic pain.
Unfortunately, the problem cannot be solved by pharmacological treatment, in some cases the pain can be reduced somewhat, but side effects often occur.
Surgical intervention, on the other hand, consists in decompressing the nerve, the pain should have disappeared within a year.
Natural remedies and osteopathy
To relieve the pain that occurs when sitting, the patient can use an air-filled seat ring or swim ring.
Of the alternative treatment approaches, osteopathy can solve the problem because it relieves the pressure that the muscles and ligaments of the pelvis put on the pudendal.
The main remedies in the treatment of pudendal neuralgia include:
- healthy eating; avoid fried foods, alcohol, meat, dairy products, coffee, desserts and ready meals;
- regular physical activity;
- discontinue medication;
- quit smoking ;
- hot shower.
This allows the body to function properly.
Kegel exercises for perineal rehabilitation can improve muscle control and thus help release tension; however, they must not be practiced to strengthen the muscles.
Many patients ask about the effectiveness of acupuncture, but in this case it could not show satisfactory results.