Pudendal neuralgia

Chronic pelvic pain involving the sensory distribution of the pudendal nerve is called pudendal neuralgia. This can be a severely painful and disabling neuropathic condition. Pudendal neuralgia can lead to pain in the clitoris, vulva, perineum, and rectum, especially when sitting. 

Symptoms are frequently one-sided (or much greater on one side)  and the pain is described as a burning, tingling, or itching sensation. Another common symptom is the sensation of a foreign body in the vagina, perineum or rectum. In most patients, the onset of symptoms is gradual and no causative factors can be identified, but bicycle riding (spinning), vaginal childbirth, episiotomy, trauma to the coccyx (tailbone), trauma to the pelvis, pelvic surgery, and vaginal surgery can all result in injury to the pudendal nerve or one of its branches. In addition, a slipped disc or a Tarlov cyst in the spine can put pressure on the sacral nerve roots and this can cause symptoms of pudendal neuralgia. Unfortunately, this syndrome if often unrecognized by many healthcare providers. 


The most important aspect of treatment is to figure out where the injury to the pudendal nerve or one of its branches has occurred. This can be done by a combination of specials MRIs and nerve blocks.  Typically, patients with pudendal neuralgia can be managed with a stepwise approach: modification of activities, pharmacological measures (tricyclic antidepressants, gabapentinoids, SNRIs), physical therapy, and pudendal nerve blocks. Pudendal nerve blocks can be performed in the office and can be both diagnostic and palliative,  providing pain relief for up to several months. If pain persists despite these measures, more invasive procedures can be performed including radio-frequency nerve ablation, cryotherapy of the pudendal nerve, pudendal nerve neuromodulation, and pudendal nerve neurolysis. 

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