recommendations include wearing padded bike shorts, standing on pedals periodically, shifting to higher gears, and taking frequent breaks. for sitting on hard surfaces, a cushion or coccyx cushion can be used to take pressure off the nerves. surgical decompression surgery is a "last resort", according to surgeons who perform the operation. it is highly controversial, given that normal cadavers show the pudendal nerve to be "entrapped" and attached, questioning the whole thesis of pudendal nerve entrapment. according to supporters of the theory of pne, surgery is indicated when severe symptoms are present after exhausting all other forms of treatment. the surgery is also another option to confirm the diagnosis of pudendal nerve entrapment. the surgery is performed by a small number of surgeons in a limited number of countries. the validity of decompression surgery as a treatment and the existence of entrapment as a cause of pelvic pain are highly controversial. while a few doctors will prescribe decompression surgery, most will not. notably, in february 2003 the european association of urology in its guidelines on pelvic pain said that expert centers in europe have found no cases of pne and that surgical success is rare: pudendal nerve neuropathy is likely to be a probable diagnosis if the pain is unilateral, has a burning quality and is exacerbated by unilateral rectal palpation of the ischial spine, with delayed pudendal motor latency on that side only. however, such cases account for only a small proportion of all those presenting with perineal pain. proof of diagnosis rests on pain relief following decompression of the nerve in alcock's canal and is rarely achieved. the value of the clinical neurophysiological investigations is debatable; some centres in europe claim that the investigations have great sensitivity, while other centres, which also have a specialized interest in pelvic floor neurophysiology, have not identified any cases.— european association of urology, guidelines on chronic pelvic pain there are several different approaches in order to perform a decompression surgery on the pudendal nerve. the different access areas include: superior transgluteal, superior retrosciatic, inferior retrosciatic, medial transgluteal, inferior transgluteal and transischial entry. the transgluteal entry involves "neurolysis of the pn at the infrapiriform canal and transection of the sacrospinal ligament." another point of entry which is described as a "perineal para-anal pathway", "follows the inferior rectal nerve to the alcock's canal." if nerve damage is discovered, other surgery options may be considered like a "neurectomy" or "neuromodulation".