Image of a person experiencing pelvic pain, highlighting the affected pudendal nerve area.

Pudendal neuralgia

Pudendal neuralgia, or Alcock's canal syndrome, results from compression or irritation of the pudendal nerve, which innervates the perineum, the area between the anus and the external genitalia.

Quickfacts
Pudendal neuralgia
Cause
Symptom
Diagnosis
Treatment
FAQ
Quickfacts
Pudendal neuralgia
Cause
Symptom
Diagnosis
Treatment
FAQ

Quick Facts – Pudendal Neuralgia

  • What is it? Compression or irritation of the pudendal nerve, causing perineal pain.
  • Main causes: Prolonged sitting, trauma, childbirth, pelvic surgery, repetitive sports activities (cycling, horse riding).
  • Symptoms: Burning pain, numbness, tingling, pain during intercourse, bowel problems, sensation of a foreign body.
  • Diagnosis: Based on the Nantes criteria, a clinical examination and imaging to rule out other causes.
  • Treatments: Medication, physiotherapy, injections, neuromodulation and, as a last resort, surgery.
  • Can it be relieved naturally? Yes, with osteopathy, relaxation, hypnosis and acupuncture.

Pudendal neuralgia

This nerve plays a key role in sensation and motor control in these areas. It can be compressed at various points along its path, particularly in Alcock's canal, causing persistent pain, often burning or continuous, exacerbated by certain positions, such as prolonged sitting. Pudendal neuralgia affects both men and women, although symptoms may vary depending on gender.

Cause

Pudendal neuralgia develops when the pudendal nerve is irritated or compressed. Various factors can cause this compression, such as:

  • Nerve compression: The nerve can be compressed by nearby muscles, ligaments or blood vessels, especially when sitting for long periods of time.
  • Trauma: Pelvic fractures, falls or accidents can damage this nerve.
  • Repetitive activities: Certain activities, such as cycling or horse riding, put prolonged pressure on the pelvic region.
  • Surgery: Operations in the pelvic region, such as those related to the uterus or prostate, can sometimes cause nerve damage.
  • Childbirth: Stretching of the tissues during childbirth can cause injury to the nerve.
  • Inflammation: Infections, autoimmune diseases or endometriosis can cause inflammation of the nerve.
  • Hormonal factors: During pregnancy or menopause, hormonal changes can weaken the nerve and make it more vulnerable to compression.
  • Anatomical abnormalities: Conditions such as displaced ligaments or muscles can also put pressure on the nerve.

Symptoms

The symptoms of pudendal neuralgia vary depending on the location and intensity of the nerve compression. The most common signs include:

  • Perineal pain: The pain is often intense, burning or stabbing, and is located in the area innervated by the pudendal nerve, between the anus and the external genitals. It may radiate to the buttocks, thighs and sometimes the lower back.
  • Numbness and tingling: Sensations of numbness, pins and needles or ‘electric shocks’ may be felt in the genital, perineal and anal areas.
  • Pain during sexual intercourse (dyspareunia): In women, pudendal neuralgia can cause pain during sexual intercourse, which affects quality of life.
  • Bowel problems: Pudendal neuralgia can cause difficulty defecating, anal pain, and constipation or episodes of diarrhoea.
  • Foreign body sensation: Some people experience a ‘foreign body’ sensation in the vaginal or anal area, which can be very uncomfortable.
  • Worsening pain when sitting: The pain tends to worsen when the patient is sitting, due to pressure on the nerve.

Diagnosis

The diagnosis of pudendal neuralgia is based on a clinical assessment and additional tests. No imaging can confirm this condition on its own, which is why several criteria are used to establish a definitive diagnosis.

The Nantes criteria: These are specific criteria used to diagnose pudendal neuralgia. They include:

  • Pain in the pudendal nerve area
  • Worsening when sitting
  • No waking up at night due to pain
  • No sensory disturbances in this area
  • Positive pudendal nerve block test

 

Clinical examination and imaging: In addition to the Nantes criteria, additional tests such as pelvic MRI and lumbar MRI may be performed to rule out other possible causes of perineal pain, such as muscle disorders, herniated discs or tumours. If these tests do not reveal any significant abnormalities, this increases the likelihood of pudendal neuralgia.

Treatment

The treatment of pudendal neuralgia depends on the underlying cause and the severity of the symptoms. Several approaches may be considered:

  • Lifestyle changes: It is advisable to avoid prolonged sitting, engage in regular physical activity and lose weight if necessary to reduce pressure on the nerve.
  • Medication: Painkillers, anti-inflammatory drugs, antidepressants or anticonvulsants may be prescribed to relieve pain and associated nerve symptoms.
  • Injections: Injections of corticosteroids or local anaesthetics into the pudendal nerve may provide pain relief.
  • Physiotherapy: Pelvic physiotherapy helps relax the pelvic muscles and improve posture, thereby reducing pressure on the nerve. Muscle stretching and muscle tension control will be used primarily.
  • Neuromodulation: Neuromodulation stimulation of the pudendal nerve may be used as a last resort to regulate nerve activity and relieve pain.
  • Surgery: Although rare, surgery may be considered if nerve compression has responded temporarily to injections.

FAQ

How to calm the pudendal nerve?

All conservative options are considered. A significant role is given to osteopathy, relaxation, hypnosis, and acupuncture.

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