Pudendal Neuralgia: Could the Pudendal Nerve Be Causing Your Pelvic Pain?
Pelvic pain that feels burning, shooting, tingling or electric can sometimes involve irritation or increased sensitivity of the pudendal nerve.
The pudendal nerve is an important nerve within the pelvis that provides sensation to areas including the vulva, perineum and around the anus, while also contributing to pelvic floor and continence function.
Pudendal neuralgia describes pain experienced within the distribution of the pudendal nerve. Symptoms can vary considerably, and having pelvic or vulval pain doesn't automatically mean the pudendal nerve is the cause.
Understanding the location, behaviour and triggers of your pain is important when determining whether pudendal nerve involvement should be considered.
The pudendal nerve originates from the sacral nerve roots S2–S4.
It travels through the pelvis before dividing into branches that supply areas including the:
Vulva
Clitoris
Perineum
Area around the anus
External genital region
It also has motor functions involving some of the pelvic floor and sphincter muscles.
Because of its location, symptoms involving the pudendal nerve can sometimes overlap with other pelvic floor, vulval, bladder and bowel conditions.
Where Is the Pudendal Nerve?
People may describe pudendal nerve pain as:
Burning
Shooting
Stabbing
Tingling
Electric or “zapping”
Pins and needles
Aching
Increased sensitivity
A feeling of pressure or fullness
A foreign-body sensation in the vagina or rectum
Symptoms may affect one side or both sides and can vary throughout the day.
What Does Pudendal Neuralgia Feel Like?
Pain aggravated by sitting is one of the characteristic features considered when assessing pudendal neuralgia.
Sitting places pressure through the perineal region and structures surrounding the pudendal nerve.
Some people find symptoms gradually increase the longer they sit and improve when standing, lying down or changing position.
However, pain with sitting isn't unique to pudendal neuralgia. Pelvic floor muscle dysfunction, vulvodynia, coccyx pain and other musculoskeletal or pelvic pain conditions can also make sitting uncomfortable.
This is why sitting pain alone isn't enough to diagnose pudendal neuralgia.
Why Does My Pelvic Pain Get Worse When I Sit?
Yes. Because branches of the pudendal nerve provide sensation to the external genital region, pudendal neuralgia can sometimes be experienced as pain or altered sensation around the:
Vulva
Clitoris
Labia
Vaginal entrance
Perineum
Some people may initially describe their symptoms simply as vulval burning or sensitivity.
There are many other causes of vulval pain, however, so appropriate assessment is important.
Can Pudendal Neuralgia Cause Vulval or Clitoral Pain?
It can.
The pudendal nerve also supplies sensation around the perineum and anus.
Symptoms may therefore be experienced as burning, aching, pressure or altered sensation around the rectal or perineal region.
Some people describe the unusual sensation that something is present within the vagina or rectum even when there isn't.
Can Pudendal Neuralgia Cause Rectal or Perineal Pain?
Pudendal nerve sensitivity can contribute to pain during or following sexual activity for some people.
Symptoms may include genital burning, sensitivity, pain around the vaginal opening or a flare in pelvic pain following intercourse.
However, painful sex can have many possible causes, including pelvic floor muscle overactivity, vulvodynia, endometriosis, hormonal changes and other pelvic conditions.
Can Pudendal Neuralgia Cause Pain During or After Sex?
Prolonged pressure through the perineal region can irritate the pudendal nerve in some people, which is why pudendal symptoms have been reported in cyclists.
However, experiencing numbness or pelvic discomfort while cycling doesn't automatically mean you have pudendal neuralgia.
Bike setup, saddle position, training load, pelvic floor function and other musculoskeletal factors may also be relevant.
Persistent genital numbness or pain associated with cycling is worth having assessed.
What Causes Pudendal Neuralgia?
There isn't always one identifiable cause.
Potential contributors may include:
Prolonged pressure or compression around the nerve
Cycling or prolonged sitting
Pelvic surgery
Childbirth
Pelvic trauma
Pelvic floor muscle overactivity
Scar tissue
Repetitive loading
Changes involving surrounding pelvic structures
For some people, no clear triggering event is identified.
Can Cycling Cause Pudendal Nerve Pain?
No — and this is an important distinction.
Pudendal neuralgia describes pain within the distribution of the pudendal nerve.
Pudendal nerve entrapment refers more specifically to compression or entrapment of the nerve along its anatomical pathway.
Not everyone with pudendal neuralgia has a mechanically entrapped nerve.
This distinction matters because telling someone their nerve is “trapped” without appropriate evidence can create unnecessary fear and may not accurately explain their symptoms.
Is Pudendal Neuralgia the Same as Pudendal Nerve Entrapment?
There isn't one simple scan or test that can definitively diagnose every case of pudendal neuralgia.
Diagnosis is generally based on a person's symptoms, clinical history and examination while considering and excluding other possible causes of pelvic pain.
Clinicians may consider features known as the Nantes criteria, including whether pain:
Occurs within the anatomical territory of the pudendal nerve
Is predominantly aggravated by sitting
Does not usually wake the person from sleep
Occurs without objective sensory loss on examination
Improves following a diagnostic pudendal nerve block
Specialist investigation may be recommended depending on the presentation.
How Is Pudendal Neuralgia Diagnosed?
Not necessarily.
Standard imaging may be useful for investigating other possible causes of pelvic pain, but a normal MRI does not automatically rule out pudendal neuralgia.
Likewise, imaging findings need to be interpreted alongside your symptoms and clinical assessment rather than being considered in isolation.
Will Pudendal Neuralgia Show on an MRI?
Pelvic floor muscle overactivity can occur alongside pudendal neuralgia.
The pudendal nerve travels through areas closely associated with pelvic muscles and connective tissues. Persistent pain may also lead to protective pelvic floor guarding.
This means there can sometimes be an interaction between nerve sensitivity, pelvic floor muscle tension and pain.
However, finding a tight pelvic floor doesn't necessarily prove that it is compressing the pudendal nerve.
Can a Tight Pelvic Floor Affect the Pudendal Nerve?
Should I Stretch if I Have Pudendal Neuralgia?
There isn't a universal stretching program for pudendal neuralgia.
Aggressive stretching isn't necessarily appropriate for an irritated or sensitive nerve, and repeatedly forcing movements that significantly reproduce symptoms may aggravate some presentations.
Exercise and movement should instead be individualised according to your symptoms, physical findings and activity goals.
Management depends on what appears to be contributing to the symptoms and may involve several healthcare professionals.
Depending on the individual, management may include:
Activity and load modification
Pelvic floor rehabilitation
Pelvic floor relaxation where appropriate
Movement and exercise rehabilitation
Reducing prolonged aggravating positions
Pain education
Medical pain management
Pudendal nerve blocks in selected cases
Specialist assessment
Psychological support for persistent pain where appropriate
Surgery is not the standard treatment for everyone with pudendal neuralgia and is generally considered only in carefully selected cases where nerve entrapment has been appropriately investigated.
How Is Pudendal Neuralgia Managed?
Where pelvic floor or musculoskeletal factors are contributing to symptoms, pelvic health care may form part of a broader management approach.
Depending on your presentation, this may include:
Pelvic floor assessment
Pelvic floor relaxation and coordination
Assessment of surrounding muscles and movement
Exercise and rehabilitation
Sitting and activity modification
Breathing strategies
Pain and nervous-system education
Gradual return to meaningful activities
Self-management strategies
Collaboration with your GP, pain specialist or other healthcare professionals
An internal pelvic floor examination is not automatically required and should only occur where clinically appropriate and with your informed consent.
How Can Pelvic Health Care Support Pudendal Neuralgia?
New genital numbness or pelvic pain should not automatically be assumed to be pudendal neuralgia.
Seek urgent medical assessment for new loss of bladder or bowel control, difficulty passing urine, numbness around the saddle/genital region accompanied by neurological changes, or new significant leg weakness, as these can indicate other neurological conditions requiring urgent investigation.
Persistent vulval, genital, perineal or rectal pain should also be appropriately assessed to consider other possible causes.
When Should I Seek Medical Advice for Pelvic Nerve Pain?
At Yarra Valley Women's Health, our pelvic health osteopaths provide individualised assessment and management where pelvic floor and musculoskeletal factors may be contributing to pudendal nerve symptoms and persistent pelvic pain.
Our aim is to help you better understand your symptoms, identify factors that may be contributing and provide you with knowledge and appropriate management strategies, while collaborating with your wider healthcare team where required.