Pudendal Neuralgia

Pudendal Neuralgia

 Pudendal nerve entrapment  

Pudendal nerve entrapment is a possible diagnosis in patients with anoperineal pain. The pudendal nerve follows a very difficult path. It supplies sensation to almost the entire pelvic area as well as motor function to the pelvic floor muscles and urethral sphincter. The junction of the sacrotuberous and sacrospinous ligaments and the pudendal canal of Alcock are two major areas of entrapment. CT guided local anaesthetic ischial spine or the Alcock's canal can help with diagnosis. Some patients undergo surgery to decompress the pudendal nerve. There are various surgical techniques with one published randomized controlled trial suggesting improvement in two thirds of patients at one year follow up. (Robert R et al ) There are few surgeons performing such surgery worldwide.  

  The clinical history and physical examination are a crucial part of the workup. Patients frequently present with extreme pain on sitting which may be relieved by standing. (Labat JJ et al ) Patients will often stand during a consultation or if they sit, it may be in an awkward position with the weight on one buttock or slouched backwards in the chair to relieve the pressure on the painful area. They may also use various cushions with a cut out. ( see pain in sitting )This difficulty with sitting can easily be overlooked by a health professional. It can also take courage on the part of the patient to discuss such difficulties. The first thing that is suggested to a patient on entering a consulting room is to take a seat. It can be extremely difficult for a patient to refuse a seat and to insist on standing. Many patients may force themselves to endure extreme pain for the duration of a consultation. 

References:

Diagnostic criteria for pudendal neuralgia by pudendal nerve entrapment (Nantes criteria )JJ Labat, T Riant, R Robert, G Amarenco et al

Neurourol Urodyn 2007 Sep 7

Decompression and transposition of the pudendal nerve in pudendal neuralgia: a randomized controlled trial and long-term evaluation. R Robert, JJ Labat, M Bensignor et al

Eur Urol 2005 Mar; 47(3);403-8

 An Information Standard certified leaflet about the diagnostic criteria and management of pudendal neuralgia can be obtained from info@pelvicpain.org.uk