Pudendal Nerve Entrapment Syndrome is mostly under diagnosed and inappropriately treated

Danielle R. Steilen-Matias, MMS, PA-C. Caring Medical Florida
Ross Hauser, MD. Caring Medical Florida

Pudendal Nerve Entrapment Syndrome is mostly under diagnosed and inappropriately treated

Many times a patient will contact us via email or phone call and describe their long medical history of dealing with problems of a pelvic area numbness and burning. They have sensations of pain or tenderness in the genitalia that would even make wearing underwear painful. Some people will describe that they have a feeling of a lump in the pelvic or groin area where there is actually no lump, just the sensation that one is there.

Both women and men may report problems of urinary problems, including frequency or urgency. Men will often report erectile dysfunction that is not responsive to traditional erectile dysfunction treatments. Women may report painful sex and other sexual dysfunctions.

The people that we see in our offices have been on a long journey to a diagnosis. What that has been elusive. Equally elusive has been any type of effective treatment.

The hunt for the cause of your pelvic pain


For many people, numerous consultations with urologists resulted in looking for a problem that a urologist treats. For many people this is the right direction. For the people that we see in our offices, this was not the right directions as indicated by this person’s continued symptoms and a history that can suggest pudendal nerve entrapment may be occurring.

This would include:

  • Pain after childbirth
  • Sports or work activity that could aggregate the pelvic region:
    • Horseback riding
    • Cycling
    • Motorcycle riding
    • Prolonged periods of heavy duty work where sitting is required, like landscapers on riding lawn mowers, farmers on tractors, heavy machinery operators, truck drivers, etc.
    • Note: CT or ultrasound should eliminate the possibility of compression from tumor or cyst.

Pudendal Nerve Entrapment Syndrome is mostly under diagnosed and inappropriately treated

This is a conversation that we have with many first time patients after an examination. It goes something like this:

“Based on the examination, it can be realistically determined that your symptoms of pain, dysfunction, difficulty walking and the other things you mentioned is being caused by pelvic instability ans sacral instability causing a compression on your pudendal nerve, we would like to begin treatmentment based on pudendal nerve entrapment.

The patient will then say something to the effect of:

“What’s that?” How come my doctors never talked to me about this? I have been going to doctors for years.”

“Pudendal nerve entrapment? What’s that?”

It is probably best at this point for you the reader to have this question answered from the medical research.

In March 2020, doctors from Augusta University in Georgia wrote in the medical publication StatPearls🙁1)

  • Pudendal neuralgia (pudental nerve pain) caused by pudendal nerve entrapment is a chronic and severely disabling neuropathic pain syndrome.
  • It presents in the pudendal nerve region and affects both males and females. It is mostly underdiagnosed and inappropriately treated, and causes significant impairment of quality of life.

The route of the pudendal nerve reveals the extent of the pain it can cause

In this illustration we see the influence damaged sacrotuberous and sacrospinous ligaments can have on pudendal nerve.  Damaged sacrotuberous and sacrospinous ligaments can be responsible for groin related pain. On possible cause of this pain is pudendal nerve compression or dysfunction. 

In this illustration we see the influence damaged sacrotuberous and sacrospinous ligaments can have on pudendal nerve.  Damaged sacrotuberous and sacrospinous ligaments can be responsible for groin related pain. On possible cause of this pain is pudendal nerve compression or dysfunction. 

  • The pudendal nerve emerges from the S2, S3, and S4 roots’ ventral rami of the sacral plexus.
    • (Simply, the spinal nerves exit the spinal column and split at the S2, S3, and S4 vertebra to form the sacral plexus, the nerves which provided motor and sensory nerves for the posterior or back of the thigh, most of the lower leg and foot, and part of the pelvis. The pudendal nerve is one of these nerves.)
  • The pudendal nerve travels between two muscles, the piriformis and coccygeus muscles.
    • Please see our article Piriformis Syndrome and Sciatica Pain. Typically pudendal neuralgia and pudendal nerve entrapment is a symptom of pelvic and lower back instability which can include concurrent symptoms of sciatica.
    • A study in the journal Current bladder dysfunction reports (x) noted that “in the athlete, flexion and abduction of the thigh are common motions, and they may lead to hypertrophy of the piriformis muscle. If the sciatic notch (where the piriformis muscle and the pudental nerve pass) is narrowed because of the posterior orientation (a distorted orientation from pelvic/spinal instability) of the ischial spine, the cross-sectional area of the greater sciatic notch is reduced. Concomitant hypertrophy of the piriformis muscle may cause compression of the pudendal nerve against the posterior edge of the sacrospinous ligament.”
  • The pudendal nerve leaves the pelvic cavity through the greater sciatic foramen ventral to the sacrotuberous ligament.
    • The greater sciatic foramen (opening) is at the rear of the pelvis. The opening is formed by the sacrotuberous and sacrospinous ligaments. The piriformis muscle passes through the foramen as well. As you can see we have piriformis muscle again interacting with the pudendal nerve in a confined space.
    • Let’s also note that the sacrotuberous and sacrospinous ligaments and pudendal nerve are having an interaction. Damaged sacrotuberous and sacrospinous ligaments can be responsible for groin related pain. Again here is a situation where pudendal nerve compression or dysfunction is not a problem in isolation. The supporting ligaments of the pelvis, when damaged can cause pudendal nerve compression as well as symptoms more closely related to Sacroiliac Joint Dysfunction. Please see our article: Sacroiliac Joint Dysfunction Treatment Options where we introduce research on pelvic and spinal ligaments being identified as a point of interest in treating groin pain related to sacroiliac joint dysfunction.
  • At the ischial spine level, (a small bony projection towards the rear pelvis at the vaginal or scrotum level) the pudendal nerve passes to and under the sacrospinous ligament to re-enter the pelvic cavity through a lesser sciatic foramen.
    • Again, an interaction is occurring between the pudendal nerve and a ligaments that attaches the pelvis to the spine to the ischial spine level to the tailbone. If this ligament is damaged, weakened, or loose, the pudendal nerve can be stretched or compressed and pudendal nerve function impaired, meaning symptoms begin.
  • The pudendal nerve then courses in the pudendal or Alcock canal (an area in the pelvis that the internal pudendal artery, internal pudendal veins, and the pudendal nerve pass. It is easy to see why pelvic instability could cause significant dysfunction in blood flow to an out of the area).

Finally, it divides into three branches: anal/rectal, perineal, and clitoral/penile.

Constipation, inability to eliminate

  • The three last branches of the pudendal nerve terminate in the ischioanal fossa.
    • One branch that terminates at the ischioanal fossa or ischiorectal fossa as it is sometimes referred is the anal/rectal branch. The ischioanal fossa is an area that controls the muscles of the anal canal (which is why some patients have complaints of constipation or inability to eliminate) including the external sphincter muscle.

Sensitivity or pain problems in the penis or clitoris

  • The clitoral/penile branch or dorsal sensory nerve of the penis or clitoris, is another of the last branches of pudendal nerve. Patients with problems of this branch may report pain during and not during sex, inability to orgasm, problems with a constantly erect penis or over stimulated clitoris without sexual stimulus.

Urinary problems

It is common to see patients with suspected pudendal nerve entrapment have problems with getting their urine flow started, or with problems of greater frequency and sudden urgency for the need to urinate.

The pudendal nerve entrapment syndromes subdivide into four types based on the level of compression.

  • Type I – Entrapment below the piriformis muscle as the pudendal nerve exits the greater sciatic notch.
  • Type II – Entrapment between sacrospinous and sacrotuberous ligaments – this is the most common cause of nerve entrapment.
  • Type III – Entrapment in the Alcock canal.
  • Type IV – Entrapment of terminal branches.
In this illustration we we the areas of the groin and vaginal area impacted by the genitofemoral nerve, the pudendal nerve, and the inferior cluneal nerve. The pudendal nerve encompasses the area of the vagina and anus.

In this illustration we we the areas of the groin and vaginal area impacted by the genitofemoral nerve, the pudendal nerve, and the inferior cluneal nerve. The pudendal nerve encompasses the area of the vagina and anus.

A message from the past to doctors in 2020: A diagnosis of Interstitial cystitis or bladder pain syndrome should immediately trigger an examination of Pudendal nerve compression

Here is a paper from March 2020 in the Journal of brachial plexus and peripheral nerve injury (1). Let’s see if you find something familiar in what these doctors from University Hospital in Basel, Switzerland and Johns Hopkins University are saying about the misdiagnosis of your problems.

Interstitial cystitis or bladder pain syndrome (a diagnosis some of you may have received to describe your symptoms of bladder and pelvic pain and frequent urge to urinate that has finally been determined not to come from urinary tract problems) is a highly painful and disabling and probably the most misdiagnosed urologic condition.

What makes this article fascinating is that the researchers are documenting that what you have has been misdiagnosed since at least 1915, when one doctor figured out that for many, this is a problem of chronic pudendal nerve compression. How? Let’s go back to the study:

. . .classic symptoms of perineal pain (the area between the anus and scrotum or anus and vagina), urinary urgency, and frequency despite sterile urine cultures (not a urinary tract infection) were already described more than a century ago in a report on soldiers during World War  I due to chronic pudendal nerve compression. Dr. Georg ZĂŒlzer over 100 years ago noted in his paper “Irritation of the Pudendal Nerve (Neuralgia). A Frequent Clinical Picture during War Feigning Bladder Catarrh (discharge. mucus),” the correct clinical observations of modern diagnosis and therapy of pudendal nerve compression.

Dr. ZĂŒlzer observed these symptoms in 1915:

  • sufferers had a triad of perineal pain, urinary urgency, and frequency despite sterile urine cultures excluding urinary infections.

That lump sensation explained:

  • sufferers had characteristic skin hypersensibility of the perineum in a rhomboid shape (a tilted rectangle) which corresponds to the innervation area of the pudendal nerve with its two branches deriving from the “pudendal plexus.” (That is that lump sensation.)
  • In 1915 Dr. Georg ZĂŒlzer probably gave the first exact clinical description of symptoms due to pudendal nerve compression. Pudendal nerve compression should always be taken into account when examining and treating patients with symptoms of IC/BPS.

Treatment for Pudendal Nerve Entrapment Syndrome

For most of the patients we see, they have already had a long history of testing and diagnosis elimination scans. This includes for women a vaginal examination, for men a rectal examination. The goals of these examinations is to palpitate or apply pressure to the branches of the pudendal nerve to reproduce a pain response or nerve sensation. Many will have already had an MRI or CT scan to document nerve compression. Some would have had nerve conduction studies to assess damage or compression of the pudendal nerve.

Many of also had nerve blocks. A painkiller to not only improve pain, but to isolate the cause of the problem on the pudendal nerve. If pain relief is achieved, even in the very short-term. Then there is confidence the problem is the pudendal nerve.

Because a nerve block does not work, for some, this should not rule out the pudendal nerve. In a May 2020 study in the journal Pain Medicine (3), researchers noted that two common methods of nerve blocks using ultrasound guidance, one injection given at the ischial spine or the other option the injection is given at the Alcock’s or Pudendal canal were on average 80% accurate for hitting their mark.

Treatments for pudendal neuralgia that you may have already tried that is not working

If you are reading this article it is likely that you have already been through a myriad of treatments.

The first options were conservative care, simply avoidance of those things that cause pain.

  • Don’t sit for too long
  • Avoid activities such as cycling, horseback riding, motorcycling, riding tractors or lawn mowers where obvious aggravation of your symptoms could occur.
  • Nerve pain medications
  • Physical therapy and exercise programs for pelvic floor muscles
  • Pudendal nerve blocks and injections
    • For many patients, a steroid or painkiller injection can have good temporary results. We see many of these patients as these results wear off and typically their doctors have been recommending  more doses. If you are reading this article, you may be one of these people where treatments provided less and less pain relief.
  • Electrical nerve stimulation
    • Electrical nerve stimulation is considered an option especially in situations of stress urinary incontinence. Many women get this treatment following childbirth when the pudendal nerve and urinary sphincter.
  • Decompression surgery

For some people, any one of these treatments may be enough to provide pain relief and an improvement in quality of life. Unfortunately the people who have success with these treatments are not the people that we see in our offices. We see the people who continue to have problems.

Pudendal Nerve Entrapment Syndrome Treatment means treating the problems of pelvic instability causing the entrapment

As we wrote earlier in this article, when a person has pudendal nerve entrapment symptoms, to treat this problem we have to find out what is causing the entrapment and fix that.

Treating Pelvic Floor Disorders

We see many patients in our clinics who have been diagnosed with pelvic floor dysfunction or chronic myofascial pelvic pain. These people exhibit similar symptoms to those found in a diagnosis of Pelvic Floor Dysfunction. These are the problems of bowel movement dysfunction and urinary incontinence.

In our article Pelvic Floor Disorders, Pelvic Girdle Pain, and Symphysis Pubis Dysfunction following childbirth, we highlight these research points

I think I have to urinate all the time.

This is a common problem in situations of Pelvic Floor Dysfunction and in pudendal nerve entrapment.

I can’t poop

This is a common problem in situations of Pelvic Floor Dysfunction and in pudendal nerve entrapment. When a patient reports that chronic constipation and discomfort with bowel movement has joined the list of symptoms, another set of diagnostic tests are brought into play.

What is described are symptoms common of pelvic floor dysfunction and pudendal nerve entrapment , they are also common of other situations.

It is estimated that nearly 25% of women suffer from pelvic floor dysfunction

It is estimated that nearly 25% of women suffer from pelvic floor dysfunction. (1) That means 1 in 4 women are currently dealing with this condition right now. Most common causes are childbirth, trauma, obesity, history of previous pelvic surgery, and pudendal nerve damage.

The sacrotuberous, sacrococcygeal and sacroiliac ligaments revisited

The sacrotuberous, sacrococcygeal and sacroiliac ligaments are vital to providing stability in the “back portion” of the pelvic rim upon which the muscles attach. The pubic symphysis provides stability in the “front portion” of the pelvic rim, onto which muscles also attach. If these supporting ligaments of the pelvis become injured or stretched out, joint instability can result. This means that the pelvic bones become unstable because its primary stabilizers (ligaments) are too weak or lax to properly hold them in place.  The same can happen if the pubic symphysis becomes stretched out or sprained.

Prolotherapy treatments

Clinical observations over the course of decades have shown Prolotherapy treatment to injured ligaments induces a mild “healing” inflammatory reaction, which stimulates the repair of injured or lax ligaments. Prolotherapy injections can strengthen the ligaments and pubic symphysis, increasing stability and relieving muscle spasm and other symptoms in pelvic floor dysfunction.

In those with pelvic floor dysfunction and associated pain in their back, pubis, pelvic floor, genitals, coccyx, and associated symptoms, Prolotherapy can help to strengthen injured or stretched out ligaments, allowing them to reinstate stability to the pelvis and allow tight muscles to relax. Regaining stability in the pelvis can help to get rid of chronic pelvic pain and help patients “get their lives back”.  If you are suffering from chronic pelvic floor dysfunction, wouldn’t you like to get back to your normal self?

Vaginal pain

Vaginal pain that has not responded to surgery or conservative treatments may become classified as chronic and with unknown origin. If an underlying cause cannot be found, patients are often advised to continue with anti-inflammatory medications or steroid shots to control their pain. While these treatments may help temporarily, cortisone shots and NSAIDs can both result in long term loss of function.

Sometimes physical therapy is recommended to try and build the muscles up through the pelvic floor, groin and low back, which often only partially help the issue.

When chronic vaginal pain cannot be resolved, ligament laxity may be the culprit. Ligament laxity can occur after a sudden injury to the low back or pelvic floor or after childbirth. During pregnancy, a hormone called relaxin is released inside the body to help relax the ligaments along the pelvic floor to better allow the baby to pass through the birth canal. It is not unheard of for women to be left with chronic vaginal or pelvic floor pain after childbirth that is related to loose ligaments.

For chronic vaginal pain due to ligament or tendon weakness, Prolotherapy is an effective treatment option. Prolotherapy is a regeneration injection therapy (RIT) that stimulates the body to repair injured tissues and painful areas. Thus, the pain radiating into the vagina and other pelvic floor areas can be eliminated.

We can help chronic vaginal and pelvic floor pain

In our office, we have success treating a lot of pain in the pelvic, groin, and vaginal region in women who have chronic pain. Our Comprehensive Prolotherapy approach typically requires three to six treatments, given approximately one month apart. For an athlete or new mom, this type of treatment is ideal because it does not require needing to take medications and allows the woman to

Prolotherapy to the pelvis involves a dextrose injection treatment to any of the numerous ligaments that may be weak and causing the pelvic instability. This treatment initiates a mild inflammatory response in the treated pelvic area. D-glucose (also called dextrose) is the normal sugar in the body, and when injected activates the immune system.  The body’s normal healing inflammatory reaction boosts the blood flow to the area and attracts immune cells to the weakened or injured ligaments being treated. These cells will cause regeneration and strengthening of the injured areas. Once the ligaments are strengthened, the pelvis becomes stabilized. Referral pain will stop, contracted muscles will relax, and the chronic pelvic pain will abate.

Pubic symphysis injury in Male Athletes –

“abdominal muscle pull” or “adductor injuries” or pubic symphysis degeneration and slippage

Rarely do patients who have pubic symphysis dysfunction have a discussion with their health care provider about the problems of the ligaments of pelvic, hip, and low back region.

  • The pubic symphysis is actually a disc. It is a fibrocartilaginous disc that, like any other disc in the body, can be damaged, disrupted and displaced. When all is well and the balance between the sacroiliac joints and the pubic symphysis is maintained, you have a pain-free stable pelvic girdle.

So what happened that caused your pain?

  • The pubic symphysis widens slightly whenever the legs are stretched far apart, and therefore activities requiring this type of movement (kicking, lunging, leg kick in butterfly stroke) have a higher risk of causing injury to the pubic symphysis. This widening leads to misalignment and instability of the symphysis pubis joint. You have a slipped disc.

Where do ligaments fit in?

  • Pain in the pubic symphysis can be caused by micro-tearing and subsequent weakening of the ligaments of the supportive structures causing excessive movement and instability.
  • The pubic symphysis  is supported on top by the superior pubic ligaments. Typically, people with groin pain are assumed to have a groin strain. This refers to a strain of the adductor muscles that attach to the pubic bone. Chronic pain that does not respond to exercise, massage, or manipulation is most likely a ligament problem.

“abdominal muscle pull” or “adductor injuries” or pubic symphysis degeneration and slippage

 

public symphysis

Cortisone injections into the pubic symphysis

Doctors from Ohio State University writing in the British Journal of Sports Medicine (1) discussed the use of cortisone injections into athletes with public symphysis pain. Here are their findings:

Pubic Symphysis Pain in the Man

Prolotherapy for pubic symphysis injury and instability are injections into the fibro-osseous junction of the superior pubic symphysis ligament and injections into the pubic symphysis itself.

Prolotherapy is extremely effective in strengthening the pubic symphysis and relieving chronic groin pain in this area. Prolotherapy solutions injected into the affected ligaments, tendons, and/or joints causes a local inflammation in the injected area. The mild, localized inflammation boosts blood supply and regenerative cells to the weakened area. This results in the deposition of new collagen, the material that the symphysis pubis is made of. The new collagen tightens the weakened, unstable joint and makes it stronger.

As mentioned above, the pubic symphysis is the front joint of the pelvic bone and the sacroiliac joint is in the back. The doctor should check for sacroiliac joint instability and treat it at the same time.

In patients with groin pain due to abdominal wall abnormalities, one finds a history of inguinal pain that worsens with strenuous activity, especially activity stressing the abdominal muscles, such as sit-ups.

On physical examination there is tenderness of the pubic tubercle and a positive jump sign is elicited. In this instance, Prolotherapy to the muscle attachments onto the pubic symphysis is often curative.

All of the other muscle attachments to the groin area, including the rectus femoris, gracilis, rectus abdominis, and adductor group, can all be treated with Prolotherapy if there is tenderness and reproduction of the man’s pain upon palpation of the area where the muscle attaches to the bone. If a positive jump sign is elicited, the diagnosis is made and Prolotherapy is given.

1 Kaur J, Singh P. Pudendal Nerve Entrapment Syndrome. In: StatPearls. Treasure Island (FL): StatPearls Publishing; 2020. [Google Scholar]
2 Gohritz A, Dellon AL. Bladder Pain Syndome/Interstitial Cystitis due to Pudendal Nerve Compression: Described in 1915-A Reminder for Treating Pelvic Pain a Century Later. J Brachial Plex Peripher Nerve Inj. 2020;15(1):e5-e8. Published 2020 Mar 6. doi:10.1055/s-0039-1700538 [Google Scholar]
3 Soucy B, Luong DH, Michaud J, Boudier-RevĂ©ret M, Sobczak S. Accuracy of Ultrasound-Guided Pudendal Nerve Block in the Ischial Spine and Alcock’s Canal Levels: A Cadaveric Study. Pain Medicine. 2020 May 25. [Google Scholar]


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