Pudendal Nerve Entrapment Syndrome: Under diagnosed and inappropriately treated

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

Many times a patient will contact us via email or phone call and describe their long medical history of dealing with problems of 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. One that has been elusive. Equally elusive has been any type of effective treatment.

The hunt for the cause of your 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 direction as indicated by this person’s continued symptoms and a history that can suggest pudendal nerve entrapment may be occurring.

In taking a medical history, these are some of the clues that would lead us towards looking at a problem of Pudendal Nerve Entrapment Syndrome.

Pudendal Nerve Entrapment Syndrome is mostly underdiagnosed and inappropriately treated

This is a conversation 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 are being caused by pelvic instability and sacral instability causing compression of your pudendal nerve, we would like to begin treatment 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. What is sacral instability? What is pudendal nerve entrapment?

“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)

Perhaps you are one of the patients where pudendal nerve entrapment is mostly underdiagnosed and inappropriately treated and this is why you have continued pain.

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

One of the reasons that Pudendal neuralgia (pudendal nerve pain) is underdiagnosed and inappropriately treated is because it is easily confused with other problems. In the illustration below we can see the route of the pudendal nerve and how closely it passes by and through other structures that can be blamed for symptoms. Namely the sacrum.

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 the pudendal nerve.  Damaged sacrotuberous and sacrospinous ligaments can be responsible for groin-related pain. One possible cause of this pain is pudendal nerve compression or dysfunction. 

 

The pudendal nerve travels between two muscles, the piriformis and coccygeus muscles. It can get trapped there.

Getting trapped between the sacrotuberous and sacrospinous ligaments

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

Constipation, inability to eliminate

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.

Sensitivity or pain problems in the penis or clitoris

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

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 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 doctor in 1915 said there is a big problem with missing the diagnosis of chronic pudendal nerve compression in bladder pain syndrome sufferers who had a triad of perineal pain, urinary urgency, and frequency despite sterile urine cultures excluding urinary infections. Doctors in 2020 agree it is still a problem 105 years later.

Here is a paper from March 2020 in the Journal of Brachial Plexus and Peripheral Nerve Injury (3). 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 Zülzer 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. Zülzer observed these symptoms in 1915:

That lump sensation explained:


Treatment for Pudendal Nerve Entrapment Syndrome

Most of the patients we see 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 goal of these examinations is to palpitate or apply pressure to the branches of the pudendal nerve to reproduce a pain response of 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 also had nerve blocks. A painkiller not only improves pain but isolates 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 is 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 did not help

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.

Many doctors tell their patients that the most important aspect of treating pudendal nerve pain is to figure out what is causing it. This of course is something we all agree on. But what if you are looking in the wrong places? Likely if you look in the wrong places you will get the wrong treatment. Many doctors focus on treating the injured pudendal nerve. This may not be the best treatment plan if you do not treat the problems of pelvic instability and sacrum instability we discussed above. Else wise the pudendal nerve will remain or repeatedly become entrapped. This could be why you are not getting long-term results and have bounced from specialist to specialist.

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

So is this you?

If you are reading this article it is likely that you have already been through a myriad of treatments and they have failed and your next step is to burn out the nerve with radio-frequency nerve ablation or pudendal nerve neurolysis, freeze out the nerve with cryotherapy, or get pudendal nerve neuromodulation to help with pain and urinary problems.

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

In this video, Dr. Hauser explains how pelvic instability can lead to symptoms related to pudendal neuralgia. The summary transcript and explanatory notes are below.

A common condition that we see is pelvic floor dysfunction which causes pudendal neuralgia or compression of the pudendal nerve. The most common treatment for pelvic floor dysfunction are the different types of physical therapy and they are often helpful but very seldom do I find that it cures people.

If somebody has really severe pudendal neuralgia they may undergo surgical decompression. In this procedure, the surgeon is trying to release the nerve surgically from being compressed along the nerve path.

What most people do not realize is that the pudendal nerve gets stretched and compressed and irritated because of pelvic instability.

At 1:25 Dr. Hauser traces the path of the nerves through the sacrum. One of these nerves is the pudendal nerve.

What would cause compression of the pudendal nerve and irritation? Rotation of the sacrum

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 sacrotuberous ligament and the sacrospinous ligament and bring the pelvis and sacrum back into their natural alignment and alleviate pressure on the pudendal nerve.

Prolotherapy to the pelvis involves a dextrose injection treatment to any of the numerous ligaments that may be weak and causing 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 chronic pelvic pain will abate.

If you have a question about Pudendal Nerve Entrapment Syndrome, get help and information from our Caring Medical staff

1 Kaur J, Singh P. Pudendal Nerve Entrapment Syndrome. In: StatPearls. Treasure Island (FL): StatPearls Publishing; 2020. [Google Scholar]
2 Possover M, Forman A. Voiding Dysfunction Associated with Pudendal Nerve Entrapment. Current Bladder Dysfunction Reports. 2012 Dec;7(4):281. [Google Scholar]
3 Gohritz A, Dellon AL. Bladder Pain Syndrome/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]
4 Soucy B, Luong DH, Michaud J, Boudier-Revéret 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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