Pudendal Neuralgia

Definition

Pudendal neuralgia occurs when the pudendal nerve is injured, irritated, or compressed.

Epidemiology

• Pudendal neuralgia (PN) is often unrecognized, so the true incidence is unknown.[1].
• Estimates from The International Pudendal Neuropathy Association are 1 in 100,000 of the general population.
• Spinosa et al. document the incidence at 1% in the general population, affecting women more than men.

Cause

Common causes include:

• Prolonged sitting (e.g., seamstress, computer operators, judges, concert pianists, locomotive engineers)
• Repetitive hip flexion (sports activities, exercising, jogging, cycling)
• Direct trauma including falls, motor vehicle accidents, and pelvic surgeries, especially when using mesh
• Radiation therapy especially in males treated for prostate cancer and patients treated for rectal and gynecological cancers

Infrequent causes include:

• Metastatic lesions to the nerve pathway and herpes simplex infection
• Stress is not causal, but maybe a potent aggravator of neuropathic pain.

Signs and symptoms

• Symptoms include burning pain (often unilateral), tingling, or numbness in any of the following areas: buttocks, genitals, or perineum (area between the buttocks and genitals).
• Symptoms are typically present when a person is sitting but often go away when the person is standing or lying down.
• The pain tends to increase as the day progresses.
• Additional symptoms include pain during sex and needing to urinate frequently and/or urgently.
• Damage to the pudendal nerve can result from surgical procedures, childbirth, trauma, spasms of the pelvic floor muscles, or tumors.
• Pudendal neuralgia may also result from certain infections (such as herpes simplex infections) or certain activities (such as cycling and squatting exercises).

Diagnosis

• Pudendal neuralgia (PN) is essentially a clinical, "bedside" diagnosis that is best confirmed using neurophysiological testing. [2].
• Imaging techniques do not help make a diagnosis.
• Abdominal and pelvic CT scans are helpful only for exclusion purposes.
• MRI of the lumbar and sacral spine are rarely useful but should be done before surgical interventions.
• Somatosensory evoked potential (SSEP) testing has been used to confirm pudendal neuropathy.
• SSEP is also a valuable tool to limit pudendal nerve damage caused by compression of the perineum caused by traction during hip surgeries.

Treatment

• Many physicians suggest using a step-ladder approach to therapy for individuals with pudendal neuralgia.
• Physical therapy with professionals who specialize in pelvic floor therapy is often the first line of treatment.
• Electrical stimulation and biofeedback have been used to assist therapists with treatment.
• Patients are also given exercises and lifestyle modifications to use at home. For muscle spasms that are not responsive to physical therapy, botulinum toxin has been used in some cases.
• Medications such as gabapentin, pregabalin, cyclobenzaprine, and tricyclic antidepressants have also been used in the treatment of patients with PN.
• In some cases, treatment may include nerve blocks, electrical stimulation of the lower end of the spinal cord, or surgery to remove tissues that might be pressing on the pudendal nerve.

NIH genetic and rare disease info

• NIH info on Pudendal Neuralgia

Pudendal Neuralgia is a rare disease.

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