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Pudendal Neuralgia

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Pudendal neuralgia: Nerve pain in the pelvis

proctalgia
pain in the rectum

Do you experience burning or electric pain in the rectum that worsens when you sit down? Then the cause may be pudendal neuralgia. This condition involves irritation or pinching of the pudendal nerve—one of the most important nerves in the pelvic floor.

At kirurgen.dk, we often see patients who fear serious illness due to these symptoms. Through a thorough clinical assessment and, if necessary, a bowel examination, we can provide clarity and develop a plan for your treatment.

What is pudendal neuralgia?

Pudendal neuralgia (PN) is a chronic pain condition that occurs when the pudendal nerve becomes irritated or pinched. The nerve runs through a narrow channel in the pelvis (Alcock's canal), and if it is subjected to pressure, it sends pain signals to the brain from the areas it supplies: the rectum, perineum, and genitals.

Typical symptoms

The symptoms of pudendal neuralgia are often very characteristic and differ from ordinary muscle pain:

  • Burning or electric pain: Often feels like "fire" or electric shocks.
  • Worsening when sitting: The pain is typically worst during the day when sitting on a chair.
  • Relief on the toilet seat: Since the perineum itself "floats" freely on a toilet seat, many people experience temporary relief here.
  • Foreign body sensation: Many patients describe a feeling of having a golf ball or lump stuck in the rectum.

How is the diagnosis made? (Nantes criteria)

Since pudendal neuralgia cannot be seen on a normal scan, we use the internationally recognized Nantes criteria to make the diagnosis:

  1. The pain is localized to the nerve's supply area (from the clitoris/penis to the anus).
  2. The pain is significantly worse when sitting.
  3. The pain does not wake the patient at night.
  4. There is no loss of sensation during the objective examination (only pain).
  5. The pain is relieved by a diagnostic block of the pudendal nerve.

The importance of a bowel examination

Although the symptoms point to a nerve, it is crucial to rule out other causes of pain in the rectum. A local intestinal examination (anoscopy or rectoscopy) is performed to rule out:

  • Anal fissures (tears).
  • Hemorrhoids.
  • Inflammatory processes or tissue changes.

In certain cases, we may supplement with a colonoscopy if there are symptoms such as bleeding or changes in bowel habits, to ensure that there is no underlying serious disease.

Treatment options

The treatment of pudendal neuralgia is often multidisciplinary and may include:

  1. Lifestyle changes: Use of special pillows (donut pillows) to relieve pressure on the nerve.
  2. Specialized physical therapy: Relaxation of the pelvic floor, as muscle tension often exacerbates nerve irritation.
  3. Medical treatment: Nerve medication or local anesthetic blocks.
  4. Surgery: In rare cases where the nerve is physically trapped (entrapment), surgery may be considered.

Scientific references (PubMed format)

  • Labat JJ, Riant T, Robert R, Amarenco G, Lefaucheur JP, Rigaud J. Diagnostic criteria for pudendal neuralgia (Nantes criteria). Neurourol Urodyn. 2008;27(4):306-10. doi: 10.1002/nau.20505. PMID: 17823944.
  • Kaur J, Singh P. Pudendal Neuralgia. [Updated 2023 Aug 21]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK544272/ PMID: 31335043.
  • Beco J, Seidel L, Albert A. Pudendal nerve decompression in perineology: a case series. BMC Surg. 2015;15:116. doi: 10.1186/s12893-015-0099-5. PMID: 26514704.
  • Itza F, Zarza D, Serra L, Gómez-Sancha F, Salinas J, Allona-Almagro A. Pudendal nerve entrapment as source of intractable perineal pain: diagnosis and treatment. Actas Urol Esp. 2010;34(6):500-6. PMID: 20113645.
  • Ploteau S, Cardaillac C, Perrouin-Verbe MA, Riant T, Labat JJ. Pudendal Neuralgia Due to Pudendal Nerve Entrapment: Warnings from the 2023 Guidelines. J Clin Med. 2023;12(11):3776. doi: 10.3390/jcm12113776. PMID: 37297971.

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