The Nu Guide: Understanding Pudendal Neuralgia

Pudendal neuralgia is a chronic pain condition caused by irritation or compression of the pudendal nerve, which supplies sensation to the perineum and controls key muscle functions of the bladder and bowel. It can be a distressing condition, significantly impacting daily life. But with the right strategies, it can be managed effectively.

What are the symptoms of pudendal neuralgia?

People with pudendal neuralgia often describe their pain as burning, stinging, or shooting. The location of symptoms is typically in the area of skin supplied by this nerve bundle. The discomfort tends to worsen as the day progresses and is typically triggered by prolonged sitting. Since the pudendal nerve plays a role in bladder and bowel function, symptoms can also include:

• Increased bladder frequency or urgency

• A sensation of incomplete bladder emptying

• Pain during intercourse

• Discomfort when having a bowel movement

Some people find that the pain improves when lying down and worsens after certain physical activities, particularly those that involve prolonged pressure on the perineal area such as riding a bicycle.

Common causes and triggers

Several factors can contribute to pudendal neuralgia, including:

• Childbirth: The pudendal nerve can be stretched or compressed during vaginal delivery. While this usually resolves within a few weeks, some women experience long-term pain

• Pelvic floor exercises: Strenuous ‘core’ workouts, including pelvic floor exercises or Pilates, can sometimes over-activate the pelvic muscles, leading to nerve irritation

• Cycling and horse riding: Sitting for extended periods on a saddle-like surface can increase pressure on the pudendal nerve

• Surgical procedures: Surgeries involving the pelvic area, such as episiotomies, prolapse repairs, or hysterectomies, can sometimes result in persistent nerve pain

Diagnosis: how is pudendal neuralgia identified?

A healthcare provider will typically diagnose pudendal neuralgia based on medical history, symptoms, and a physical examination. A key diagnostic feature is pain that worsens with sitting and improves when lying down.

Additional tests may include:

• Pudendal nerve block: A local anesthetic is injected into the area to see if the pain temporarily resolves, helping to confirm the diagnosis

• Imaging scans: MRI or ultrasound may be used to rule out other pelvic conditions that could be contributing to symptoms

Management and treatment strategies

Although there is no definitive ‘cure’ for pudendal neuralgia, the condition can be effectively managed through a combination of lifestyle modifications, physiotherapy, and medical treatments.

1. Lifestyle changes

• Modify sitting habits: Avoid direct pressure on the perineum by using a coccyx-cutout seat cushion and adjusting your sitting position. Stand periodically throughout the day to reduce strain.

• Avoid aggravating activities: Minimise high-impact exercises like cycling, trampoline jumping, and heavy weightlifting, which can compress the nerve

• Optimise bowel health: Prevent constipation and straining by consuming a high fibre diet, staying hydrated, and using a footstool to achieve a better posture on the toilet

2. Physiotherapy

A pelvic floor physiotherapist can help by teaching relaxation techniques and gentle stretching exercises to release tension in overactive pelvic muscles, which may be contributing to nerve irritation

3. TENS (Transcutaneous Electrical Nerve Stimulation)

TENS therapy, sometimes referred to as the ‘tingly machine,’ can help relieve pain by delivering mild electrical pulses to the affected area. A physiotherapist can guide proper placement of the electrodes.

4. Medications

Medical management is similar to other chronic pain conditions. Options may include:

• Topical treatments: Creams or ointments that provide localised pain relief

• Low-dose nerve pain medication (e.g. amitriptyline, nortriptyline): These can help modulate nerve pain

5. Acupuncture

For some individuals, acupuncture may provide relief, particularly if symptoms have recently developed after childbirth or surgery.

What can you do if you suspect you’re suffering from this condition?

Living with pudendal neuralgia can be challenging, but with a tailored management plan, many people find significant relief. If you suspect you have this condition, consulting a healthcare provider or pelvic health specialist can help guide you toward the best strategies for reducing discomfort and improving your quality of life.