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Pudendal nerve entrapment

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Pudendal nerve entrapment
Other names
  • Pudendal neuralgia.
  • Alcock canal syndrome.[1][2]
  • Pudendal nerve entrapment syndrome.[3]
  • Pudendal canal syndrome.[4]
  • Pudendal syndrome.[5]
  • Pudendal neuropathy.[5]
  • Cyclist syndrome.[6]
  • Pudendal canal entrapment.[7]
SpecialtyNeurology Edit this on Wikidata

Pudendal nerve entrapment (PNE) is an uncommon, chronic pelvic pain condition in which the pudendal nerve (located in the pelvis) is entrapped and compressed. There are several different anatomic locations of potential entrapment (see Anatomy). Pudendal nerve entrapment is an example of nerve compression syndrome.

Pudendal neuralgia (PN) refers to pain along the course of the pudendal nerve and in its distribution. This term is often used interchangeably with pudendal nerve entrapment. However, it has been suggested that the presence of symptoms of pudendal neuralgia alone should not be used to diagnose pudendal nerve entrapment. That is because it is possible to have all the symptoms of pudendal nerve entrapment, as per the diagnostic criteria specified at Nantes in 2006, without actually having an entrapped pudendal nerve.[8] Another study of 13 normal female cadavers found that the pudendal nerve was attached or fixed to the sacrospinous ligament (therefore "entrapped") in all cadavers studied, suggesting that the diagnosis of pudendal nerve entrapment may be overestimated.[9]

The pain is usually located in the perineum, and is worsened by sitting. Other potential symptoms include genital numbness, sexual dysfunction, bladder dysfunction or bowel dysfunction. Pudendal neuralgia can be caused by many factors including nerve compression or stretching of the nerve. Injuries during childbirth, sports such as cycling, chronic constipation and pelvic surgery have all been reported to cause pudendal neuralgia.

Management options include lifestyle adaptations, physical therapy, medications, long acting local anesthetic injections and others. Nerve decompression surgery is usually considered as a last resort. Pudendal neuralgia and pudendal nerve entrapment are generally not well-known by health care providers. This often results misdiagnosis or delayed diagnosis. If the pain is chronic and poorly controlled, pudendal neuralgia can greatly affect a person's quality of life, causing depression.

Terminology

In pain research, there are different types of pain, although these types may be combined in some conditions and in some cases.

  • Nociceptive pain is pain that occurs with activation of nociceptors and arises from actual (or threatened) damage to non-neural tissue. In contrast with neuropathic pain, nociceptive pain involves a normally functioning somatosensory nervous system.[10]
  • Neuropathic pain is due to nerve damage. It is pain caused by a lesion or disease of the somatosensory nervous system.[10] In this type of pain, something is causing the nerve(s) to function abnormally.[10]
  • Nociplastic pain is pain that arises from altered nociception (perception of pain) even though there is no detectable tissue damage causing the activation of peripheral nociceptors, and no evidence for any disease process or lesion affecting the somatosensory nervous system which could explain the pain.[10] Nociplastic pain is a feature of central sensitization, in which peripheral neurons are functioning normally but there is distorted processing of pain signals in the central nervous system. In central sensitization, nociceptive neurons in the central nervous system have increased responsiveness to normal or subthreshold afferent (incoming) input signals.[10]

Several related terms are used in the context of pain research and the literature surrounding this pain condition:

  • Peripheral neuropathy (or simply neuropathy) is a disturbance of function or pathological change in a nerve outside the brain and spinal cord (the peripheral nervous system).[10]
  • Pudendal neuropathy is any damage or disease process affecting the pudendal nerve, regardless of whether said disease process involves nerve entrapment and manifests as pain or not. It is an example of mononeuropathy (neuropathy affecting one peripheral nerve).
  • Neuralgia is pain in the distribution of a nerve.[10] Usually, such conditions involve paroxsysmal pain (sudden, severe, electric shock like pain). Neuralgia can be considered as a subtype of neuropathic pain.
  • Pudendal neuralgia is neuropathic pain which is perceived along the course of and in the distribution of the pudendal nerve or its branches (anus, perineum, vulva, clitoris, glans penis, posterior aspect of scrotum).[11] Pudendal neuralgia is caused by some pathology affecting the pudendal nerve or its branches.[11] The pain in pudendal neuralgia may or may not be of similar character to other medical conditions which are classified as neuralgia. One potential cause of pudendal neuralgia is pudendal nerve entrapment.[12] However, symptoms of pudendal neuralgia are also possible without any detectable entrapment of the pudendal nerve.[8]
  • Neuritis is inflammation of a nerve.[10] It is a subtype of neuropathy.[10] However, not all neuropathies involve inflammation.
  • Neuritic pain is pain related to neuritis. Neuritic pain could be considered as a subtype of neuropathic pain.

Therefore, strictly speaking pudendal neuralgia is the neuropathic pain component of the chronic pelvic pain syndrome which is often (but not always), associated with compression and subsequent neuropathy (nerve damage) of the pudendal nerve.[13] In the literature however, "pudendal nerve entrapment" and its equivalent terms are often used synonymously with "pudendal neuralgia" and "pudendal neuropathy".

Symptoms

According to the Nantes diagnostic criteria, the presence of pain is essential for a diagnosis of pudendal nerve entrapment (although some sources describe the possibility of entrapment of the pudendal nerve causing non pain symptoms, without pain necessarily being present, or not being present initially).[7][13] Non pain symptoms include bladder, bowel and sexual dysfunctions.[13] This is because the pudendal nerve is a mixed nerve and has sensory, motor and autonomic fibers.[13]

Pelvic pain

The pain is located in the sensory distribution of the pudendal nerve.[5][14] In over 50% of cases, the pain is in the perineum, but may be located in the genital areas (vulva, vagina, clitoris in females; glans penis, scrotum in males).[13] Pain may also be perceived in the rectum (described as "sitting on a golf ball" or a "hot poker in the rectum").[13] Pain may also involve the supra-pubic region and the sacrum.[5] The pain is usually on both sides.[13] Another possible site of pain is the coccyx. The onset of pain symptoms is usually gradual without any single causative event,[13] although sometimes the condition may appear suddenly after some trauma, a long distance trip (cars, planes, etc.), long distance cycling, or a surgical procedure in the region.[14] The character of the pain may be burning, Paresthesia (tingling / pins and needles), aching, stabbing, or like an electric shock.[13][14] This is typical of neuropathic pain.[14] Additionally, there may be referred as sciatic pain, or pain in the medial thigh which may indicate involvement of the obturator nerve.[13] Pain may also be referred to the calf, foot and toes.[13] Sometimes, pain is perceived in the region of the lower abdomen, posterior (back) and inner thigh, or lower back.[13] Hyperesthesia may be present.[4] There may be a sensation of a foreign body in the rectum or vagina.[14] The pain typically gets slowly worse over the course of the day.[13] The pain is positional and typically provoked or aggravated by sitting and relieved by standing, lying down or sitting on a toilet seat.[15] If the perineal pain is positional (i.e. changes with a person's position, for example sitting or standing), this suggests a tunnel syndrome.[clarification needed][16] According to one opinion, pain while sitting which is relieved by standing or sitting on a toilet seat is the most reliable diagnostic parameter.[17] The pain may be intense, chronic, and debilitating.[13]

Urinary

There may be bladder dysfunction such as urinary incontinence,[18] urinary frequency, dysuria, urinary urgency, or dyspareunia. There may be symptoms which are similar to interstitial cystitis.

Rectal

Bowel dysfunction may be present such as fecal incontinence[19] There may be numbness of the anal region.

Sexual

A systematic review found that PN may be implicated in various sexual dysfunctions such as persistent genital arousal disorder (PGAD), erectile dysfunction / impotence, premature ejaculation, and vestibulodynia.[7] There may be pain after ejaculation and pain after sex.[13] Additionally, another review that looked at cycling-related sexual dysfunction suggested that cycling may indirectly cause sexual dysfunction by disturbing the testosterone signaling aspect of the hypothalamic-pituitary-gonadal axis of the body.[20] There may be numbness of the genital area. Numbness of the penis and erectile dysfunction without neuropathic pain may be caused by pudendal nerve compression, especially in cyclists.[7] Compression of both the pudendal nerve and the pudendal artery may be occur and cause erectile dysfunction and premature ejaculation.[7] Persistent genital arousal disorder has been linked to minimal but chronic compression of the dorsal branch of the pudendal nerve.[7]

In cyclists

In male competitive cyclists, it is often called "cyclist syndrome".[6] This is a rare condition in which recurrent numbness of the penis and scrotum develops after prolonged cycling. There may be altered sensation of ejaculation, disturbance of micturition (urination), and reduced awareness of defecation.[21][22] Nerve entrapment syndromes, presenting as genital numbness, are amongst the most common bicycling associated urogenital problems.[23]

Anatomy

Anatomy of the pudendal nerve from the spinal nerve roots to the terminal branches in an adult male.
Main article: Pudendal nerve

The pudendal nerve carries both motor (controlling muscles) and sensory axons. It stems from the spinal nerves S2–S4 of the sacral plexus.[24][25] The nerve progresses between the piriformis and coccygeus muscles and exits the pelvis by passing through the greater sciatic foramen.[24] The pudendal nerve then re-enters the pelvic cavity by passing through the lesser sciatic foramen. After re-entering the pelvis, it breaks off into three branches known as the inferior rectal nerve, the perineal nerve, and the dorsal sensory nerve of the penis or clitoris.[24] These three nerves are also referred to as the terminal branches, and they are more susceptible to injuries due to their locations.[medical citation needed]

There are also four levels of pudendal nerve entrapment compressions:[26]

Although there has been no evidence for a direct functional connection between the pudendal nerve and sacrotuberous ligament, many clinical studies have pointed at the sacrotuberous ligament as a potential cause of PNE.[27] Around the ischial level of the spine, the pudendal nerve runs between the sacrotuberous ligament and the sacrospinous ligament (posteriorly and anteriorly, respectively), allowing potential compression of the pudendal nerve.[28]

Causes

Trauma from childbirth

Vaginal birth may lead to pudendal nerve damage. Childbirth causes stretching of the pelvic muscles[13] and the pudendal nerve. Such stretch-induced pudendal neuropathy may occur with a 12% stretch of the nerve.[29] The nerve is especially vulnerable to stretch damage during childbirth because of the course of the nerve,[25] as it runs in close proximity to pelvic muscles (piriformis and coccygeus) and ligaments, before exiting and then re-entering the pelvic cavity.[24] Stretching occurs during delivery, especially from the child's head.[13] The risk increases when delivering larger-than-average babies or with prolonged or difficult labour.[13]

Surgical trauma

Surgical procedures in the pelvic region may cause damage to the pudendal nerve.[25] Pudendal nerve injury has been reported in obstetric, perineal, and colorectal procedures.[25] Individuals with atypical pelvic anatomy are at higher risk of development of pudendal neuralgia after pevlic surgery.[25][30] Specific examples of procedures which have been reported to cause pudendal nerve injury include:

Surgical procedures which aim to correct prolapse of pelvic organs is reported to be the most common cause of pudendal neuralgia.[24] The risk is higher if mesh is used.[24] In some cases, subsequent removal of the mesh resulted in improvement in pain symptoms.

Cycling and other sports

PNE can develop in cyclists; likely due to both the compression and stretching of the pudendal nerve for prolonged time.[31] Heavy and prolonged cycling, especially if an inappropriately shaped or incorrectly positioned bicycle seat is used, may eventually thicken the sacrotuberous and/or sacrospinous ligaments and trap the nerve between them, resulting in PNE.

Other sport activities which involve repetitive hip flexion may also be involved, for example, exercising, jogging, etc.[13]

Prolonged sitting

People whose professions involve prolonged sitting are at risk. Examples include programmers, office workers, concert pianists, drivers, etc.[13]

Other direct trauma

Trauma not related to pelvic surgery, such as falls or road traffic accidents, may cause pudendal neuralgia.[13]

Other causes

Chronic straining due to constipation may stretch the pudendal nerve and cause pudendal neuralgia.[13] Radiotherapy for cancers of the pelvic region may also be implicated (eg, prostate cancer, rectal cancer, or gynecological cancer).[13]

Other, infrequent causes of pudendal neuralgia are viral infections (HIV, herpes zoster or herpes simplex), multiple sclerosis, and diabetes.[13] Benign tumors originating immediately adjacent to the nerve pathway or within the nerve tissue itself may also be a cause.[13] A malignant tumor (cancer) in another part of the body may metastasize (spread) to involve the nerve or the area around it.[13]

Psychological stress, while not a cause by itself, is known to be a significant aggravating factor in neuropathic pain conditions such as pudendal neuralgia.[13]

Anatomic abnormalities can result in PNE due to the pudendal nerve being fused to different parts of the anatomy, or trapped between the sacrotuberous and sacrospinalis ligaments. Pelvic trauma can also cause pudendal neuralgia.

Pathophysiology

Main article: Pathophysiology of nerve entrapment

Prolonged pressure on the pudendal nerve and chronic traction injuries interrupt the normal microvasculature (blood supply via small blood vessels) of the pudendal nerve, triggering a cascade of physiological changes. Firstly, there is a breakdown of the blood-nerve barrier. Secondly, edema and connective tissue changes occur. This is followed by diffuse demyelination, and finally by Wallerian degeneration. In the acute form, a metabolic block by an impaired blood supply will interrupt normal function of the pudendal nerve. In the chronic form, neuropraxia and axonmetesis (Sunderland type 1 and 2) injuries will create positive symptoms (e.g. pain and paresthesias) and negative symptoms (loss of sensation).[32][33][34] The damage is cumulative.[13]

Repetitive overuse of pelvic floor muscles may lead to remodeling of the bone in the region of the ischial spine and the inferior lateral angle of the sacrum.[13]

Diagnosis

The diagnosis of pudendal nerve entrapment is based on the medical history, clinical examination and a positive result of the injection test.[14] Labat et al state that "there are no specific clinical signs or complementary test results of this disease".[35]

Diagnostic pudendal nerve block

Pudendal nerve block confirms the pudendal nerve is the source of pain through temporary relief of pain while the local anesthetic is working (see Injections).[24] Infiltration is usually near the ischial spine.[35] The duration of pain relief from pudendal nerve block is different depending on the individual.[36] These diagnostic blocks can also be used in place of spinal anesthesia during delivery.[25]

Imaging

There are no specific and consistent radiological findings in patients with PNE.[24] Such imaging cannot be used as evidence of a diagnosis of pudendal nerve entrapment,[14] but they may be helpful to exclude other conditions (see: differential diagnosis).[24]

Magnetic resonance imaging or computed tomography are sometimes used. In people with unilateral pudendal entrapment in the pudendal canal, it is typical to see asymmetric swelling and hyperintensity affecting the pudendal neurovascular bundle.[37]

High-frequency ultrasonography may help to locate the site of compression. On the ultrasound, compressed nerves and accompanying veins appear flat. Inflamed nerves appear edematous.[24]

Doppler ultrasonography, which measures flow in blood vessels, may also help detect nerve entrapment. The pudendal nerve is accompanied by the internal pudendal artery and the internal pudendal vein in the pudendal neurovascular bundle. It is assumed that if the nerve is compressed, then the vein will also be under compression. Doppler ultrasound may detect this.[24]

Other diagnostic tests

Other diagnostic tests that are sometimes used are:

Nantes diagnostic criteria

Pudendal nerve entrapment is difficult to diagnose and there are no specific examinations that can clearly confirm the diagnosis. A multidisciplinary group in Nantes, France developed a set of diagnostic criteria (the "Nantes Criteria") to serve as a guide to physicians in diagnosing PNE.[29] It consists of inclusions, exclusions, and complementary characteristics of the syndrome.[24] Some sources discourage the use of this guide due to errors found in the criteria.[citation needed]

Inclusion criteria are:[24]

  1. The involved area corresponds to the area of supplied by the pudendal nerve (anus to the clitoris or penis).[29]
  2. Pain worsened by sitting, because of increased pressure on the nerve.[29]
  3. The patient is not awoken by pain during sleep.[29]
  4. No objective loss of sensation on clinical examination. Loss of superficial sensation in the perineal area is more indicative of a lesion at the root of the sacral nerves.[29]
  5. Pain relieved by an anesthetic block of the pudendal nerve.[29]

Exclusion criteria are:[24]

  • Imaging results that identify the cause of the pain
  • Pain is exclusively paroxysmal (it comes and goes in short bursts)
  • Pruritus (itching), which suggests a skin lesion
  • Pain not in the area innervated by the pudendal nerve

Complementary criteria are:[24]

  • Nerve pain associated with extreme sensitivity to touch (allodynia)
  • Described as burning/shooting/stabbing pain
  • Posterior pain following defecation
  • Predominantly unilateral pain (pain on one side only)
  • Foreign body sensation in the rectum or vagina
  • Tenderness around the ischial spine during rectal or vaginal examination
  • Abnormal neurophysiological tests

A systematic review by Indraccolo et al analyzed PN due to pudendal entrapment and PN without pudendal entrapment in women with chronic pelvic-perianal pain. The review classified the Nantes' criteria as the gold standard for diagnosing PN secondary to PNE.[38] Because of this, the authors of the systematic review additionally suggest that the criteria may be useful in assessing the efficacy and effectiveness of the pudendal nerve entrapment treatments that people may undergo.

Differential diagnosis

Differential diagnosis includes conditions with potentially similar symptoms, such as chronic prostatitis/chronic pelvic pain syndrome,[15] interstitial cystitis, external compression of the nerve (e.g. from a benign or malignant tumor, or metastatic lesions), complex regional pain syndrome (CRPS), superficial skin infections, damage to the sacral nerve plexus, trauma from childbirth causing stretching of the perineum, prostatodynia, vulvodynia, vulvar vestibulitis, coccygodynia, sacroiliac joint dysfunction, piriformis syndrome, and ischial bursitis.[24]

Management

Treatments include behavioral modifications, physical therapy, analgesics and other medications, pudendal nerve block, and surgical nerve decompression.[8] A newer form of treatment is pulsed radiofrequency.[39] Most medical treatments are intended for symptomatic relief, such as pain. If symptoms are not managed through this standard of care, surgery is considered.[18]

Lifestyle modification

With the help of an occupational therapist, affected individuals may be advised to adapt their lifestyle by avoiding compression of the pudendal nerve in order to protect the nerve and reduce symptoms. Firstly, activities involving perineal pressure which trigger pain may be avoided.[24] For example, cycling, motorcycling, horse riding.[14]

Secondly, to avoid a sitting disability, a seat cushion which allows sitting without direct pressure on the perineum may be used.[13] These ergonomic devices may be described as "orthopedic cushions" or "coccyx cushions". They are generally available in a round doughnut design (which was recommended by the expert consensus panel),[14] or as a rectangular seat with an area at the back removed. The cushions may have a wedge-shaped cross section which is designed to tilt the pelvis forwards.

Other adaptations include use of desks which allow for both sitting and standing (standing desk), and working from home.[14]

Cycling technique and equipment

For those with pudendal neuralgia who choose to continue cycling, which is not recommended by the expert consensus panel,[14] others have published advice. Such recommendations may also serve as preventative advice for currently unaffected individuals who cycle a lot and who do not wish to develop symptoms. A 2021 systematic review of preventative and therapeutic strategies found that cyclists who take precautions in maintaining proper posture may prevent the development of a more severe disorder.[40] It is also suggested that using a wider seat when cycling could prevent damage to the nerve, but more evidence is necessary to show long-term benefit.[31] Other recommendations to decrease nerve compression while cycling include having a soft, wide seat in a horizontal position, setting the handlebar height lower than the seat, wearing padded bike shorts, standing on the pedals periodically, shifting to higher gears, and taking frequent breaks.[40] There are also bicycle seats designed to prevent pudendal nerve compression. Such seats usually have a narrow channel in the middle of them.

Physical therapy

Mobilization of the nerves and muscles in the pelvic region is a proposed way to treat symptoms associated with a nerve entrapment. An example of this is neural mobilization. The goal of neural mobilization is to restore the functionality of the nerve and muscles through a variety of exercises involving the lower extremities. Exercises to specifically target the pudendal nerve would be determined based on the anatomical layout of the nerve. It is important to note that evidence is limited to show support for this therapy.[41]

Another possible treatment for nerve entrapments in the pelvic region would be stretching and strengthening exercises. A treatment plan would be determined by a physical therapist to specifically manipulate the pudendal nerve through a variety of stretches. Strengthening exercises may also be recommended to relieve the excessive pressure caused by the entrapment, but there is currently limited evidence to support this choice of therapy.[41]

Medications

Based on many studies on the pharmaceutical management of neuropathic pain in general, the expert consensus recommended a low and progressive dose of a tricyclic antidepressant medication such as Amitriptyline, or a selective serotonin reuptake inhibitor such as Duloxetine, or an anti-epileptic such as Gabapentin.[14][39][15] Another medication which has been used for pudendal neuralgia is Palmitoylethanolamide.[42] Monotherapy is recommended rather than polypharmacy.[14] That is, using only one medication rather than a combination of different medications. The choice of medications also depends on medication history and side effects.[13] Use of opiate pain killers is discouraged because of the risk of opiate addiction and side effects.[14]

Injections

Illustration of imaging from a CT-guided injection of the pudendal nerve at the pudendal canal.

One way to identify and alleviate pain associated with the pudendal nerve is a "CT-guided nerve block."[43] During this procedure, "a long-acting local anesthetic (bupivacaine hydrochloride) and a corticosteroid (e.g. methylprednisolone) are injected to provide immediate pudendal anesthesia."[15] A pudendal nerve block can be inserted from several different anatomical locations including: transvaginal, transperitoneal, and perirectal. A reduction in pain following this injection is typically felt quickly. The most common side effect of a pudendal nerve block is injection site irritation.[36] Relief from chronic pain may be achieved through this procedure due to the reduced inflammation from the steroid medication, and "steroid-induced fat necrosis" which "can reduce inflammation in the region around the nerve" to lessen strain on the pudendal nerve. This treatment may alleviate symptoms for up to 73% of people.[15] Treatment of pudendal nerve entrapment by nerve block is not often prescribed due to "discomfort associated with the local injections as well as the risk of injuring critical structures."[36]

Pulsed radiofrequency

This can be used instead of pudendal nerve perineural injections.[13] In recent years, Pulsed radiofrequency (PRF) is starting to become more common for managing chronic pain, and has shown to have long-term benefits and low problem occurrences.[44] Pulsed radiofrequency has also been successful in treating a refractory case of pudendal neuralgia, but additional research is needed to study the effectiveness of pulsed radiofrequency on treating pudendal nerve entrapment.[39] Pudendal Nerve Stimulation (PNS) was found to significantly decrease subjective pain levels in people with pudendal neuralgia. A majority of people who underwent PNS reported "significant" or "remarkable" pain relief at 2 weeks after treatment.[45]

Surgical

According to the 2022 expert consensus recommendations, pudendal nerve release surgery is an effective treatment for pudendal nerve entrapment.[14] However, the panel stated that only patients for whom all 5 Nantes criteria were present, including the pudendal block injection test, should undergo surgery.[14] They also advised that surgery should only be attempted in such patients after the failure of a combination of non surgical treatments.[14] The surgery should aim to release the trunk of the nerve throughout its course, and to restore the mobility of the nerve.[14]

Decompression surgery is a "last resort", according to surgeons who perform the operation.[16] It is highly controversial.

According to supporters of the theory of PNE, surgery is indicated when severe symptoms are present after exhausting all other forms of treatment. The surgery is also another option to confirm the diagnosis of pudendal nerve entrapment.[13]

The surgery is performed by a small number of surgeons in a limited number of countries. The validity of decompression surgery as a treatment and the existence of entrapment as a cause of pelvic pain are highly controversial.[46][47] While a few doctors will prescribe decompression surgery, most will not.

There are several different approaches in order to perform a decompression surgery on the pudendal nerve. The different access areas include: superior transgluteal, superior retrosciatic, inferior retrosciatic, medial transgluteal, inferior transgluteal and transischial entry.[26] The transgluteal entry involves "neurolysis of the PN at the infrapiriform canal and transection of the sacrospinal ligament." Another point of entry which is described as a "perineal para-anal pathway", "follows the inferior rectal nerve to the Alcock's canal."[18]

If nerve damage is discovered, other surgery options may be considered like a "neurectomy" or "neuromodulation".[18]

Prognosis

Pudendal neuralgia is not well-known. As a result, there may be misdiagnosis and inappropriate treatments, or it may take a long time before a correct diagnosis is achieved. Affected individuals may undergo various tests and investigations, and over time may seek treatment with multiple different medical specialists such as gynecologists, colorectal surgeons, and urologists. Attempts at treatment may be ineffective at resolving pain. As a result, the long-term, poorly-controlled pain may dramatically reduce quality of life. In some cases, opioid addiction or depression develops. There have been confirmed suicides because of delays in diagnosis and treatment. However, if the condition is quickly identified and properly managed, long-term control of symptoms should be possible.[13]

Epidemiology

The exact prevalence is unknown, but pudendal nerve entrapment and pudendal neuralgia are thought to be uncommon[1][48][6] or rare.[8]

Pudendal neuropathy may occur in males and females, and at any age from toddlers to 90-year-olds.[5]

History

Much of the early research on this condition appeared in France,[49] home of the Tour de France bicycle race. Although the term "pudendal neuralgia" had appeared in earlier publications, the connection between compression of the pudendal nerve and pudendal neuralgia was first described by Gerard Amarenco, a French neurologist, who described the condition in cyclists in a French language publication in 1987.[50] In the following years, the same group of researchers and others released several French language publications about the condition.[51][52][53][54] By the early 1990s, English language publications began to appear.[49] Prior to discovery of the condition, such pain symptoms were sometimes diagnosed as psychogenic pain because health care providers could not detect any cause.[55] Diagnostic criteria were developed and validated by a multidisciplinary group in Nantes, France in 2006, and published in 2008.[35] These diagnostic criteria are known as the Nantes criteria. In 2019, a group named Convergences in Pelvic and Perineal Pain organized the development of consensus recommendations for the diagnosis and management of entrapment of the pudendal nerve. A group of mostly French experts in pudendal nerve entrapment discussed and revised the set of recommendations, which was validated and published in 2022.[14] As of 2022, research on pudendal neuralgia and pudendal nerve entrapment is relatively sparse, awareness of the condition continues to be limited, and available management options are highly variable depending on geographic location.[14]

References

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