pudendalgia review

1. PUDENDALGIA

2. Definition
• A.k.a : Alcock syndrome, Pudendal
algia, Pudendal nerve entrapment
syndrome, Pudendal neuralgia by
pudendal nerve entrapment,
Pudendalgia :
• Is a long-term pelvic pain that
originates from damage or irritation of

3. Innervation
• The pudendal nerve emerges from the S2, S3, and S4 roots'
ventral rami of the sacral plexus.

4. The pudendal nerve supplies areas
including the:
• lower buttocks
• area between the buttocks and genitals
(perineum)
• area around the anus and rectum
• vulva, labia and clitoris in women
• scrotum and penis in men

7. Symptoms of pudendal neuralgia
• The main symptom of pudendal neuralgia
is pelvic pain. Any of the areas supplied by
the pudendal nerve can be affected.
• The pain may:
– feel like a burning, crushing, shooting or prickling sensation
– develop gradually or suddenly
– be constant – but worse at some times and better at others
– be worse when sitting down and improve when standing or
lying down

8. • Other symptoms can include:
• numbness and pins and needles in the pelvic area
• increased sensitivity to pain – you may find just a
light touch or wearing clothes uncomfortable
• feeling as though there's swelling or an object in your
perineum – often described as feeling like a golf or
tennis ball
• needing to go the toilet frequently or suddenly
• pain during sex, difficulty reaching orgasm,
and erectile dysfunction in men

9. Cause :
• Mechanical or non-mechanical injury.
1. The mechanical : can be due to
compression, transaction, or stretching.
compression caused by PNE is the most
common cause.
2. The non-mechanical : include viral
infections (herpes zoster, HIV), multiple
sclerosis, diabetes mellitus, and others.

10. • Pelvic surgery - The surgery for repair of prolapse of pelvic organs is reportedly
the most common cause of pudendal neuralgia. The incidence increases if it is a
mesh placement surgery; this may require mesh removal in cases of chronic
persistent pain.[8][9] It can also develop after mid-urethral sling surgery,
hysterectomy, and anterior colporrhaphy.
• Direct trauma to buttocks or back can also result in pudendal neuralgia.[10]
• Childbirth - Vaginal delivery causes a significant stretch of pelvic floor muscles
by the fetal head, which results in pudendal nerve damage.[11][12]
• Chronic constipation
• Excessive cycling - It is presumed to happen because of chronic perineal
microtrauma which causes fibrosis in the pudendal canal and also of
sacrospinous and sacrotuberous ligaments.[6]
• Prolonged sitting can also contribute to this condition.

11. Causes of pudendal neuralgia
• Pudendal neuralgia can happen if the pudendal nerve is
damaged, irritated or trapped.
• Possible causes include:
– compression of the pudendal nerve by nearby muscles or tissue –
sometimes called pudendal nerve entrapment or Alcock canal syndrome
– prolonged sitting, cycling, horse riding or constipation (usually for months
or years) – this can cause repeated minor damage to the pelvic area
– surgery to the pelvic area
– a broken bone in the pelvis
– damage to the pudendal nerve during childbirth – this may improve after a
few months
– a non-cancerous or cancerous growth pressing on the pudendal nerve

12. • The presenting features of PNE are discussed below[4]
• It causes pain, numbness, and dysfunction in the distribution of
pudendal nerve that includes genitalia, rectum, and terminal urinary
tract.
• Sexual dysfunction, including persistent arousal, dyspareunia,
vulvodynia, and male impotence.[14]
• Sphincter dysfunction presenting as dyschezia, fecal incontinence,
and urinary hesitancy.[15]
• Foreign body sensation in the anus, rectum, urethra, or vagina.

13. Nantes criteria fot PNE :
• Inclusion criteria:
1. Pain co-relates with the anatomical distribution of pudendal
nerve: Pudendal nerve supplies external genitalia. The pain can
be superficial or deep in the vulvovaginal, anorectal, and distal
urethra.
2. Pain predominantly in sitting position: This symptom favors
nerve compression because if there is a decrease in mobility of
the nerve, it makes the nerves vulnerable to compression
against hard ligamentous structures. This aspect of pain is
dynamic as the pain results from compression and not by sitting
position.

14. 3. The patient does not get up with pain at night, although many
patients may experience difficulty going to sleep because of pain.
4. There is no sensory loss: The presence of superficial perineal
sensory impairment indicates sacral root lesion rather than PNE.
5. Relief of pain with pudendal nerve block: This essential criterion is
not specific as any perineal disease other than entrapment can
cause pain in the anatomic region of the pudendal nerve. A negative
block also doesn’t exclude the diagnosis if there is a lack of
precision or when performed too distally.

15. • Complementary diagnostic criteria:
1. Pain is of burning, shooting, or stabbing in
nature and associated with numbness.
2. Allodynia or hyperpathia
3. Foreign body sensation or heaviness in
rectum or vagina.
4. The pain progressively increases and
peaks in the evening and stops when the

16. 5. Pain is more on one side.
6. Pain more prominent posteriorly and is
triggered minutes or hours after defecation.
7. Tenderness felt around the ischial spine
during a digital vaginal or rectal examination.
8. An abnormal result on neurophysiological
tests

17. • Exclusion criteria:
1. Pain exclusively in the territory not served by the
pudendal nerve. It can be in hypogastrium, coccyx,
pubis, or gluteus.
2. Pain is associated with pruritus ( more suggestive
of a skin lesion).
3. Pain entirely paroxysmal in nature.
4. If imaging abnormality can justify the cause of the
pain

18. • Associated signs:
1. Pain in the buttock
2. Referred sciatic pain
3. Pain in the medial thigh (indicates obturator nerve)
4. Pain in the suprapubic region
5. Increased frequency of urine or pain with a full bladder
6. Pain after ejaculation
7. Pain worsens hours after sexual intercourse
8. Erectile dysfunction
9. A normal result on electrophysiological tests

19. How to Examine ?
• a vaginal or rectal exam – to see if the pain occurs when
applied pressure to the pudendal nerve with their finger
• an MRI scan – to check for problems such as a trapped
pudendal nerve and rule out other possible causes of the pain
• nerve studies – a small device inserted into rectum is used to
stimulate nearby nerves with mild electrical impulses to check
how well the nerves are working
• nerve block injections – painkilling medication is
injected around the pudendal nerve to see if the pain improves

20. Treatments :
• Avoiding things that make the pain worse, such
as cycling, constipation or prolonged sitting
• Medicines to alter the pain
• Physiotherapy – a physiotherapist can teach you
exercises to relax your pelvic floor muscles (muscles
that you use to control urination) and other muscles
that can irritate the pudendal nerve

21. • painkilling injections – injections of local
anaesthetic and steroid medication)
• decompression surgery – if something is pressing
on the pudendal nerve, such as a piece of tissue,
surgery to move it away from the nerve may help
improve the pain
• nerve stimulation – a small device is surgically
implanted under the skin to deliver mild electrical
impulses to the nerve and interrupt pain signals sent
to the brain

22. Daftar Pustaka
• 1. https://www.nhs.uk/conditions/pudendal-
neuralgia/