Pudendal Neuralgia is the irritation or inflammation of the pudendal nerve which branches off of the lower nerves of the sacrum. It then branches off into three regions going to the vagina/penis, the middle area (perineum), and the rectal area (anus). You will find the common causes of Pudendal Neuralgia in this blog.
Pudendal Nerve route (Wikepedia)
What Are the Symptoms of Pudendal Neuralgia?
While irritation of the pudendal nerve can be caused anywhere from simple cycling to surgery, it is important to understand that pudendal neuralgia symptoms are rather specific. It is characterized by burning, shooting pain along the distribution of the pudendal nerve branches when sitting or standing for a while. This pain may involve all 3 branches or a specific branch that covers the vagina/pelvis, anus, and the area in between. That is of course why listening to the patient and taking proper history is so crucial in making the right diagnosis and follow-up treatment.
What Is the Best Treatment for Pudendal Neuralgia?
Unless it is absolutely obvious that surgery is the only option due to trauma, it only makes sense to try the conservative route as many find relief without any surgery.
Spinal Manipulation/Mobilization
Since the Pudendal nerve branches off of the sacral plexus, the network of nerves that exit the sacrum (part of the pelvis, the end of which is the tailbone), it is important to follow the nerve from the exit point from the spine to where it ends up going. Spinal manipulation and mobilization will address the exit line at the pelvis and internal manual pelvic floor therapy is not the answer here.
(courtesy of https://orthoinfo.aaos.org/)
Nerve Flossing
When a nerve gets compressed or stretched, it becomes irritated and becomes symptomatic. With nerve flossing, through a series of movements, the nerve moves within its covering sheath as explained in this video:
When it comes to Pudendal nerve flossing, I really like this video:
Active Release Technique
Active Release Technique (ART) is my favorite type of soft tissue work that involves working on the muscle, its tightness, and shortness by the provider while asking the patient to perform movements that involve the muscles that are being worked on. The muscles to work on in the case of Pudendal Neuralgia are the Psoas, Iliacus, Abdominal obliques, Obturator Externus, Piriformis, all of the Adductors, and Hamstrings.
Internal Manual Therapy of the Pelvis
While not all issues related to pelvic floor dysfunction require internal pelvic work, with pudendal neuralgia, the assessment of the 3 layers of muscles that are accessible only through the internal manual work should be performed. You can learn about these 3 layers of muscles more in my blog: “ Are Kegel and Pelvic Floor Exercises the Same’.
Developmental Kinesiology Exercises
These are exercises that we all did as babies. While you can learn about Developmental Kinesiology exercises in detail, let me explain to you the gist of it in short. All babies on the planet go through the same developmental movements in the same exact way and around the same timeline which is the indication that we are programmed to go through the process at birth. There are no bands, weights, straps, physical therapist, chiropractor, trainer, sit-ups, squats, etc. We all go from that helpless infant to the running toddler. How do we do it? Developmental Kinesiology exercises such as Dynamic Neuromuscular Stabilization (DNS) is the study of the process in detail and applying it in the world of physical medicine and rehabilitation. And here is the step-by-step progression of exercises I recommend:
Breathing:
The most important factor in the treatment of all pelvic floor dysfunction cases including Pudendal Neuralgia is breathing. Breathing is more than providing oxygen to your body. It is the ‘power on’ to the computer no matter what software and apps you may have on your computer. Breathing provides the axial line, the line of support for your body to build strength and movement around. When it comes to Pudendal Neuralgia, your posture plays a huge role in how compressed or stretched, and how irritated or inflamed this nerve may become. Here is the video that tells you the details:
Elongate the Spine and Relax the Muscles of the Floor
Now that you are breathing correctly, let’s get on the floor and do the exercise that elongates your spine and relaxes the muscles of the pelvis. This exercise btw is helpful for lower back pain, scoliosis, and all issues related to posture and movement.
Happy Baby Pose (done right!)
I did this simple exercise wrong for so long because I mechanically duplicated the move instead of functionally performing it. This move is a 6-month-old DNS exercise that also is a great one to stretch those tight hamstrings. Remember, if you cannot reach your feet and your hamstrings are too tight, you can bend one knee with the foot on the ground while you do the ‘happy baby pose’ on the other leg. Work your way up to involve both legs.
Low Squat
If you do the exercises shown so far, it is time to try the right way to squat down while doing the proper breathing. This will allow the elongation of the spine, neutral lower back, and relaxation of the pelvis which are all necessary for the conservative treatment of Pudendal Neuralgia.
Ergonomics and Lifestyle
In order to get to the root of a problem, we not only need to get rid of the cause but also whatever else that may be feeding that cause. That means your work environment and lifestyle. Pudendal Neuralgia is often seen in Cyclists and Equestrians because of the hard seats.
For Cyclists, there are wider and softer based bike seats available on the market that you should consider exchanging your current bike seat for. For Equestrians, if you are on the lighter side, as an Equestrian myself, I recommend Bob Marshall’s treeless saddle which has been one of my favorite saddles I could ride on for hours and hours. Very soft on the seat and comfy for the horse. If on the heavier side, consider custom padding for OVER the saddle or try other styles of riding that may involve less impact on the pelvis.
When it comes to your work environment, my best recommendation is the checklist I give to my patients that requires barely any new purchases but is highly effective for all conditions including pudendal neuralgia.
Pudendal Neuralgia is not a life sentence and surgery many times is done when effective treatments have been missed. If you have any questions, you may contact me any time.
Dr. Shakib
