Diagram of Sacral Plexus


If you are reading this blog, chances are that you suspect having a Pudendal nerve issue or have been told that you have Pudendal Neuralgia. The symptoms of Pudendal Neuralgia typically include sharp, stabbing, prickling, or shooting sensations in the pelvic area and lower back pain. In the beginning, many mistake it for gas pain or lower back pain and treat it as such. By the time the diagnosis of Pudendal Neuralgia is made, most people have suffered for a long time. They have been treated for many ‘other’ conditions such as lower back pain or pelvic pain without addressing the actual cause.

Where is the Pudendal Nerve?

Diagram of the lower spine and its nerves

courtesy of teachmeanatomy.info

The Pudendal nerve is the lower section of a series of nerves that come from the lower back and sacrum called the Sacral Plexus.  The Pudendal nerve comes out of the S2-5 area, goes under the Piriformis muscle, leaves the pelvis through the greater sciatic foramen, back to the lessor sciatic foramen, over the sacrospinous ligament, and under the sacrotuberous ligament.


Pudendal Nerve route

Pudendal Nerve route (Wikepedia)

Anywhere along the path, from the lower back and sacral area to the ending of the pudendal nerve (vagina/pelvis, anus, and perineum), this nerve can be pressured on, compressed, irritated, and entrapped causing symptoms that lead to the diagnosis of Pudendal Neuralgia.

Who Diagnosis Pudendal Neuralgia?

Typically since most of the symptoms of Pudendal Neuralgia are related to the genitals and pelvis, it is a urologist, urogynecologist, or gynecologist that makes the diagnosis of Pudendal Neuralgia. In many instances, it is the primary physician or a chiropractor that suspects the diagnosis and makes the referral to the mentioned physicians for further testing and diagnosis.

The following is then performed to confirm the suspected diagnosis of Pudendal Neuralgia:

  • Pudendal Nerve (PN)Terminal Motor Latency Test: to assess the motor component of the anal branch of the nerve
  • Staged Sacral Reflex Testing: to test the motor component of the clitoris/penis branch of the nerve
  • Somatosensory Evoked Potential (SSEP) to assess the sensory nerve path of the PN and the brain
  • Warm Detection Threshold Testing to assess the sensory task of the Pudendal nerve
  • MR Neurography to detect any obvious blockages of the Pudendal nerve
  • Pudendal Nerve Block to see if the symptoms disappear or improve since parts of the nerve are not always seen in the studies while irritation or entrapment can still take place.

Who Treats Pudendal Neuralgia?

Treatment of Pudendal Neuralgia is multi-disciplinary since different sections of the Pudendal nerve pathway can be irritated or impacted. Given its sensory, motor, and sympathetic (autonomic nervous system) involvement, there are different tasks to restore and in short, the treatment is more complex.

Unfortunately, by the time the standard medical and procedural protocols for Pudendal Neuralgia diagnosis are done, quite a bit of time has lapsed. The key is to always rule out Pudendal Neuralgia as soon as mild symptoms are observed and in my opinion, when patients present with:

  • Pelvic pain
  • Lower back pain
  • Sacro-iliac pain and
  • Decline in posture

The last three posted may or may not come with pelvic pain which then brings the differential diagnosis of Pudendal Neuralgia closer to the surface.

It is important for general practitioners, chiropractors, and physical therapists who may encounter patients with the beginning of pudendal nerve irritation from symptoms such as back pain, sacroiliac pain, and at times mild pain in the pelvis to rule out pudendal neuralgia. It is much easier to address the issue with stabilization of the pelvis, hips, and lower back and improve posture so the nerve is not compromised.

In case of surgeries or trauma in the pelvis, and chronic muscle guarding of the pelvis, internal pelvic floor treatment should be a part of recovery to assure scar tissue formation does not impact this nerve negatively. Postural stabilization should be the next step in preventing this complex nerve from being impacted regardless of the cause of Pudendal Neuralgia.

What is the Best Postural Stabilization Exercise?

There are many claims of the ‘best’ postural stabilization exercises when it comes to the rehabilitation world; however, what makes sense is to go with the ONE exercise type that applies to all human beings! I am talking about Developmental Kinesiology which is what all babies on this planet use to go from helpless infants to running toddlers.

At our clinic, we use Dynamic Neuromuscular Stabilization or DNS to bring back all types of musculoskeletal insufficiencies that may or may not lead to nerve issues.

It is important to keep in mind that not all pelvic floor therapists focus on postural correction and most that claim they do, barely spend quality time to assure the stabilization of the trunk or torso as well as the hips. It is important to have internal manual work done but you can’t expect the ‘floor’ to be stabilized if the ‘house’ (pelvis) is shaky and unstable.

If you suspect having Pudendal Neuralgia, are told you have it, or wish to rule out Pudendal Neuralgia, contact me.

Dr. Shakib