According to Orphanet, the European Rare Disease Database pudendal neuralgia affects 4% of patients presenting for consultation for pelvic pain, of whom 30% are men and 70% are women, mostly aged 50 to 70 years.
The pudendal nerve is a nerve of the sensory, motor and autonomic nervous system that emerges from the sacral roots and then travels to the pelvis, giving off its three terminal branches: the spinal nerve of the penis or clitoris, the inferior rectal nerve and the perineal nerve.
Because of its anatomical path, this nerve can be easily compressed by surrounding structures such as the pelvic ligaments, and it is this compression that causes painful symptoms.
Overview of Chronic Pelvic Pain
The cause of pain can be organic or infectious diseases, then they talk about chronic pelvic pain.
In some cases, no pathology is detected or the severity of pain does not correspond to the severity of the proven changes. In this case, a diagnosis of chronic pelvic pain syndrome (CPPS) is made.
Impaired blood microcirculation and increased excitability of the nervous system play a role in the development of CPPS. In conditions of lack of oxygen and nutrients, nerve endings transmit impulses that are perceived by the brain as pain.
Therefore, the treatment plan includes:
- therapy of the underlying disease;
- physiotherapy - improves blood circulation;
- decreased excitability of the nervous system - affects the peripheral and central parts of the nervous system responsible for the perception of pain.
Clinical anatomy
Sacrococcygeal plexus The
pudendal nerve is a paired nerve, the branches of which are located on the right and left sides of the human body.
- Nerve roots – S2-S4
- Sensory branches - innervate the external genitalia of men and women, as well as the skin around the anus, anal canal and perineum.
- Motor branches - innervate a number of pelvic floor muscles, the external urethral sphincter and the external anal sphincter.
- Autonomic - carry sympathetic nerve fibers to the skin of the dermatomal area S2-S4.
Entrapment of the pudendal nerve at different levels (sciatic spine, sacrospinous and sacrotuberous ligaments, Alcock's canal) is the cause of disabling, chronic and intractable pelvic pain. This pain is highly varied and complex because it is often associated with a variety of functional symptoms that are confusing.
Causes of chronic pelvic pain
Organic causes of the disease:
- inflammatory diseases of the reproductive system, for example: salpingitis, oophoritis, endometritis, cervicitis;
- benign and malignant tumors, cysts;
- endometriosis ー appearance of endometrial tissue (inner lining of the uterus) in atypical places, i.e. on other organs;
- adhesive process in the pelvic cavity;
- varicose veins of the pelvis;
- urological diseases: urolithiasis, cystitis, pyelonephritis;
- intestinal pathology;
- lumbosacral osteochondrosis.
A disease without an organic cause is detected in less than 2% of cases. This is typical for people with an unstable emotional state, hypochondria, a tendency to nervous breakdowns, neurasthenia, and depression.
Classification of chronic pelvic pain syndrome
There are three stages of development of CPPS:
- Organ stage
. The pain is local, limited to one area, and does not spread to nearby organs. According to the patient's subjective assessment, it corresponds to the severity of the disease. There are no psychoemotional disorders. - Supraorgan stage
. The pain spreads to other areas along the nerves. - Polysystem stage
. In addition to the high intensity of the pain syndrome, there are disorders of the functioning of the pelvic organs. The consequences are: disruptions of the menstrual cycle, metabolic disorders due to hormonal dysfunction. At this stage, serious psycho-emotional disorders develop.
Pathophysiology
Pathological conditions associated with pudendal nerve damage
The exact mechanism of nerve dysfunction and damage depends on the etiology. The damage may be one or two sided.
Causes of PN can include compression, stretching, direct nerve injury, and radiation. Pudendal neuralgia is a functional pinching in which pain occurs during compression or stretching of the nerve. Symptoms worsen over time due to repeated microtrauma, ultimately leading to persistent pain and dysfunctional complaints. The pudendal nerve becomes pinched during prolonged sitting or cycling.
Pudendal neuropathy can be caused by stretching of the nerve due to straining during labor or constipation. Other etiological factors include fitness classes, working out in the gym, weighted squats, leg presses, karate, kickboxing and roller skating. Sports popular among young people are considered a risk factor, which may be associated with bone remodeling of the ischial spine. Vibration injuries can occur from driving on rough roads and agricultural fields. Pudendal neuralgia can also be caused by falling on the buttocks.
Symptoms of chronic pelvic pain syndrome
The main manifestations of CPPS:
- painful sensations of aching, burning or cutting nature in the pelvis, sacrum, pubic area, lower abdomen, perineum;
- pain and discomfort are not related to the menstrual cycle;
- pain during and/or after sexual intercourse;
- urination disorder: pain, delay, frequency;
- insomnia, frequent nightmares;
- depression, causeless anxiety.
Treatment
For the treatment of NP, it is advisable to use three types of drugs:
- Muscle relaxants.
- Analgesics.
- Anticonvulsants.
Invasive treatment
These interventions are performed by experienced doctors:
- Surgical release of the pinched pudendal nerve (in some cases, patients may experience pain after surgery and will need the help of a physical therapist to recover).
- Botox/botulinum toxin injections (type A).
- Pulsed high-frequency stimulation of the pudendal nerve, sacral nerve roots or sacroiliac joint.
- Cortisone injections.
- Platelet-rich plasma (PRP) injections.
- Hyaluronic acid injections.
- Neuromodulation using implanted electrodes.
The selection of candidates for surgical treatment must necessarily include a single diagnostic injection of an anesthetic into the area of the pudendal nerve. Let us recall that this procedure represents the fifth criterion for diagnosing PN according to Nantes.
Clinical management of the patient depends on the cause of the nerve injury. When the cause is not obvious, patients are advised to try the least invasive and least risky treatments first.
Non-invasive or conservative therapy
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Physical therapy
The long-term goals of physical therapy are pain relief and improved quality of life.
Physical therapy analysis includes a motor assessment of the patient. It can help detect inappropriate movement patterns that may be causing symptoms of the disease. The analysis also often includes examination of the pelvic muscles (done with great care), which makes it possible to determine the ability of these muscles to contract and relax.
Treatment includes:
- conversation with the patient about the mechanism of pain;
- correction of the biomechanics of movements, body position or activity of the patient;
- internal manual therapy to facilitate healthy muscle contraction and relaxation (if applicable).
Pelvic floor muscle relaxation exercises (PFM)
This is the most preferred strategy for those physical therapists who specialize in pelvic diaphragm dysfunctions and disorders. Peter Doran and Michel Coppetiers, two Australian physical therapists, conducted a study in which, among other things, they reported a protocol for the treatment of pelvic girdle pain due to pudendal nerve lesions. They have had great success with a small group of patients using externally guided techniques to mobilize the sacroiliac joints, reducing tension on the sacrotuberous and sacrospinous ligaments. This is a noninvasive approach that should be considered before more aggressive approaches are attempted.
Self-help for PN:
The patient should use a cushion/cushion (doughnut or C-shaped) that supports the ischial tuberosities and elevates the pelvic floor off the seat. This support relieves excess tension on the MTD and pudendal nerve. The patient should also avoid positions and movements that provoke pain.
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The treatment uses exercises that relax the tense pudendal nerve and provide temporary pain relief:
- Bridge with legs wide apart.
- Swing your legs back in a standing position.
- Abduction and extension of the legs in a side lying position.
- Leg extension in the knee-wrist position.
- Cobra pose.
- Back arches.
The effectiveness of special exercises or yoga asanas in the treatment of chronic pudendal neuralgia has been little studied and requires more thorough research.
Forecast
Pudendal neuralgia greatly affects the patient’s quality of life, but does not affect its duration. Many patients with PN reported on medical forums and support groups that they also experienced depression and a constant feeling of discomfort. However, after correct diagnosis of the disease and with treatment, these symptoms gradually decreased.
Diagnosis of chronic pelvic pain syndrome
Patients with CPPS should be carefully examined for organic pathology, inflammatory processes and neoplasms. To do this, the doctor will prescribe the following tests and examinations:
- gynecological examination;
- Ultrasound of the pelvic organs;
- hysterosalpingoscopy;
- tests for genitourinary infections;
- X-ray methods: urography, cystography;
- endoscopic examinations: hysteroscopy, colonoscopy, cystoscopy;
- diagnostic laparoscopy;
- MRI, CT.
In the absence of a pathology that can cause intense pain, the patient needs consultation with several doctors: a gynecologist, urologist, neurologist, gastroenterologist, orthopedist, oncologist, psychologist, psychiatrist.