By Alexa Savitz, DPT, PHRC Pasadena
Cauda equina syndrome and pudendal neuralgia can present with similar alarming symptoms, which may complicate the diagnostic process. However, prompt and urgent referral is critical when cauda equina syndrome is suspected to prevent the progression of symptoms. In contrast, pudendal neuralgia is not an emergent condition though we acknowledge pudendal neuralgia symptoms can be quite severe and feel like there is an emergency.
Recognizing both the overlapping features and the key differences between these diagnoses is essential for ensuring appropriate treatment and management.
Many health care professionals who are not familiar with pelvic pain syndromes typically think of cauda equina when they hear patient reports of urinary and bowel symptoms, many pelvic floor providers may not think of cauda equina because so many other tissues, nerves and structures create the same symptoms. We hope this post helps both sides recognize what’s what and help people get the care they need!
Cauda Equina
Cauda equina symptoms:
- Bladder dysfunction (retention is most common, leakage)
- Bowel dysfunction
- Saddle numbness (in the area of the perineum, bony pelvis)
- Changes in sexual function/erectile dysfunction
- Acute or chronic low back pain
- Loss of or altered sensation (numbness/tingling) in the buttocks, legs, feet
- Weakness in the lower extremities
According to Hawa et. al, there is no consensus for the exact symptoms, however most commonly sensory loss and bladder dysfunction with retention are the most important factors to consider. Back pain, bladder dysfunction, and weakness can often present under different timelines over days or prolonged development over months.1
Causes:
- Herniated discs
- Lumbar spine stenosis
- Fracture
- Tumor
- Infection
- Cysts
Treatment:
- Surgical decompression to the affected levels of the spine to take pressure off the spinal nerve roots that are impacted.
- The timing of surgical intervention has been suggested to be within 48 hours in previous studies. However other research reported no significant correlation between clinical success and timing of surgery. It is recommended that surgical intervention be performed at “the earliest practical opportunity”.1
Pudendal Neuralgia
Pudendal Neuralgia is pain in the sensory distribution of the pudendal nerve that is described as tingling, stabbing, shooting in nature. The pudendal nerve originates at sacral nerve roots S2-S4, then divides into 3 branches – inferior rectal, perineal, and dorsal clitoral/penile. The pudendal nerve is a mixed nerve containing sensory, motor and autonomic fibers. It innervates the majority of the pelvic floor muscles, the distal ⅓ of the urethra and rectum, and the sensory distribution includes the genitals, perineum, and anus.
Common Symptoms:
- Bowel dysfunction (Constipation, pain in the anus or anywhere is in the sensory distribution before, during or after bowel movements)
- Bladder dysfunction (Urinary urgency/frequency, pain, urination triggering symptoms elsewhere in the sensory distribution)
- Pain in the sit bones or ischial tuberosities
- Pain with orgasm
- Pain in the vulva, penis, perineum, clitoris
The pudendal nerve also has autonomic fibers which make this nerve unique in its presentation causing symptoms including:
- increase in heart rate
- decrease in the mobility of the large intestines
- constriction of blood vessels
- pupil dilation
- perspiration
- increased blood pressure
- goosebumps
- sweating, agitation, and anxiety
Causes:
- Prolonged sitting
- Activities such as cycling, horseback riding, weightlifting
- Childbirth
- Trauma/Falls
- Radiation to the pelvis
Treatment:
- Physical Therapy
- Botox
- Nerve blocks
- Medications (ie. Lyrica, Cymbalta) with proper therapeutic dose and length of time for effectiveness.
- Lifestyle modifications
Please check out our pudendal neuralgia resource guide for more information!
How can we differentiate between the two?
Consider:
- Mechanism of injury: how did the symptoms begin?
- Imaging. If you suspect cauda equina may be the cause of symptoms, urgent referral for imaging is recommended.
- Pain location
- Unilateral or bilateral symptoms present
- Lower extremity sensory loss and motor weakness is more indicative of cauda equina or spinal pathology.
- Note: the pudendal nerve can also cause distal lower extremity numbness/tingling along the S2 dermatome. However, motor weakness in the lower extremity is not a symptom of PN.
As you can see, there are a few overlapping symptoms of cauda equina and PN, however their treatments take a much different approach. This highlights the importance of conducting a thorough subjective history, examination, and a prompt referral if needed, for your patient presenting with any of these signs and symptoms.
References:
Hawa A, Denasty A, Elmobdy K, Mesfin A. The Most Impactful Articles on Cauda Equina Syndrome. Cureus, 2023 Apr 24;15(4):e38069. doi: 10.7759/cureus.38069
Prendergast, S. How do I know if I have Pudendal Neuralgia or Pudendal Entrapment. 2013 Nov 14. Pelvic Health and Rehabilitation Center Blog. https://pelvicpainrehab.com/blog/how-do-i-know-if-i-have-pudendalneuralgia-or-pudendalnerveentrapment/.
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Check out our recently published e-book titled “Vulvodynia, Vestibulodynia, and Vaginismus,” designed to empower and inform individuals on their journey towards healing and understanding.
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tags: nerve pain, pain relief, chronic pelvic pain, severe pain, pudendal nerve pain, bladder and bowel, pain management