By PHRC Team
Several different nerves that supply the pelvis can cause neuropathic pain (nerve pain). We’re going to review a bit of what is involved with neuropathic pain, how to treat neuropathic pain, and follow up with all the questions we received on the topic!
The pudendal nerve is probably the most common nerve that causes neuropathic pain in the pelvis, but there are other nerves that should be considered. The area of the pelvis that each of these nerves are responsible for can overlap making a correct diagnosis challenging.
Pudendal Neuralgia
What to look out for? This condition is often felt on one side of the body, often exacerbated by exercise or functional neurologic activities. Pain is often worse with sitting, better with standing.
Want more information? Check out our blog on these four neuralgias!
Ilioinguinal Neuralgia
It can be confused with pudendal neuralgia because both nerves can cause pain in the labia and penis. The primary difference between ilioinguinal neuralgia and pudendal neuralgia is that ilioinguinal neuralgia is going to cause pain in the inguinal canal (groin) whereas pudendal neuralgia will not.
Obturator Neuralgia
It can be confused with pudendal neuralgia because both will typically cause pain with sitting, particularly around the sit bones or ischial tuberosities. The difference between obturator neuralgia and pudendal neuralgia is that obturator neuralgia will also cause pain in the upper inner thigh whereas pudendal neuralgia will not.
Genitofemoral Neuralgia
Genitofemoral Neuralgia can be confused with pudendal neuralgia because both nerves can cause pain in the clitoris and penis! The primary difference between genitofemoral neuralgia and pudendal neuralgia is that genitofemoral neuralgia is going to cause pain in the inguinal canal (groin) whereas pudendal neuralgia will not.
Questions and Answers
Q: Which one could cause muscle weakness and tiredness ? As if I had run for miles making my legs exhausted and my pelvic area very tight.
A: Peripheral neuralgias are generally not the primary cause of muscle weakness. While weak muscles can be associated with nerve dysfunction, we recommend seeing a doctor who can perform a full evaluation and help you determine where your symptoms are coming from. An evaluation with a physical therapist would likely be helpful as well.
Q: Can knee pain be connected to these areas?
A: Yes. The body is all connected! Seeing a pelvic floor PT can help you determine if your knee pain may be associated with your pelvic floor.
Q:
Q: Finally information about neuropathic pain! Can you have genitofemoral neuralgia only on Rt side? Could you please share some advice for the management of the pain? I’m concerned this could turn into chronic neuropathic pain..open to any pain relief resources or advice!
A: Yes, you can have GF neuralgia on either the right or the left side, or both. Pain management is multidisciplinary and can involve treatment with a physical therapist, pain management provider, PCP, and pain psychology if needed.
Q: What makes nerve pain different from “regular” pain? is it always sharp
A: Pain is complex and often multifactorial, so have a discussion with a specialist. Nerve pain can mimic almost any other sensation. Often it is described as burning, sharp, pinching, stabbing, etc. Nerve pain is often made worse with pressure or stretching of the nerve. Nerve pain can also be exacerbated by physical, mental, or emotional stressors. In general, nerve pain feels better when you take away the pressure, stretch, or stress.
Q: Ol neuralgia ever happen with no mechanism of injury?
A: Usually there is some mechanism of injury for any symptom you experience, but that mechanism can be chronic constipation or prolonged sitting… things that you may not think of as an “injury”. A pelvic floor PT can help you ID and treat potential predisposing factors to your symptoms.
Q: What causes this??? And what helps it? Feels like my pelvic floor is on and off throbbing, aching for about a month. Came out of nowhere. Gynecologist said it’s a strain in the psoas muscle and referred me to a sports medicine doctor.
A: Many things can cause neuropathic pain. If your gynecologist thinks that there is a muscular component, seeing a pelvic floor PT would likely be helpful!
Q: What if you have occasional burning in all those areas? Would you think probably from a hypertonic floor?
A: There are many other conditions that can contribute to occasional pain in these areas, including but not limited to pelvic floor dysfunction. A pelvic floor physical therapist can help determine what is happening in your case.
Q: So what specifically does the ilioinguinal nerve affect?
A: The ilioinguinal nerve is a sensory nerve that covers these areas (see our nerve maps here). The symptoms someone may have is sensory changes in the areas of skin that the nerve innervates. It does not innervate muscles, so there will not be any direct muscular changes with impact to this nerve.
Q: Do you have recommendations of exercises to avoid when having a pudendal neuralgia flare?
A: As a general guideline, avoiding deep squatting and cycling (or other activities where you are directly putting pressure on the nerve) are important to avoid. Additionally, anything that may cause stretch to the nerve depending on where you are at in your healing process. Kegels are also not recommended. However, to know what specific exercises are appropriate or not for you, this should be discussed with your physical therapist.
Q: The feeling of an ice pick diagonal through the pelvis would be what nerve?
A: This can be a description of nerve pain for some, however, it is important for a proper evaluation to see exactly what is causing the pain (nerve, viscera, muscle, etc) as there are different referral patterns and there are crossover in symptoms, in order to recommend an appropriate treatment plan.
Q: Is an MRI the best tool to get a clear diagnosis on which nerve is causing the pain?
A: Most imaging (MRI, US, CT) will not identify a neuralgia (nerve pain). Neuralgias are most often a functional issue. Imaging may be helpful in identifying entrapment of nerves. Most diagnoses for neuralgias are the result of a thorough history and examination +/- diagnostic nerve blocks.
Q: Could endometriosis cause neuropathic pain in the pelvis?
A: Endometriosis absolutely can cause neuropathic pain in the pelvis in a variety of ways, directly, and indirectly. If endometriosis is impacting a nerve directly, it can impact the function of that nerve (sensory, motor, or autonomic functions). Endo can also indirectly contribute to neuropathic pain by viscerosomatic reflex (organ to tissue like muscle or skin) due to the chronicity of the disease and central sensitization.
Q: Pelvic floor therapy, SI injection, caudal injection, and another from PM can’t remember names. Nothing helped pain. Also had botox and trigger points from urogyn. Sitting is impossible. What else can I do? Also on lyrica.
A: We are sorry to hear about your symptoms and the lack of improvement. Unfortunately, we cannot determine the cause of your pain or why these interventions did not work for you without actually discussing your case with you directly or evaluating you in person. There can be a number of reasons these interventions didn’t work including the length of time and dosage of medications, or general timing and order of interventions, inadequate physical therapy (i.e. no manual therapy, too short duration of physical therapy), or correct diagnosis/evaluation of all the impairments. Sitting pain can result from a combination of factors including poor joint mobility, soft tissue impairments, impact to the nerves, spinal or hip involvement, or any combination of the above.
Whether you have neuropathic pain or not, help is out there! If you are concerned about having chronic neuropathic pain or are just on the hunt for pain relief, finding a provider that is familiar with neuropathic pain can make a huge difference when it’s time for treatment!
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