By Elizabeth Akincilar, MPT, Cofounder, PHRC Merrimack
Over the last couple of years PHRC has shared many YouTube videos and educational material on Instagram educating our viewers and readers about pelvic health. We have received an overwhelming response to several of our posts discussing pudendal neuralgia. Listed below are some of the most common questions we’ve received and our answers. A video Q&A can also be found on our YouTube channel.
Q: Is pudendal neuralgia something that can go away on its own? If so, how much time should you wait before seeing someone?
A: If the nerve is minimally irritated and the cause of irritation has resolved or is no longer irritating the nerve, then it may resolve on its own. However, if the nerve has been irritated for a long period of time and the cause of the irritation is either still present or unknown, then it will likely not resolve on its own. It will likely need some sort of medical intervention. At the least, pelvic floor physical therapy, but it may also require pain management interventions such as medications and/or nerve directed therapies.
Q: Is there a direct cause of PN?
A: Yes, in many cases there are direct causes of pudendal neuralgia, but in some cases there are a combination of things that can result in pudendal neuralgia. Direct injuries to the pudendal nerve can happen during childbirth, during a pelvic surgery, or due to a fall on one’s buttocks. Indirect injuries or irritation can happen over time due to activities, such as heavy squatting, or due to constipation, or due to surrounding musculature that has become tight and now putting pressure on the pudendal nerve. This is really something that is teased out during an evaluation with a pelvic floor physical therapist as we learn more about the person’s specific situation and history.
Q:Is it possible to have pudendal neuralgia without having urinary or bowel incontinence symptoms ?
A: Yes, it is possible. The pudendal nerve has three branches. One that innervates the anus and contributes to bowel function, one that innervates the perineum and contributes to urinary function and the last innervates the penis or clitoris and contributes to sexual functioning. It is possible for one, two or three of these branches to be affected with pudendal neuralgia. Therefore, if the only branch irritated is the branch that innervates the clitoris or penis, also known as the dorsal branch, the person would most likely not have urinary or bowel symptoms, like urinary urgency or pain with urination or defecation. And specifically, urinary or bowel incontinence would likely only occur if there was a pudendal neuropathy, which is when the nerve is actually damaged, to either the rectal or perineal branch of the pudendal nerve. Urinary and/or bowel incontinence is not typically a symptom reported with pudendal neuralgia.
Q: What exercises should I stay away from?
A: This is difficult to answer because depending on which branch of the pudendal nerve is irritated and what other musculoskeletal and myofascial impairments are present, will also affect exercise prescription. In general, the exercises that will often further irritate the pudendal nerve are exercises that flex the hip past 90 degrees. Therefore, deep squats, end range hamstring stretches, some stretches for external hip rotators, climbing stairs or a stair master-type machine, any exercise that causes one to hold their breath and bear down. For example, lifting weights that are too heavy for the person so the person bears down or holds their breath to complete the lift. When you do this you contract your pelvic floor muscles which can compress the pudendal nerve.
Q: What exercises CAN I do?
A: You can do lots of exercise! Exercise does not have to be strenuous or aggressive to be effective. Most folks with pudendal neuralgia can walk, even briskly, most can swim with a light scissor kick, use the elliptical machine, strength train, practice yoga, and/or work with a Pilates instructor on a one on one basis for an individualized program. Exercise prescription should really be discussed with your pelvic floor physical therapist who will be familiar with the specifics of the person’s case and will best be able to talk about what exercises are most appropriate.
Q: Are feelings of fiery-ness, sharp poker and throbbing congruent with PN symptoms?
A: Yes, they could be. Typical symptoms of any type of neuralgia are sharp, shooting, knife-like, burning and/or lancinating pain. Typical symptoms of pudendal neuralgia are this type of pain in the distribution of the pudendal nerve which is roughly the urethra, vagina, vulva, penis, scrotum, perineum, anus, peri-anal area, and/or rectum.
Q: How many different types of entrapments are there?
A: The pudendal nerve can become entrapped in two primary locations. First, within Alcock’s Canal, which is a canal that the nerve travels through. This canal is made up of part of the obturator internus muscle and the sacrotuberous ligament. The other location the nerve can become entrapped is between the sacrospinous and sacrotuberous ligament. This is the most common location of entrapment.
Q: Can the nerves remain dysfunctional after decompression?
A: Unfortunately the pudendal nerve can remain sensitive or painful even after the decompression surgery. Decompressing the nerve addresses one aspect of the pain syndrome. It does not address any musculoskeletal dysfunction or activity or behavioral contributions to the neuralgia. Therefore, if the other contributors to the pain syndrome are not being addressed, the pain will persist. Additionally, if the person has had significant neuropathic pain for a long time, there is the issue of central sensitization that also needs to be addressed. Lastly, after decompression surgery, it is not unusual for the person to have a flare up of pain since the surgery itself can be provocative. That flare up of pain typically subsides within weeks.
Q: Is central sensitization a reason for failure of surgery??
A: When pain is not alleviated with pudendal nerve decompression surgery, central sensitization can be one of the reasons. We and our medical colleagues strongly recommend working with a pain management doctor to best utilize appropriate medications to help reduce central sensitization before surgery and through rehabilitation afterwards. Too often patients are not properly educated about the most effective medications and why they can help.
Educating the community about pelvic health continues to be one of PHRC’s primary goals. Please remember that our educational material does not replace a comprehensive evaluation by a healthcare professional. If possible, an in-person comprehensive evaluation by a healthcare professional is always recommended to address your pelvic health concerns appropriately.
If you would like to schedule a virtual appointment with one of our experts, you can do so via our website.
If you would like more information about PHRC, email us a message and we’ll get back to you asap!
If you would like to schedule an in-person evaluation, please call the PHRC location that is most convenient for you.
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Are you unable to come see us in person in the Bay Area, Southern California or New England? We offer virtual physical therapy appointments too!
Virtual sessions are available with PHRC pelvic floor physical therapists via our video platform, Zoom, or via phone. For more information and to schedule, please visit our digital healthcare page.
In addition to virtual consultation with our physical therapists, we also offer integrative health services with Jandra Mueller, DPT, MS. Jandra is a pelvic floor physical therapist who also has her Master’s degree in Integrative Health and Nutrition. She offers services such as hormone testing via the DUTCH test, comprehensive stool testing for gastrointestinal health concerns, and integrative health coaching and meal planning. For more information about her services and to schedule, please visit our Integrative Health website page.
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FAQ
What are pelvic floor muscles?
The pelvic floor muscles are a group of muscles that run from the coccyx to the pubic bone. They are part of the core, helping to support our entire body as well as providing support for the bowel, bladder and uterus. These muscles help us maintain bowel and bladder control and are involved in sexual pleasure and orgasm. The technical name of the pelvic floor muscles is the Levator Ani muscle group. The pudendal nerve, the levator ani nerve, and branches from the S2 – S4 nerve roots innervate the pelvic floor muscles. They are under voluntary and autonomic control, which is a unique feature only they possess compared to other muscle groups.
What is pelvic floor physical therapy?
Pelvic floor physical therapy is a specialized area of physical therapy. Currently, physical therapists need advanced post-graduate education to be able to help people with pelvic floor dysfunction because pelvic floor disorders are not yet being taught in standard physical therapy curricula. The Pelvic Health and Rehabilitation Center provides extensive training for our staff because we recognize the limitations of physical therapy education in this unique area.
What happens at pelvic floor therapy?
During an evaluation for pelvic floor dysfunction the physical therapist will take a detailed history. Following the history the physical therapist will leave the room to allow the patient to change and drape themselves. The physical therapist will return to the room and using gloved hands will perform an external and internal manual assessment of the pelvic floor and girdle muscles. The physical therapist will once again leave the room and allow the patient to dress. Following the manual examination there may also be an examination of strength, motor control, and overall biomechanics and neuromuscular control. The physical therapist will then communicate the findings to the patient and together with their patient they establish an assessment, short term and long term goals and a treatment plan. Typically people with pelvic floor dysfunction are seen one time per week for one hour for varying amounts of time based on the severity and chronicity of the disease. A home exercise program will be established and the physical therapist will help coordinate other providers on the treatment team. Typically patients are seen for 3 months to a year.
What is pudendal neuralgia and how is it treated?
Pudendal Neuralgia is a clinical diagnosis that means pain in the sensory distribution of the pudendal nerve. The pudendal nerve is a mixed nerve that exits the S2 – S4 sacral nerve roots, we have a right and left pudendal nerve and each side has three main trunks: the dorsal branch, the perineal branch, and the inferior rectal branch. The branches supply sensation to the clitoris/penis, labia/scrotum, perineum, anus, the distal ⅓ of the urethra and rectum, and the vulva and vestibule. The nerve branches also control the pelvic floor muscles. The pudendal nerve follows a tortuous path through the pelvic floor and girdle, leaving it vulnerable to compression and tension injuries at various points along its path.
Pudendal Neuralgia occurs when the nerve is unable to slide, glide and move normally and as a result, people experience pain in some or all of the above-mentioned areas. Pelvic floor physical therapy plays a crucial role in identifying the mechanical impairments that are affecting the nerve. The physical therapy treatment plan is designed to restore normal neural function. Patients with pudendal neuralgia require pelvic floor physical therapy and may also benefit from medical management that includes pharmaceuticals and procedures such as pudendal nerve blocks or botox injections.
What is interstitial cystitis and how is it treated?
Interstitial Cystitis is a clinical diagnosis characterized by irritative bladder symptoms such as urinary urgency, frequency, and hesitancy in the absence of infection. Research has shown the majority of patients who meet the clinical definition have pelvic floor dysfunction and myalgia. Therefore, the American Urologic Association recommends pelvic floor physical therapy as first-line treatment for Interstitial Cystitis. Patients will benefit from pelvic floor physical therapy and may also benefit from pharmacologic management or medical procedures such as bladder instillations.
Who is the Pelvic Health and Rehabilitation Team?
The Pelvic Health and Rehabilitation Center was founded by Elizabeth Akincilar and Stephanie Prendergast in 2006, they have been treating people with pelvic floor disorders since 2001. They were trained and mentored by a medical doctor and quickly became experts in treating pelvic floor disorders. They began creating courses and sharing their knowledge around the world. They expanded to 11 locations in the United States and developed a residency style training program for their employees with ongoing weekly mentoring. The physical therapists who work at PHRC have undergone more training than the majority of pelvic floor physical therapists and as a result offer efficient and high quality care.
How many years of experience do we have?
Stephanie and Liz have 24 years of experience and help each and every team member become an expert in the field through their training and mentoring program.
Why PHRC versus anyone else?
PHRC is unique because of the specific focus on pelvic floor disorders and the leadership at our company. We are constantly lecturing, teaching, and staying ahead of the curve with our connections to medical experts and emerging experts. As a result, we are able to efficiently and effectively help our patients restore their pelvic health.
Do we treat men for pelvic floor therapy?
The Pelvic Health and Rehabilitation Center is unique in that the Cofounders have always treated people of all genders and therefore have trained the team members and staff the same way. Many pelvic floor physical therapists focus solely on people with vulvas, this is not the case here.
Do I need pelvic floor therapy forever?
The majority of people with pelvic floor dysfunction will undergo pelvic floor physical therapy for a set amount of time based on their goals. Every 6 -8 weeks goals will be re-established based on the physical improvements and remaining physical impairments. Most patients will achieve their goals in 3 – 6 months. If there are complicating medical or untreated comorbidities some patients will be in therapy longer.