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.
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.
Melissa Patrick is a certified yoga instructor and meditation teacher and is also available virtually to help, for more information please visit our therapeutic yoga page.
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