Pudendal Neuralgia Pelvic Floor Physical Therapy

The pudendal nerve is a mixed peripheral nerve arising from sacral nerve roots two, three and four. This nerve is unique in that it contains sensory, motor, and autonomic fibers. We have a right and left pudendal nerve and each pudendal nerve has three main branches: the dorsal, perineal, and inferior rectal nerve branches. This nerve is involved with genito-pelvic sensation and urinary, bowel and sexual functioning.

Pudendal neuralgia is a clinical diagnosis described as burning, stabbing, or shooting pain in the distribution of the pudendal nerve.  The distribution includes the clitoris/penis, perineum, anus, lower ⅓ of the urethra and rectum, and all of the pelvic floor muscles. If the nerve gets compressed or is put under tension symptoms can arise in all or some of these areas.

The pudendal nerve being a mixed nerve, it supplies the vagina, rectum, and urethra with motor, sensory, and autonomic fibers. The three branches include the perineal, dorsal, and inferior rectal. The perineal branch innervates the lower ⅓ of the vagina and urethra, skin of the labia and scrotum, urethral sphincter, and the pelvic floor muscles including the transverse perineum, bulbospongiosus, ischiocavernosus, and portion of the external anal sphincter. The dorsal branch innervates the skin of the penis or clitoris. The inferior rectal branch innervates the anal canal, lower ⅓ of the rectum, peri-anal skin, and part of the external anal sphincter. With all branches considered it supplies bowel, bladder, and erectile function (penis and clitoris).

One of the things that make the pudendal nerve so unique is that it doesn’t just have motor and sensory fibers like other nerves that exist outside of the brain and spinal cord, it also has autonomic fibers. This is significant because motor and sensory fibers innervate somatic structures, like muscles, giving us voluntary control over them. Structures innervated by autonomic fibers are not under our voluntary control. The heart, lungs, and GI tract are examples of such structures.

The autonomic fibers of the pudendal nerve activate our pelvic floor muscles,  always maintaining a degree of tone, which enables us to remain continent. As our bladder and rectum fill the autonomic fibers of the PN will cause the pelvic floor muscles and our sphincters to reflexively contract.  The voluntary motor fibers of the PN give us the ability to override the tone in our pelvic floor muscles and further contract or relax them when we wish. Because of these autonomic fibers, patients with PN can experience disturbing feelings of sympathetic upregulation when their pain spikes. Symptoms such as: an increase in heart rate, a decrease in the mobility of the large intestines, a constriction of blood vessels, pupil dilation, perspiration, a rise in blood pressure, goosebumps, sweating, agitation, and anxiety. These concurrent symptoms are not all in your head! With the appropriate treatment these symptoms can resolve.

Common causes of pudendal neuralgia can include musculoskeletal impairments, injury from childbirth, trauma or injury, cycling, change in an exercise program, biomechanical deficits, prolonged sitting, chronic constipation, increased stress. The nerve is vulnerable to compression issues, examples include bike riding or prolonged sitting. Chronic constipation and vaginal deliveries are examples of tension injuries. Infections and diseases can also irritate the PN.

It is surprising for our patients to hear that most physicians do not receive formal medical training in pelvic pain syndromes. The physicians that are knowledgeable likely sought out advanced training to learn.

Currently there are no imaging options to confirm a diagnosis of PN, though an MRI may be suggestive of soft tissue impairments around the nerve that could be contributing to dysfunction. The current standard of care states an MRI cannot definitively rule in or out a diagnosis of pudendal neuralgia.

It depends. Generally speaking, the longer the symptoms have been present the less likely it is that a block will provide long-lasting relief after the anesthetic wears off. In cases where the pain has been there less than 6 months and someone has a positive Tinel’s Sign on physical examination they may be a good candidate for a nerve block.

Pudendal nerve blocks can help with diagnosing pudendal neuralgia. If a pudendal nerve block is performed correctly there should be numbness in the PN distribution immediately following the block. If there is numbness elsewhere or not in the distribution the person injecting the nerve may not have gotten close enough to the nerve. If the pain goes away during the period of time the anesthetic is in effect it may suggest a PN diagnosis, however, it is important to note the nerve also supplies sensation to a number of structures, such as the pelvic floor muscles, and they will also be numb from the block. A pudendal nerve block is not necessary to make a PN diagnosis.

Most people with pudendal neuralgia also have pelvic floor and girdle muscle dysfunction. As physical therapists we are trained to address musculoskeletal and biomechanical impairments that may be contributing to pudendal nerve irritation. With pelvic floor physical therapy we are able to address the pelvic floor muscles with manual therapy to release any myofascial trigger points or soft tissue and connective restrictions of the pelvic girdle that may be contributing to pain and symptoms. We address motor coordination to alleviate pelvic floor muscle tension and place the pelvic floor in a more relaxed state to decrease compression of the pudendal nerve. We can also mobilize the nerve when appropriate and prescribe exercises on an individual basis. 

Additionally, we are oftentimes the provider who is “steering the ship” in terms of creating a multidisciplinary approach to treatment. We connect with pain management specialists, urologists, gynecologists, and orthopedists, to best manage and individualize our patients’ cases. A provider that is in your corner to help manage and suggest medical management in conjunction with pelvic floor physical therapy is part of our role. 

It depends on the branch of the pudendal nerve that is involved, however common positions including prolonged sitting, deep squatting, and any position involving flexing the hip past 90 degrees can irritate the pudendal nerve. Hamstring and piriformis stretches tend to aggravate symptoms, so we suggest foam rolling instead.

Exercise prescription should really be discussed with a 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. If the pelvic floor muscles are involved with PN and are more overactive, performing more pelvic floor relaxation exercises are most appropriate. Pudendal nerve glides, when a person is mostly symptom free, can help during the later stages of physical therapy.

It depends on which branch of the pudendal nerve is irritated and what other musculoskeletal and myofascial impairments are present. This 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 stairmaster-type machine, or 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.

Diagnosing pudendal nerve entrapment is still considered a clinical diagnosis and Labat et. al 2008 created a clinical criteria, the Nantes Criteria, that suggests a diagnosis of pudendal neuralgia. The only way to confirm the presence of PNE vs just PN is during surgery.

Nerves have a tendency to feel irritated more so after treatment where some experience a latent onset of pain or return of symptoms. With any soft tissue or connective tissue mobilizations muscular soreness can present for up to 72 hrs, however we expect an overall downshift in pain and symptoms with consistent future treatment sessions. If this pain persists after physical therapy sessions, be sure to discuss your treatment plan moving forward with your physical therapist.

There are a few websites to help people find providers who can help: Herman and Wallace Find a Provider, Pelvic Guru, American Physical Therapy Association Section on Pelvic Health,

Finding a physical therapist who is trained and specializes in the pelvic floor evaluation and treatment is optimal in addressing pudendal neuralgia. It is advisable due to the involvement of the pudendal nerve in bladder, bowel, and sexual function to truly assess and treat the appropriate structures and tissues.

Many people with PN also have pain in the Obturator Internus muscle which can be a sign of ‘high tone’ or ‘tight’ muscles. Botox can help reduce high tone which may allow there to be more space in Alcock’s Canal, which in turn can reduce PN symptoms. If muscle tightness and pain is not present botox may not be helpful. A physical examination with a trained PT or doctor will reveal if there is concurrent muscle dysfunction.

Unfortunately many patients think that severe or unresolving symptoms means that the source of the pudendal neuralgia is pudendal nerve entrapment. There are no diagnostic tests to confirm PNE, but various parts of a patient’s history may be suggestive. If the symptoms were brought on by a surgery such as pelvic reconstruction, with pelvic trauma, or after a traumatic childbirth and do not respond to conservative treatments PNE may need to be considered.

Oftentimes the leading cause of pudendal neuralgia is myofascial dysfunction which is one of the major causes of pelvic floor dysfunction. There are other reasons for pelvic floor dysfunction such as motor coordination impairments, however iIncreased pelvic floor muscle tone, myofascial trigger points and connective tissue restrictions can cause pudendal nerve irritation. The pudendal nerve has a winding path to traverse via the pelvic floor and any musculoskeletal impairments can contribute to pudendal neuralgia symptoms.

Labat et. al 2008 described the Nantes Criteria to suggest a diagnosis of pudendal nerve entrapment (PNE) include the following: pain in the anatomical region of the pudendal nerve, symptoms are worsened with sitting, no night pain, no objective sensory loss on physical examination, positive anesthetic pudendal nerve block.

The term ‘neuralgia’ refers to ‘pain’ but many people with neuralgia also have bowel and bladder symptoms.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.

Pain is complex, especially when we consider long-standing chronic pain. However, pudendal neuralgia tends to remain in the distribution of the pelvis as mentioned above. If you are experiencing pain in the back of the legs or gluteals, it is likely there is another cause for your symptoms. The PN nerve is in close proximity to the posterior femoral cutaneous nerve and the sciatic nerve and can sensitive these structures to cause pain into the legs.

A diagnosis of PN is a clinical diagnosis, which means the diagnosis is based on signs, symptoms and medical history of the patient rather than on laboratory examination or medical imaging. Generally, PN symptoms are said to include burning, stabbing and/or shooting pain anywhere in the territory of the nerve. A provider can examine the patient’s pelvic floor internally via the rectum or the vagina and upon examination test the pudendal nerve by performing a technique called a “Tinel’s Sign”. A Tinel’s Sign is a way to detect irritated nerves. It is performed by lightly tapping over the nerve to elicit a sensation of tingling or “pins and needles” in the distribution of the nerve. As you may have already realized, many of these symptoms overlap with symptoms of other pelvic floor problems. This can make it difficult to arrive at a definitive, iron-clad diagnosis of PN.

https://www.pudendalassociation.org/resources  Pudendal Neuralgia Support Pudendal Neuralgia Hope  Chronic Pelvic Pain – The Mind/Body Connection

Pudendal neuralgia can be mistaken for coccygodynia, chronic pelvic pain, vulvo/vestibulodynia, endometriosis, vaginismus, persistent genital arousal disorder, sciatica. However, sometimes these diagnoses can co-exist.

• Myofascial trigger point release all along the involved pelvic girdle and pelvic floor muscles.
• Manual techniques that normalize the length, tone, and help patients regain control of the pelvic floor muscles.
• Connective tissue manipulation to normalize dysfunctional tissue.
• Restoration of normal neural mechanics through direct glides and mobilizations and indirectly by treating other impairments.
• Mobilization and stabilization of the sacroiliac and hip joints.
• Individualized Home Exercise Program
• Temporary Lifestyle Modifications

The pudendal nerve can become entrapped in many locations but two primary locations are most common. 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.