Chronic pelvic pain can be challenging to diagnose and manage, especially in athletes who perform sports involving prolonged sitting, cycling, or repetitive hip movements. One crucial but often overlooked cause is pudendal nerve entrapment, which can lead to persistent pelvic pain known as pudendal neuralgia. So, what is pudenal neuralgia and how do we manage it?
What Is Pudendal Nerve Entrapment?
The pudendal nerve arises from the sacral plexus (S2–S4) and travels through the pelvis, passing between several tight ligaments and muscles before reaching the perineum. It supplies sensation to the genitals, perineum, and anus, and provides motor function to some pelvic floor muscles.
When the nerve is compressed along its course—most often in the Alcock’s canal or between the sacrospinous and sacrotuberous ligaments—athletes may develop symptoms of pudendal neuralgia. In sports, the most common cause of pudendal neuralgia is pressure on the perineum from a bike saddle. Additionally, entrapment can occur due to scar tissue forming between the sacrotuberous and sacrospinous ligaments. Other causes include direct trauma to the buttocks or perineum.
Chronic pelvic pain can be challenging to diagnose and manage, especially in athletes who perform sports involving prolonged sitting, cycling, or repetitive hip movements. One crucial but often overlooked cause is pudendal nerve entrapment, which can lead to persistent pelvic pain known as pudendal neuralgia. So, what is pudenal neuralgia and how do we manage it?
What Is Pudendal Nerve Entrapment?
The pudendal nerve arises from the sacral plexus (S2–S4) and travels through the pelvis, passing between several tight ligaments and muscles before reaching the perineum. It supplies sensation to the genitals, perineum, and anus, and provides motor function to some pelvic floor muscles.
When the nerve is compressed along its course—most often in the Alcock’s canal or between the sacrospinous and sacrotuberous ligaments—athletes may develop symptoms of pudendal neuralgia.
In sports, the most common cause of pudendal neuralgia is pressure on the perineum from a bike saddle.
Symptoms
Athletes with pudendal nerve entrapment usually report:
-
Burning, stabbing, or aching pain in the perineum, buttock, genitals, or inner thigh
-
Pain made worse by sitting, especially on a bicycle saddle or a hard surface
-
Relief of symptoms when standing or lying down
-
Numbness or altered sensation in the genital or anal area
-
Pain with sexual activity, cycling, or prolonged sitting
-
In severe cases, urinary, bowel, or sexual dysfunction
Unlike sciatica, which radiates down the back of the leg, pudendal neuralgia is localised to the perineal and pelvic region.
Clinical Assessment
The diagnosis of pudendal nerve entrapment is based on a detailed history and examination. Key features include:
-
Pain located in the pudendal nerve distribution (genitals, anus, perineum)
-
Pain that worsens with sitting and improves when standing or lying down
-
Local tenderness along the course of the pudendal nerve, particularly near the crossing of the sacrotuberous and sacrospinous ligaments.
-
A normal neurological exam of the legs helps distinguish it from lumbar radiculopathy.
The “Nantes criteria” are often used clinically to support the diagnosis and include perineal pain worsened by sitting, no nocturnal awakening, no objective sensory loss, and relief with a pudendal nerve block.
Investigations
Although pudendal neuralgia is primarily a clinical diagnosis, investigations can help exclude other causes of pelvic pain:
-
MRI pelvis: Useful to rule out masses, inflammatory conditions, or pelvic pathology that may compress the nerve.
-
Ultrasound: Can sometimes identify nerve thickening or entrapment sites.
-
Nerve conduction studies: Technically challenging but may provide supportive evidence.
-
Diagnostic nerve block: Injection of local anaesthetic around the pudendal nerve can provide temporary relief and confirm the diagnosis of pudendal nerve entrapment. Generally, these blocks are performed with ultrasound guidance, targeting the nerve as it passes between the sacrotuberous and sacrospinous ligaments.
Treatment
Treatment of pudendal neuralgia focuses on relieving pain and reducing nerve compression.
-
Activity modification: Avoiding prolonged sitting and adjusting cycling saddles or posture.
-
Physiotherapy: Pelvic floor physiotherapy to address muscle spasm and reduce tension around the nerve.
-
Medication: Neuropathic pain agents such as Amitriptyline or Duloxetine may help.
-
Ultrasound-guided: Corticosteroid or nerve hydrodissection injections around the pudendal nerve can relieve inflammation and free the nerve. The nerve is targeted as it passes between the sacrotuberous and sacrospinous ligaments into the perineum.
-
Surgical decompression: Considered in resistant cases, aiming to release the pudendal nerve from tight ligaments or fibrotic tissue.
More on Pudendal Nerve Block
A pudendal nerve block is a challenging injection to perform. Generally, doctors perform this injeciton with ultrasound guidance. Ultrasound scanning is used to find the ischial spine, sacrotuberous ligament, sacrospinous ligament, and pudendal artery. Studies show that ultrasound guidance has a lower risk of sciatic nerve numbness than X-ray guidance.
Doctors place the needle close to the nerve and inject a small dose of lidocaine, 5% dextrose and a small dose of cortisone. We call this injeciton a nerve hydrodissection.
Final Word from Sportdoctorlondon on Pudendal Nerve Entrapment
Pudendal nerve entrapment is an under-recognised but essential cause of chronic pelvic pain, particularly in athletes such as cyclists. Awareness of pudendal neuralgia, its symptoms, and the importance of careful clinical assessment is key to making an accurate diagnosis. With a combination of physiotherapy, activity modification, targeted injections, and occasionally surgery, many patients achieve meaningful pain relief and improved quality of life.
Leave A Comment