Chronic pelvic pain is hard to diagnose and manage, especially in athletes whose sport involves prolonged sitting, cycling, or repetitive hip movement. One important but often overlooked cause is pudendal nerve entrapment, which leads to persistent pelvic pain known as pudendal neuralgia. So what is pudendal neuralgia, and how do we manage it?

Pudendal nerve entrapment is one of several causes of groin nerve pain.

What is pudendal nerve entrapment?

The pudendal nerve arises from the sacral plexus (S2–S4) and travels through the pelvis, passing between tight ligaments and muscles before reaching the perineum. It supplies sensation to the genitals, perineum, and anus, and motor function to some pelvic floor muscles.

When the nerve is compressed along its course — most often in Alcock’s canal or between the sacrospinous and sacrotuberous ligaments — pudendal neuralgia develops. In sport, the commonest cause is pressure on the perineum from a bike saddle. Entrapment can also follow scar tissue between the two ligaments, or direct trauma to the buttock or perineum.

pudendal nerve anatomy

Symptoms of pudendal neuralgia

Athletes with pudendal nerve entrapment usually report:

  • Burning, stabbing, or aching pain in the perineum, buttock, genitals, or inner thigh
  • Pain worsens with sitting, especially on a saddle or hard surface
  • Relief when standing or lying down
  • Numbness or altered sensation in the genital or anal area
  • Pain with sexual activity, cycling, or prolonged sitting
  • Urinary, bowel, or sexual dysfunction in severe cases

Unlike sciatica, which radiates down the back of the leg, pudendal neuralgia stays in the perineal and pelvic region. It’s so common in cyclists that it’s often called cyclist’s syndrome — if you’re a cyclist with perineal pain, a bike fit and saddle change are a sensible first step.

Clinical assessment

Diagnosis rests on a detailed history and examination. Key features include:

  • Pain in the pudendal nerve distribution — genitals, anus, perineum
  • Pain is worse sitting, better standing or lying
  • Local tenderness along the nerve, especially where the sacrotuberous and sacrospinous ligaments cross
  • A normal leg neurological exam, distinguishing it from lumbar radiculopathy

The Nantes criteria support the diagnosis: perineal pain worse with sitting, no waking at night from pain, no objective sensory loss, and relief from a pudendal nerve block.

Investigations

Pudendal neuralgia is mainly a clinical diagnosis, but investigations exclude other causes:

  • MRI pelvis to rule out masses, inflammation, or compressive pathology
  • Ultrasound to identify nerve thickening or entrapment sites
  • Nerve conduction studies — technically challenging but sometimes supportive
  • Diagnostic nerve block — local anaesthetic around the pudendal nerve gives temporary relief and confirms the diagnosis, performed under ultrasound between the sacrotuberous and sacrospinous ligaments

How do we treat pudendal nerve entrapment?

Treatment focuses on relieving pain and reducing nerve compression:

  • Activity modification — avoid prolonged sitting, adjust the cycling saddle and posture
  • Pelvic floor physiotherapy — to ease muscle spasm and tension around the nerve
  • Ultrasound-guided injection — cortisone or nerve hydrodissection around the nerve to reduce inflammation and free it
  • Surgical decompression — for resistant cases, releasing the nerve from tight ligaments or scar tissue

More on the pudendal nerve block

A pudendal nerve block is technically demanding and performed under ultrasound guidance. We scan to find the ischial spine, sacrotuberous and sacrospinous ligaments, and the pudendal artery — ultrasound guidance carries a lower risk of sciatic nerve numbness than X-ray guidance. The needle is placed close to the nerve, and we inject a small dose of lidocaine, 5% dextrose, and a small dose of cortisone — a nerve hydrodissection, a technique Dr Masci teaches across the UK and Europe.

Frequently asked questions about pudendal nerve entrapment

Is pudendal neuralgia the same as pudendal nerve entrapment?

Closely related. Pudendal nerve entrapment is the cause — compression of the nerve — while pudendal neuralgia is the resulting pain syndrome. In practice, the terms are often used interchangeably.

Why does it hurt more when I sit?

Sitting — especially on a saddle or hard surface — directly compresses the pudendal nerve in the perineum. Relief on standing is a hallmark of the condition and one of the Nantes criteria.

Is pudendal neuralgia permanent?

Not usually. Many people improve with activity modification, physiotherapy, and targeted injections. A diagnostic block that relieves the pain also opens the door to longer-lasting options if needed.

Can cycling cause pudendal nerve entrapment?

Yes — it’s the classic cause, hence “cyclist’s syndrome”. Saddle pressure on the perineum compresses the nerve. A proper bike fit, saddle change, and reduced saddle time often help significantly.

Final word from Sport Doctor London about pudendal nerve entrapment

Pudendal nerve entrapment is an under-recognised but important cause of chronic pelvic pain, particularly in cyclists. Awareness of the symptoms and careful clinical assessment are key to an accurate diagnosis. With physiotherapy, activity modification, targeted injections, and occasionally surgery, many people achieve meaningful relief.

To book a one-stop assessment with Dr Masci in London, contact the team here or call +44 (0) 203 488 0350.

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