Pudendal nerve entrapment is an uncommon, chronic pelvic pain condition in which the pudendal nerve (located in the pelvis) is entrapped and compressed. There are several different anatomic locations of potential entrapment (see Anatomy). Pudendal nerve entrapment is an example of nerve compression syndrome. Pudendal neuralgia refers to neuropathic pain along the course of the pudendal nerve and in its distribution. This term is often used interchangeably with pudendal nerve entrapment. However, it has been suggested that the presence of symptoms of pudendal neuralgia alone should not be used to diagnose pudendal nerve entrapment. That is because it is possible to have all the symptoms of pudendal nerve entrapment, as per the diagnostic criteria specified at Nantes in 2006, without actually having an entrapped pudendal nerve. The pain is usually located in the perineum, and is worsened by sitting. Other potential symptoms include genital numbness, sexual dysfunction, bladder dysfunction or bowel dysfunction. Pudendal neuralgia can be caused by many factors including nerve compression or stretching of the nerve. Injuries during childbirth, sports such as cycling, chronic constipation and pelvic surgery have all been reported to cause pudendal neuralgia. Management options include lifestyle adaptations, physical therapy, medications, long acting local anesthetic injections and others. Nerve decompression surgery is usually considered as a last resort. Pudendal neuralgia and pudendal nerve entrapment are generally not well-known by health care providers. This often results in misdiagnosis or delayed diagnosis. If the pain is chronic and poorly controlled, pudendal neuralgia can greatly affect a person's quality of life, causing depression.
Definitions Pudendal neuropathy is any damage or disease process affecting the pudendal nerve, regardless of whether said disease process involves nerve entrapment and manifests as pain or not. It is an example of mononeuropathy (neuropathy affecting one peripheral nerve). Pudendal neuralgia is chronic, neuropathic pain which is perceived along the course of and in the distribution of the pudendal nerve or its branches (anus, perineum, vulva, clitoris, glans penis, posterior aspect of scrotum). Pudendal neuralgia is caused by some pathology affecting the pudendal nerve or its branches. The pain in pudendal neuralgia may or may not be of similar character to other medical conditions which are classified as neuralgia. One potential cause of pudendal neuralgia is pudendal nerve entrapment. In other words, pudendal nerve entrapment is a subtype of pudendal neuralgia. However, symptoms of pudendal neuralgia are also possible without any detectable entrapment of the pudendal nerve. Therefore, pudendal neuralgia is the neuropathic pain component of a chronic pelvic pain syndrome that is sometimes (but not always), associated with compression and subsequent neuropathy (nerve damage) of the pudendal nerve. In the literature however, "pudendal nerve entrapment" and its equivalent terms are often used synonymously with "pudendal neuralgia" and "pudendal neuropathy".
Symptoms According to the Nantes diagnostic criteria, the presence of pain is essential for a diagnosis of pudendal nerve entrapment (although some sources describe the possibility of entrapment of the pudendal nerve causing non pain symptoms, without pain necessarily being present, or not being present initially). Non pain symptoms include bladder, bowel and sexual dysfunctions. This is because the pudendal nerve is a mixed nerve and has sensory, motor and autonomic fibers.
Pelvic pain The pain is located in the sensory distribution of the pudendal nerve. In over 50% of cases, the pain is in the perineum, but may be located in the genital areas (vulva, vagina, clitoris in females; glans penis, scrotum in males). Pain may also be perceived in the rectum. Pain may also involve the supra-pubic region and the sacrum. The pain may be only on one side, or on both sides. Another possible site of pain is the coccyx. The area where the pain is perceived may be influenced by the exact site of nerve impingement, anatomic variations of the nerve and its branches, and also central sensitization. The onset of pain symptoms is usually gradual without any single causative event, although sometimes the condition may appear suddenly after some trauma, a long distance trip (cars, planes, etc.), long distance cycling, or a surgical procedure in the region. The character of the pain may be burning, aching, stabbing, knife-like, tearing, strangling, or shooting like an electric shock. This is typical of neuropathic pain. There may be paresthesia (tingling / pins and needles). Additionally, there may be referred as sciatic pain, or pain in the medial thigh which may indicate involvement of the obturator nerve. Pain may also be referred to the calf, foot and toes. Sometimes, pain is perceived in the region of the lower abdomen, posterior (back) and inner thigh, or lower back. Hyperesthesia may be present. There may be a sensation of a foreign body in the rectum or vagina (described as "sitting on a golf ball" or a "hot poker in the rectum"). The pain typically gets slowly worse over the course of the day. The pain is positional and typically provoked or aggravated by sitting (including physical effort in the sitting position, e.g. cycling), and relieved by standing, lying down, or sitting on a toilet seat. If the perineal pain is positional (i.e. changes with a person's position, for example sitting or standing), this suggests a tunnel syndrome. According to one opinion, pain while sitting which is relieved by standing or sitting on a toilet seat is the most reliable diagnostic parameter. Individuals with pudendal nerve entrapment may prefer to stand to get relief from pain. In those with pain on only one side, sitting on one buttock may be an adaptive behavior. Sitting on soft seats may be more painful than on hard seats. The pain may be intense, chronic, and debilitating. The severity typically varies over time.
Urinary There may be bladder dysfunction such as urinary incontinence, urinary frequency, dysuria, urinary urgency, or dyspareunia. There may be symptoms which are similar to interstitial cystitis.
Rectal Bowel dysfunction may be present such as fecal incontinence There may be numbness of the anal region. There can be pain after defecation; typically minutes or hours later.
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