Pudendal nerve entrapment

Pudendal nerve entrapment (PNE) is a source of chronic pain, in which the pudendal nerve (located in the pelvis) is entrapped or compressed. Pain is worsened by sitting, and can include prickling, stabbing, burning, numbness, and the sense of a foreign object in the urethra, vagina, or rectum. In addition to pain, symptoms can include sexual dysfunction, impotence, anal and urinary incontinence.

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Causes

PNE can be caused by pregnancy, scarring due to surgery and accidents. Anatomic abnormalities can result in PNE due to the pudendal nerve being fused to different parts of the anatomy, or trapped between the aforementioned ligaments. Heavy and prolonged bicycling, especially if an inappropriately shaped or incorrectly positioned bicycle seat is used, may eventually thicken the sacrotuberous and/or sacrospinous ligaments and trap the nerve between them, resulting in PNE.

Treatment

Physical Therapy

There are stretches and exercises which have provided reduced levels of pain for some people. There are different sources of pain for people since there are so many ligament, muscles and nerves in the area. Sometimes women do pelvic floor exercises for compression after childbirth. However, there have been cases where the wrong stretches make the constant pain worse. Some people need to strengthen the muscles, others should stretch, while for some people it is purely neurological. There have been cases where doing stretches have helped bicyclists. A helpful stretch for some is bending over and touching your toes. Another stretch includes bringing your knee to your chest on the compressed side while laying on your back. One more possibly helpful stretch for bicyclists include sitting in the lotus position and moving your head to the ground supporting yourself with your hands and keeping your buttocks up. Stretches should not be held long (about 8 seconds) and be spreadout through the day. Acupuncture has helped decrease painlevels for some people, but is generally ineffective.^{(Citation needed)} Chiropractic adjustments to the lower back have also helped some patients with pudendal nerve issues.

Corticoids treatment

Alcok canal infiltration with corticosteroids is a minimally invasive technique which allows for pain relief and could be tried when physical therapy has failed and before surgery.

Surgical

Decompression surgery is done primarily in Nantes, France, Aix-en-Provence, France, Phoenix, Arizona, Lake Elmo, Minnesota, Baltimore, MD, Santa Monica, CA, Houston, Texas, Switzerland, Belgium, Nashua, NH and in Egypt. The validity of decompression surgery as a treatment and the existence of entrapment as a cause of pelvic pain are controversial. While certain doctors will prescribe decompression surgery, others will not. Notably, in February 2003 the European Association of Urology in its Guidelines on Pelvic Pain said:

the reality is that pudendal nerve neuropathy is probably only a likely diagnosis if the pain is unilateral, has a burning quality and is exacerbated by unilateral rectal palpation of the ischial spine, and the pudendal motor latency is delayed on that side only. However, such cases account for only a small proportion of all those presenting with perineal pain and the proof of the diagnosis resting on relief of pain following decompression of the nerve in Alcock's canal is rarely achieved. The value of the clinical neurophysiological investigations is debatable; some centres in Europe claim that the investigations have great sensitivity (1,2), while other centres, which also have a specialized interest in pelvic floor neurophysiology, have not positively identified any cases.[1]

Three types of surgery can be done to decompress the pudendal nerve: transperineal, transgluteal and transichiorectal. The results on pain are very similar (around 60% of cure). Impotence, anal and urinary incontinence can also be cured by these procedures.

References

• Am J Phys Med Rehabil. 2003 Jun;82(6):479-84. (PMID 12820792)
• Eur Urol. 2005 Mar;47(3):277-86 (PMID 15716187)
• Clin Exp Neurol. 1991;28:191-6. (PMID 1821826)
• BMC Surg 2004, 4(1):15 full text