Pudendal neuralgia
The pudendal nerve supplies sensation to the perineum, the external genitals and the area around the anus, and it also drives the muscles that hold in urine…
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Medicines commonly prescribed for Pudendal neuralgia
For informational purposes only. Always consult a doctor before using any medicine.
Dosage form: TABLET, 10 mgActive substance: amitriptylineManufacturer: Pan Quimica Farmaceutica S.A.Prescription requiredDosage form: TABLET, 25 mgActive substance: amitriptylineManufacturer: Pan Quimica Farmaceutica S.A.Prescription requiredDosage form: TABLET, 50 mgActive substance: amitriptylineManufacturer: Tarbis Farma S.L.Prescription required
The pudendal nerve supplies sensation to the perineum, the external genitals and the area around the anus, and it also drives the muscles that hold in urine and stool. When that nerve is damaged or trapped it starts sending pain for no reason at all, and the result is pudendal neuralgia. The condition is rare but recognisable, and its real problem is not the rarity but the embarrassment: this is pain people find hard to talk about. Many spend years being treated for prostatitis, cystitis or piles, changing doctors and hearing that the test results are fine. What follows is plain-spoken: what this pain is like, what gives it away, why it does not show up on a scan, and what can be done about it.
What the pain is like
The pain sits in the perineum, the strip between the external genitals and the anus, and also in the genitals themselves and around the anus; it sometimes radiates into the buttock and the inner thigh. In women it involves the vulva, the clitoris and the vaginal opening; in men the penis and the scrotum, most often around the base.
Its character is typical of nerve pain: burning as if scalded, shooting jolts like an electric shock, rawness, tingling, a sense of being pulled tight. The skin of the perineum may go numb, or the opposite, becoming so sensitive that the seam of underwear is unbearable. Many people describe the feeling of something being inside: as if sitting on a golf ball, or as if something were lodged in the rectum or the vagina.
Usually one side hurts, though it can be both. The pain rarely arrives all at once; more often it builds over weeks and months. And it almost never wakes people at night: falling asleep is possible, while the day gets harder hour by hour.
Why sitting hurts and standing or lying eases
This is the most recognisable feature and the one worth testing on yourself. In pudendal neuralgia the pain increases on sitting and settles when the person stands up or lies down. By evening, after a day at the wheel or at a desk, it is worse than it was in the morning.
There is a subtler clue as well: sitting on a lavatory seat usually does not hurt. The explanation is straightforward. On an ordinary chair the weight rests on the sitting bones, with the nerve running between them, whereas a seat with a cut-out leaves that area free. If you have caught yourself perching on the edge of chairs, putting a cushion under you, driving half turned to one side or preferring to stand on the bus, tell your doctor: it is part of the picture.
That is why the condition disrupts daily life more than it sounds: a working day, a journey, lunch with friends, a visit to family all become impossible to sit through. The tiredness, irritability and low mood that follow are also worth naming at the appointment.
What else changes
The pudendal nerve does more than serve the skin, so the complaints rarely stop at pain:
- needing to pass urine often, a feeling that the bladder has not emptied, stinging on passing urine;
- pain on opening the bowels and afterwards, and constipation, partly because people start putting off going to the lavatory for fear of the pain;
- a sense of fullness or pressure in the rectum or the vagina;
- pain during sex and after it;
- in men, difficulty getting an erection; in women and men alike, difficulty reaching orgasm and painful orgasm;
- sometimes the reverse: a persistent sensation of arousal without desire that will not settle and wears the person down.
None of this is comfortable to say out loud, but all of it needs listing for the doctor: without these details the diagnosis is nearly impossible to assemble, and half of them point straight at the nerve.
Why the diagnosis comes late, and how it is finally made
The diagnosis is delayed for two reasons. The first is that the symptoms overlap with far commoner conditions, and doctors think of those first: chronic prostatitis and chronic pelvic pain syndrome in men, cystitis, vulvodynia and endometriosis in women, piles and anal fissure in everyone. The second reason matters more: pudendal neuralgia has no blood test and no scan that shows it.
To say it plainly, this condition does not show up on an MRI. Magnetic resonance imaging, CT and ultrasound are used here not to find the neuralgia but to rule out what might be pressing on the nerve or imitating it: a pelvic tumour, changes in the sacrum, a disc prolapse, an infection. A clean scan does not overturn the diagnosis and does not mean the pain is imagined. Electromyography, too, confirms it only some of the time.
The diagnosis rests on clinical criteria, meaning the pattern of features taken together. The doctor looks for:
- pain in the territory the pudendal nerve supplies;
- pain that increases on sitting and eases on standing or lying down;
- no waking at night because of that pain;
- no obvious loss of sensation on examination, since genuine numbness sends the search elsewhere;
- tenderness over a specific point felt on vaginal or rectal examination;
- relief of the pain after a diagnostic nerve block with local anaesthetic.
The block works here as a test: if the pain goes for a while after the injection, that is strong evidence for the diagnosis and a way of getting relief at the same time. A vaginal or rectal examination is neither humiliating nor a formality; it is with a finger that the doctor finds the tender point no machine will show.
When to seek help immediately
The neuralgia itself is not life-threatening, but similar sensations are produced by conditions that cannot wait. Call an ambulance (in Spain, Italy, Portugal, Poland and Ukraine the single number is 112) if there is:
- numbness in the perineum and the inner thighs, the area that would touch a saddle, together with an inability to pass urine or, conversely, leakage of urine or stool;
- weakness in the legs, unsteadiness or a sense that the legs have gone soft on top of that;
- perineal pain with rapidly growing swelling, redness or darkening of the skin and a high temperature, especially in someone with diabetes, since a purulent infection in this area spreads very fast.
See a doctor the same day rather than in a week's time if the pain came on suddenly and for the first time, if it comes with weight loss, blood in the urine or stool or a lump you can feel, or if there has recently been a fracture of the sacrum or tailbone. These are not the common causes, but they are exactly why the visit should not be put off.
How it is treated
There is no quick fix here, and it is better to know that in advance. A nerve that has learned to hurt needs time, and treatment is almost always assembled from several parts at once.
- Pelvic floor physiotherapy. The first line and the most underrated part of the whole plan. The therapist works on the over-tightened muscles of the perineum, teaches them to release, breaks the spasm and adjusts posture and loading. One caution: the usual pelvic floor strengthening exercises often make things worse here, so you need someone who treats pain rather than incontinence.
- Medicines for nerve pain. Ordinary painkillers barely touch this kind of pain. What helps comes from other groups: tricyclic antidepressants, dual-acting antidepressants and the gabapentinoid anticonvulsants. The dose is built up gradually and the effect judged after several weeks. Opioids solve nothing in the long run and with prolonged use raise pain sensitivity in their own right.
- Nerve blocks. Local anaesthetic, sometimes with a steroid, injected along the course of the nerve under ultrasound or CT guidance. They buy relief and help confirm that the right place is being targeted.
- Radiofrequency treatment and neuromodulation. Considered when blocks help but not for long.
- Surgery. Releasing the nerve from what is compressing it. This is weighed up when entrapment has been demonstrated and conservative treatment has been given a fair trial. Improvement does not arrive at once but over months.
- Work with a psychologist. Not because the pain is in the head. Long-standing pain rewires the nervous system, and cognitive behavioural therapy is a proven way of turning down its intensity and getting life back, not an admission that you made it up.
What you can do yourself
- Cut down sitting time: get up every twenty or thirty minutes, work part of the day standing, and break up long journeys.
- Find a cushion with a cut-out under the perineum, either rectangular with a slot or U-shaped. A ring or doughnut cushion usually does not help and sometimes makes the pain worse.
- Put cycling aside while the pain lasts. If giving it up is impossible, you need a saddle with a central channel and an upright posture so the weight goes through the sitting bones.
- Avoid the loads that make things worse: deep squats, bending with weight, heavy lifting and hours behind the wheel.
- Do not let constipation set in: fibre, water and a gentle laxative if needed. Straining injures the nerve directly.
- Wear loose underwear and trousers and give up tight clothing and cinched belts.
- A warm bath and local warmth give many people an hour or two of relief. That is not treatment, but it is a breather.
- Keep a short diary of what made the pain worse and what eased it. After a month it will be the most useful piece of paper at the appointment.
Online consultation
This pain is hard to talk about, and a conversation from home is often the first in which someone calls things by their proper names. Online you can describe everything calmly and work out whether the picture fits pudendal neuralgia or looks more like something else; draw up the list of investigations that are genuinely needed so as not to go round in circles; go through scans and reports already done; discuss which nerve pain medicine to raise with your doctor and how to judge whether it is working; find a pelvic floor physiotherapist and clarify which specialist to ask for a referral to. A face-to-face examination will still be needed, since the diagnosis cannot be confirmed without an internal examination, and numbness of the perineum with retention of urine or leakage needs an ambulance rather than an appointment.
This material is for information only and does not replace medical advice.
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