Pudendal neuralgia is a rare condition that causes severe, sometimes flashing, pain in the genital area and perineal region. The disease is preceded by mechanical or inflammatory damage to the pudendal nerve. The therapeutic goal is to regenerate the nerve to relieve symptoms.
What is pudendal neuralgia?
The term pudendal neuralgia is formed from the word stems pudendus and neuralgia. Neuralgia is the term for seizure-like shooting nerve pain, and pudendus refers to the pudendal nerve. This arises in the lower spinal cord. It has three branches that innervate the anus, external anal sphincter, perineum, penile root muscles, urethral muscle, glans and labia with clitoris. The pudendal nerve is also responsible for controlling the pelvic floor muscle. Patients describe the pain, which can extend to the abdomen or the sole of the foot, as pins and needles, stabbing,pulling or burning. The skin in these regions is very sensitive to pain and highly sensitive. Pudendal neuralgia should be distinguished from pudendal neuropathy, in which permanent discomfort occurs.
Causes
The most common cause of pudendal neuralgia is mechanical damage to and constriction of the pudendal nerve. Its causes include prolonged lower pelvic surgery, prolonged ducking of the nerve such as may occur while riding a bicycle, and injury. In some patients, narrowing of the connective tissue canal at the spine has been demonstrated. Less commonly, pudendal neuralgia is caused by inflammation of the nerve. These result from herpes zoster viruses, tumors in the pelvic region, or diabetic nerve disease. Diabetic polyneuropathy is the most common trigger of inflammation and is the result of poorly controlled diabetes mellitus or damage to the small blood vessels. Diabetics thus represent a special risk group for neuralgia.
Symptoms, complaints, and signs
Typical of pudendal neuralgia are flashes of severe pain in the genital area, which sufferers describe as stabbing, burning, or pressing. In women, they usually extend from the outer vagina to the anus; men experience the pain predominantly in the perineal area, and the penis may also be affected. The complaints usually occur on one side, but can change sides – only occasionally does the pain symptomatology exist on both sides at the same time. The pain, which is perceived as very agonizing, is sometimes accompanied by sensory disturbances or muscle paralysis, which can massively impair bowel movements and urination. In severe cases, pudendal neuralgia can cause urinary and fecal incontinence. Often, the pain also occurs during sexual intercourse and lasts for a while afterwards; men occasionally experience erectile dysfunction. As a rule, the discomfort intensifies when sitting, which is often only possible with the help of a seat ring. Sports activities as well as prolonged standing lead to an aggravation of the pain symptoms, while sitting on the toilet relieves the patient. When lying down, the symptoms also subside, and undisturbed sleep is generally possible. The condition often takes a chronic course, as pudendal neuralgia hardly responds to the usual painkillers.
Diagnosis and course
When diagnosing pudendal neuralgia, the physician must first rule out other conditions that could cause pain in the affected area. These include, in particular, skin inflammation. Diabetes mellitus must also be ruled out by means of a blood test. Imaging procedures are used to check for a tumor. It is also standard to ask about psychological causes of the pain in the genital area. If these factors can be ruled out, further diagnostics are performed by a neurologist. Based on the patient’s medical history and clinical examination, the neurologist usually obtains sufficient indications for the diagnosis, which he can support by means of technical examination methods. However, measurement of the nerve conduction velocity of the pudendal nerve or measurement of the electrical activity in the external anal sphincter are rarely useful. Another diagnostic method is the injection of a local anesthetic into the nerve canal during computed tomography.If the pain subsequently subsides significantly, pudendal neuralgia must be diagnosed.
Complications
Due to pudendal neuralgia, affected individuals usually suffer from very severe pain. This pain occurs mainly in the intestines or genitals and is very uncomfortable for most sufferers in the process. If this pain persists over a longer period of time, it can lead to psychological discomfort or even depression. It is not uncommon for most patients to appear irritable or slightly aggressive. Sometimes the pain manifests itself as burning or stabbing. In some cases, this can also lead to restricted movement and inflammation of the skin. Even certain activities in everyday life are no longer possible for the patient without further ado or are always associated with severe pain. If treatment is not received, the nerve can be irreversibly damaged by pudendal neuralgia. Treatment of pudendal neuralgia is done with the help of medications. Complications do not occur in this process. However, regeneration of the nerve is also necessary to prevent the pain from recurring. Pudendal neuralgia does not usually lead to a reduction in the patient’s life expectancy.
When should you see a doctor?
Pudendal neuralgia should always be evaluated and treated by a physician. In most cases, self-healing does not occur and pudendal neuralgia cannot be treated by self-help measures. Medical treatment is therefore essential. A doctor should be consulted if the affected person suffers from lightning-like and very severe stabbing pain. This pain can occur in different situations and also in different parts of the body. However, this pain usually occurs in the area of the intestines and upper abdomen. Pudendal neuralgia can also cause discomfort during urination, and patients also often show paralysis in the muscles or even erectile dysfunction. A doctor must be consulted for these symptoms as well. The initial diagnosis of pudendal neuralgia can be made by a general practitioner or by a urologist. However, further treatment is performed by a specialist.
Treatment and therapy
Injection of local anesthetics is not only used for diagnosis, it is also the main therapy for pudendal neuralgia. Because the effect usually wears off after a few weeks, continuous catheter care may also be used. In some cases, cortisone is administered instead of local anesthetics. Most physicians initially prefer this method to drug therapy, since here the active ingredient is taken regularly. The drugs used are tricyclic antidepressants, which even in low doses show good results in the treatment of nerve pain, and antiepileptic drugs. Some neurologists believe that only a combination of both drugs promises lasting therapeutic success. Transcutaneous electrical neurostimulation (TENS) in the intimate area, which the patient performs regularly at home, also promises good healing prospects. Treatment of the underlying disease is also important, but is not sufficient as the only measure in advanced disease. Surgery remains as the last option after all drug and non-drug conventional medical therapies have failed. In a procedure known as neurolysis, an attempt is made to expose the nerve in its canal and thus free it from mechanical pressure. Beyond conventional medicine, sufferers also find help in traditional Chinese medicine with relaxation exercises and acupuncture.
Prevention
Because of the wide range of causes, it is not possible to make predictions about the course of the disease, nor can preventive measures be mentioned. Timely care, including psychological care, is important to counteract chronification. A healthy lifestyle with sufficient exercise also seems to be helpful. Pudendal neuralgia has different underlying causes. Acute treatment must be pain-relieving, but also related to the causative disease. Therefore, the follow-up of pudendal neuralgia is very individual. Often, a pudendal block performed several times helps to resolve the pain. In the aftercare, the lasting success of the treatment must be ensured and checked. If it is a long-term condition, therapy with stronger painkillers may be necessary.Follow-up care then mainly concerns a good adjustment of the medication to maintain freedom from pain, as well as the monitoring of side effects of these drugs. The pain-relieving drugs often have to be taken over a long period of time and the dose has to be adjusted individually to the patient under certain circumstances. In the long term and as a supportive measure, after acute treatment of pudendal neuralgia, consideration may be given to resorting to adjunctive measures that can help alleviate the symptoms. Here, above all, the psychological accompaniment of pain therapy through the learning and application of relaxation techniques should be mentioned. Other supportive therapy measures such as TENS, acupuncture and homeopathic remedies should be considered by an expert medical practitioner and presented to the patient.
Here’s what you can do yourself
Treatment of pudendal neuralgia can be supported by the sufferer through dietary measures and general lifestyle changes. Which steps are useful in detail depends primarily on the causative disease and the advice of the physician. If diabetes mellitus underlies the symptoms, the physician will recommend appropriate insulin medication, which can be supported by a change in diet. If a tumor in the pelvis is the cause, it must first be removed. After surgical removal of the tumor, the patient must initially remain on bed rest. The patient should also visit the doctor regularly so that any recurrences or other complications can be detected quickly. In the case of acute pain attacks, natural painkillers such as St. John’s wort or aloe vera can also help, in addition to paracetamol and the like. In addition, antispasmodics should be taken, for example sage and various herbal teas. Accompanying to it different relaxation procedures offer themselves. These include measures such as yoga and physiotherapy, but also osteopathy, homeopathy and acupuncture. Pudendal neuralgia can be treated well by applying these measures. In individual cases, such as severe pain or accompanying symptoms that make physical exercise impossible, home remedies should not be used. The patient must then adhere strictly to the physician’s instructions and, if necessary, be treated in a hospital.