Understanding Pudendal Neuralgia: Diagnosis, Misconceptions, and Treatment

🔍 Pudendal Neuralgia: An Under-Recognised and Often Misunderstood Cause of Chronic Pelvic Pain

Pudendal neuralgia is a complex form of chronic pelvic pain arising from irritation or dysfunction
of the pudendal nerve. Despite its potentially profound impact on quality of life, it remains
under-recognised, frequently misdiagnosed, and often poorly explained, particularly outside specialist pain and pelvic health services.

Patients commonly experience long diagnostic delays, repeated investigations, and conflicting opinions,
leading to frustration, anxiety, and loss of confidence in the healthcare system.

⚠️ Why Pudendal Neuralgia Is Under-Recognised

Pudendal neuralgia is relatively uncommon and many GPs and non-specialists have limited exposure
to the condition during training. Symptoms are therefore often attributed to gynaecological,
urological, bowel-related, musculoskeletal, or psychological causes in isolation.

In reality, pudendal neuralgia sits at the intersection of multiple systems — neurological,
musculoskeletal, pelvic floor, and psychosocial — and requires a holistic, specialist-led approach.

👩‍⚕️👨‍⚕️ Pudendal Neuralgia Affects Both Women and Men

Pudendal neuralgia affects both females and males. Although it is sometimes perceived as a
female-only condition, men may experience equally severe symptoms involving the perineum,
penis, scrotum, anus, or rectum.

Pain is often described as burning, stabbing, aching, electric, or pressure-like in nature and is
characteristically worsened by sitting. Many patients report improvement when standing,
lying down, or sitting on a toilet seat, which reduces direct pressure on the nerve.

🧠 Pudendal Neuralgia vs Pudendal Nerve Entrapment

A critical distinction must be made between pudendal neuralgia and
pudendal nerve entrapment. While entrapment is one possible cause, it is
uncommon, difficult to definitively diagnose, and frequently over-diagnosed.

Specialist pelvic pain education emphasises that most cases of pudendal neuralgia reflect
functional nerve irritation rather than fixed mechanical compression.
Contributors may include pelvic floor muscle spasm, altered biomechanics, prior trauma,
surgery, childbirth, prolonged sitting, or central sensitisation.

🧲 Imaging: MRI and MR Neurography (MRN)

MRI scans and MR neurography (MRN) are frequently requested in suspected pudendal neuralgia.
Their primary role is to exclude alternative or serious pathology, such as tumours or
significant structural disease.

In many patients with genuine pudendal neuralgia, imaging is entirely normal.
Importantly, pudendal nerve entrapment cannot be reliably confirmed on imaging alone,
and reported abnormalities often do not correlate with symptoms.

Over-reliance on imaging findings can drive patient anxiety and reinforce fixation on
entrapment, delaying more effective, clinically guided treatment.

🧘 Pelvic Floor and Musculoskeletal Contributors

Specialist training highlights the major role of the pelvic floor muscles and surrounding
musculoskeletal structures in pudendal neuralgia. Overactivity or spasm of muscles such as
the obturator internus and levator ani can irritate the pudendal nerve or mimic neuropathic pain.

Persistent pain can also lead to central sensitisation, where the nervous system becomes
hyper-responsive, amplifying pain even in the absence of ongoing tissue injury.

💉 Diagnostic Pudendal Nerve Blocks

A diagnostic pudendal nerve block is one of the most valuable tools in assessing pudendal neuralgia.
Temporary pain relief following a properly performed block strongly supports pudendal nerve involvement.

At PainSpa, these injections are performed using ultrasound guidance, allowing accurate
visualisation of anatomy, avoidance of vascular structures, and improved precision compared
with landmark-based techniques.

⚡ Pulsed Radiofrequency (PRF) for Longer-Term Benefit

For patients who experience meaningful but temporary relief from diagnostic blocks,
pulsed radiofrequency (PRF) of the pudendal nerve may provide longer-term benefit.

PRF is a non-destructive neuromodulatory technique that alters pain signalling without damaging
the nerve. It is considered safer than continuous radiofrequency and can be repeated if benefit diminishes.

• May provide sustained pain reduction
• Preserves nerve structure and function
• May reduce medication reliance
• Supports rehabilitation and functional recovery

🏥 Experience at PainSpa

At PainSpa, Dr Krishna has extensive experience in assessing and managing complex pelvic pain,
including pudendal neuralgia in both women and men.

Dr Krishna is highly experienced in performing ultrasound-guided diagnostic pudendal nerve blocks
and offering pulsed radiofrequency treatment where appropriate, using meticulous technique
and a calm, patient-centred approach.

🌱 Key Take-Home Messages

Disclaimer: This article is for educational purposes only and does not replace individual
medical assessment or personalised treatment advice.