Pudendal nerve entrapment is a rare and painful condition.
Pudendal neuralgia by pudendal nerve entrapment is described as severe, sharp pain along the course of the pudendal nerve. Genital numbness and erectile dysfunction are two of the major symptoms and the prevalence has been reported to be 50–91% and 13–24% respectively. This can be caused by trauma, infection, tumour, child birth, iatrogenic injury, surgery and/or microtrauma from cycling. It has been reported that 7–8% of cyclists on long-distance multiday rides experience pudendal neuralgia. Diagnosis of pudendal nerve entrapment is often delayed or misdiagnosed, causing people to suffer with this for 2–10 years. It is important to understand the clinical presentation and diagnostic criteria to allow early diagnosis and appropriate treatment.
Pudendal nerve entrapment syndrome
Symptoms and signs:
Constant penis pain and a dull ache in the perineum
Patient must fulfil all Nantes and at least 1 complementary criteria.
Nantes Criteria
Inclusion criteria:
Pain co-relates with the anatomical distribution of pudendal nerve: Pudendal nerve supplies external genitalia. The pain can be superficial or deep in the vulvovaginal, anorectal, and distal urethra.
Pain predominantly in sitting position: This symptom favors nerve compression because if there is a decrease in mobility of the nerve, it makes the nerves vulnerable to compression against hard ligamentous structures. This aspect of pain is dynamic as the pain results from compression and not by sitting position.
The patient does not get up with pain at night, although many patients may experience difficulty going to sleep because of pain.
There is no sensory loss: The presence of superficial perineal sensory impairment indicates a sacral root-lesion rather than PNE.
Relief of pain with pudendal nerve block: This essential criterion is not specific as any perineal disease other than entrapment can cause pain in the anatomic region of the pudendal nerve. A negative block also doesn’t exclude the diagnosis if there is a lack of precision or when performed too distally.
Complementary diagnostic criteria:
Pain is of a burning, shooting, or stabbing nature and associated with numbness.
Allodynia or hyperpathia
Foreign body sensation or heaviness in rectum or vagina.
The pain progressively increases and peaks in the evening and stops when the patient sleeps.
Pain is more on one side.
Pain is more prominent posteriorly and is triggered minutes or hours after defecation.
Tenderness that is felt around the ischial spine during a digital vaginal or rectal examination.
An abnormal result on neurophysiological tests
Exclusion criteria:
Pain exclusively in the territory not served by the pudendal nerve. It can be in the hypogastrium, coccyx, pubis, or gluteus.
Pain is associated with pruritus (more suggestive of a skin lesion).
Pain entirely paroxysmal in nature.
An imaging abnormality can justify the cause of the pain.
Associated signs:
Pain in the buttock
Referred sciatic pain
Pain in the medial thigh (indicates obturator nerve)
Pain in the suprapubic region
Increased frequency of urine or pain with a full bladder
Pain after ejaculation
Pain worsens hours after sexual intercourse.
Erectile dysfunction
A normal result on electrophysiological tests
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