Pelvis / Coccyx
Pudendal Neuralgia
음부신경통
Chronic perineal pain from pudendal nerve entrapment/irritation
- How common
- Rare (<1% of population)
- Typical age
- Ages 40–60, female predominance
What is it?
Pudendal nerve is entrapped at sacrotuberous/sacrospinous ligaments or Alcock's canal, causing ischemia, inflammation, and central sensitization.
Commonly affected: Pudendal nerve (S2–S4) and Alcock's canal
How it develops
- Mechanical IrritationCycling, sitting, pelvic surgery irritate nerve
- EntrapmentCompression at ligaments/Alcock's canal
- NeuropathyIschemia, inflammation, demyelination
- Central SensitizationChronic pain amplification
Symptoms
- Worse with sittingRelieved on toilet or soft cushion
- Perineal burningBurning in vulva, anus, perineum
- Foreign body sensationSensation of sitting on a ball
- DyspareuniaPain with intercourse
- Urinary/bowel irritationPossible urgency/frequency
How it is examined
- Nantes criteriaApply 5 Nantes criteria
- Ischial spine tendernessIschial spine tenderness on PV/PR exam
- Tinel-like signTapping reproduces radiation
- Diagnostic nerve blockPudendal nerve block relieves pain (diagnostic)
Imaging
X-ray contributes little and is usually normal.
- Usually normal
- Rules out pelvic lesions
- Rules out sacral pathology
- Nonspecific
MR neurography evaluates nerve edema/entrapment; diagnosis relies on clinical + nerve block.
- Pudendal nerve edema (T2↑)
- Alcock's canal changes
- Ligament hypertrophy
- Often imaging-negative
Non-surgical care
- Avoid triggersStop cycling, donut cushion
- Neuropathic medsGabapentin, pregabalin, amitriptyline
- Pelvic floor PTPelvic floor relaxation, biofeedback
- Image-guided nerve blockPudendal nerve block — diagnostic/therapeutic
Conservative options are generally tried first. Medications listed here can have side effects — discuss them with your prescriber.
When surgery is considered
Conservative failure meeting Nantes criteria
Procedures that may be discussed
- Pudendal nerve decompression (transperineal/transgluteal/laparoscopic)
- Neuromodulation
Outlook
Variable — 50% improve with conservative care; 60–70% improve with surgery.