Chronic pelvic pain is quite common and can be caused by many factors. The urinary, reproductive, gastrointestinal system, as well as musculoskeletal system, can all be a culprit. Pudendal neuralgia is a cause of chronic pelvic pain in around 4% of patients. It can be treated with pulsed radiofrequency if exercise and simple medications fail. Surgery is the last result.
Symptoms of pudendal neuralgia
Pudendal neuralgia affects both men and women and can cause a lot of impairment and reduction of the quality of life. People with pudendal neuralgia usually have burninsg and sharp pain along the pudendal nerve that is worse when sitting. This can manifest as buttock pain, groin pain, or thigh pain. Lying down or standing usually relieves this pain. Pudendal neuralgia can affect one or both sides, and the symptoms can vary depending on which branch of the nerve is affected. There can be changes in sensation as well as muscle strength. Oftentimes, there is overactivity of the muscles that make up the pelvic floor.
Causes of pudendal neuralgia
Pudendal neuralgia is caused by the pudendal nerve being trapped between muscle planes. This can happen at the piriformis muscle, between the gluteus maximus fascia and the sacrospinous ligament, or between the sacrospinous ligament and the superior gemellus fascia The entrapment can also occur within the pudendal canal. Pudendal neuralgia usually affects those who sit for too long. People at risk include taxi drivers, avid cyclists, women who had natural labour, and patients who had gone for hip/pelvic surgery.
Where possible, pudendal neuralgia should be treated by addressing the underlying cause such as a poorly placed suture that is constricting the pudendal nerve. Since the cause is not always obvious, treatment is often focused on pain management and improvement of quality of life and function. A change in lifestyle should be encouraged such as stopping cycling and sitting on soft cushions. Patients should try getting up and walking around every 20-30min if they have a deskbound job. Pelvic physiotherapy can be useful in reducing the overactivity of the pelvic floor muscles.
Medications that can be tried include:
- Nonsteroidal anti-inflammatory drug (NSAIDs) such as ibuprofen
- COX-2 inhibitors such as celecoxib and etoricoxib
- Anti-epileptic drugs like gabapentin and pregabalin
- Anti-depressants like amitriptyline
If medications and physiotherapy are not sufficient or if symptoms are severe or medications poorly tolerated, pudendal nerve blocks can be used. The nerve blocks serve both to diagnose and provide longer-term relief. Pulsed radiofrequency of the pudendal nerve can be done as day surgery and can lead to lasting pain relief for years. Pulsed radiofrequency also helps to avoid open surgery to free up the nerve.