Pudendal Neuralgia (PN)
Pudendal neuralgia could be a cause of pelvic pain. The pain associated with the following disorders may be caused by (or in part by) pudendal neuralgia or pudendal nerve entrapment: vulvodynia, vulvar vestibulitis, interstitial cystitis, irritable bowel syndrome, prostatitis, prostadynia, proctalgia fugax, burning scrotal syndrome, hemorrhoids, coccydynia, piriformis syndrome, anorectal neuralgia, pelvic congestion, ischial bursitis, or levator ani syndrome.
What causes PN?
Some causes of PN are due to medical diagnosis such as an infection, inflammation or an autoimmune disease. It is important to see your medical doctor for correct diagnosis.
Causes of PN that Pelvic Floor Physical Therapists successfully treat include:
*Tension of the nerve from muscles, ligaments, scar tissue or from pelvic misalignment.
*Trauma to the nerve from a fall, exercise, childbirth, prolonged sitting/cycling, or surgery in the abdominopelvic region.
*Stress that provokes or increases the pain of PN.
*Tension or scar tissue that has occurred and is still present following a medical diagnosis which has been treated and cured.
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Symptoms of Pudendal Neuralgia
(Symptoms may vary for each person.)
• Pain in the area innervated by the pudendal nerve; pain or tenderness along the course of the nerve when an examiner presses on the nerve during a pelvic or rectal exam; pain that is intermittent or constant, and on one or both sides
• Burning, tingling, numbness, electric shock, stabbing, knife- like or aching pain, hot poker sensation or feeling of a lump or foreign body in the vagina or rectum, twisting or pinching, abnormal temperature sensations, or hypersensitivity to touch or pressure
• Painful bowel movements--muscle spasms, straining, constipation, or burning
• Feeling the need to urinate when the bladder is empty, urethral burning with/after urination, frequency, retention, need to push to urinate, or difficulty feeling urine passing through the urethra
• Pain during or after intercourse/orgasm, loss of sensation and difficulty achieving orgasm, or persistent feeling of uncomfortable arousal in the absence of sexual desire
• Intolerance to tight pants or elastic bands around the legs
• Pain that is worse with sitting or is constant in all positions and may be relieved by sitting on a toilet seat
• Pain that is often not immediate but delayed and stays long after activity is discontinued
• Pain that is lower in the morning and increases throughout the day
• Pain affecting other pelvic nerves and muscles causing buttock sciatica and everything that goes with it: numbness, coldness, and sizzling sensation in legs, feet, or buttocks
Pudendal neuralgia may be more severely symptomatic when associated with other systemic pain processing disorders such as fibromyalgia, chronic migraine, chronic regional pain syndrome, and other peripheral neuropathies.
Pelvic Physical therapy Treatment
It is important that treatment for PN is provided by a physical therapist who has knowledge and experience in treating patients with pudendal neuropathy such as the therapists at The Center for Pelvic Floor and Core Rehabilitation.
For PNE patients, one thing to avoid intially with physical therapy is kegal exercises. With kegals, the focus is on strengthening the pelvic floor. But if you have pudendal neuralgia, your pelvic floor is already tense and shortened. Kegal exercises should be avoided until most of the PN symptoms have disappeared.
Goals of Pudendal Neuralgia/Entrapment Physical Therapy:
1. Eradicate myofascial trigger points - Trigger points are discreet irritable painful points in the muscles or connecting tissues. Common Myofascial trigger point sites include the rectus abdominus, adductors, gluteus minimus, medius, and maximus, obturator internus, piriformis, pelvic floor and quadratus lumborum. Physical therapists will utilize various techniques to help with trigger points. They include manual therapy, trigger point injections, TENS, and dry needling.
2. Lengthening the Pelvic Floor - Most PN patients have an extremely tense and shortened pelvic floor. The goal is to reduce the tension to allow the pelvic floor muscles to lengthen so that the muscles are no longer in a constant state of contraction. A shortened pelvic floor can compress the pudendal nerve. Physical therapy will use internal vaginal and/or rectal manual therapy, trigger point injections and myofascial release to help lengthen the pelvic floor.
3. Minimize connective tissue restrictions. If the tissues are restricted there will be a decrease in blood flow, muscle atrophy, and thickening of the subcutaneous tissue. Physical therapists will utilize a technique called connective tissue manipulation (CTM) and is performed with minimal pressure as the therapist pushes through the subcutaneous tissue. The goal of CTM is to restore connective tissue integrity and improve circulation.
4. Reduce adverse neural tension. The path pf the pudendal nerve takes through the body may be narrowed or impinged. This disrupts its normally smooth movement. Typically this occurs as the nerve passes through a muscle or around a bone. Symptoms, such as tingling and numbness, often arise further along the path of the nerve. Physical therapists will use nerve glides, connective tissue manipulation and or ultrasound to lessen the constriction and give more space for the nerve, so it is no longer impinged.
5. Normalize structure and mechanics - Sometimes, people with pudendal neuralgia can also have structural issues, such as sacroiliac joint dysfunction, pelvic obliquity, issues with core strength and neuromuscular control, and hip mechanics. In the case of sacro-iliac joint dysfunction, abnormal joint positions such as pelvic bone rotations will result in increased tension on the ligaments through which the pudendal nerve passes. As a result, the ligaments may compress or shear the nerve and lead to inflammation.
6. Educate in appropriate lifestyle changes. Avoid activities that aggravate pain, such as exercise, cycling, constipation, bending, squatting, and prolonged sitting. Use a gel cushion when sitting as necessary. Walking on level ground and swimming are exercises that some patients can tolerate.
7. Advise and guide complementary treatments. Acupuncture, yoga, water therapy, cognitive behavior therapy, and meditation may be helpful