Pudendal Neuralgia and Pelvic Pain
If you are in pain and want to explore pudendal neuralgia treatment options, call Dr. Attaman’s Seattle office (206-395-4422) or Bellevue, WA office (425-247-3359), or email us to schedule an appointment.
It is amazing how many causes of chronic pelvic pain there are; infection, endometriosis, pelvic muscle imbalances, gastrointestinal causes, joint pathology, etc. There are literally dozens of causes of chronic pain in this region.
One of the rarer causes of chronic pelvic and genital pain is a disease called Pudendal Neuralgia. I have treated many patients over the past few years with this diagnosis, and it has been professionally rewarding for me.
“Pudendal neuralgia is a commonly overlooked condition when evaluating chronic pelvic and genital pain disorders. The
pain associated with many of 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, chronic or non-bacterial prostatitis, prostadynia, burning scrotal syndrome, chronic pelvic pain syndrome, proctalgia fugax, hemorrhoids, coccydynia, piriformis syndrome, anorectal neuralgia, pelvic congestion, pelvic floor dysfunction, ischial bursitis, levator ani syndrome, and others. All of these disorders can have the same symptoms as pudendal neuralgia or actually be caused by PN. Sadly, it is common for patients with any of these conditions to be told their problem is psychosomatic and to seek psychiatric help.” — Health Organization for Pudendal Education
The pudendal nerve is a very little known but very important nerve in the pelvis. It is a nerve that provides sensation to your inner buttocks, anus, perineum (the area between your anus and genitalia), and genitals. This nerve can be injured or irritated for many reasons. In roughly 50% of patients, we have no idea what triggered the issue. Some patients have Pudendal neuralgia from falling on their buttocks while snowboarding. It can be as simple as that. Some patients have endured serious surgeries such as pelvic sling mesh placement and have woken up with this pain. Regardless of the cause, the symptoms can be severely debilitating.
Typically my female patients with pudendal neuralgia experience severe perineal burning electrical pain and pain around the genitals, especially the vulva and the clitoris. They often complain of a sensation of “sitting on a rock” near their sitting bones (ischial tuberosities).
Men with pudendal neuralgia typically have pain more focused around the scrotum or end of the penis. The most common cause in men by far is extreme bicycling.
The images you see demonstrate the course of the pudendal nerve, and you can imagine that burning, electrical, stinging pain anywhere along this nerve would be extremely distressing.
The first step in beating pudendal neuralgia is education. This means finding physicians that are versed in this nerve. Unfortunately, there are very few of us. This seems to be due to the fact that we are not taught about the pudendal nerve in medical school, residency, or even fellowship training. Indeed, I’ve spoken to urologists and gynecologists who either had forgotten about this nerve or had no idea it can play a role in chronic pain. Even though I completed a very intensive Pain Medicine fellowship, I never learned of it either. It was not until I started seeing patients in my clinic for whom nobody had found a diagnosis that I did further research and came to appreciate the importance of this nerve.
I’d strongly recommend you visit www.pudendalhope.info to get educated on this condition. It is a wonderful resource for education and resources.
You can read an interview I granted with www.pudendalhope.info about spinal cord stimulation (SCS) for Pudendal Neuralgia. You can click on the following link to read my interview: Interview with Dr. Attaman by pudendalhope.info
The next step is getting diagnosed and treated. Typically, this means seeing a urologist, uro-gynecologist, or OB/GYN specialist who likes to treat pelvic pain. One such person I can highly recommend in my state of Washington is Dr. Cindy Mosbrucker. If it is found that your pain is not due to issues with your internal organs, then the pain may be due to pudendal neuralgia. This is when I can help.
Typically I will review your records from the other specialists you have seen to be sure no diagnosis has been overlooked. I review any tests such as MRIs you may have had. I then perform a very careful history and gentle physical exam. We then discuss treatment options.
The treatment options are generally “multi-modal,” which means it would involve referral to various specialists with unique skills in treating this issue, such as physical therapists who work on the pelvic floor. Medications such as custom made suppositories to relax your pelvic nerves and muscles may be prescribed. Special Imaging studies such as MRI neurogram of the pudendal nerves may be ordered. Typically, I will want to confirm your Pudendal nerves are causing your pain by using an ultrasound machine to see the nerves and guide a thin needle to them through your buttocks and turn them off temporarily via a local anesthetic injection. This is called an ultrasound-guided pudendal nerve block. Oftentimes the treatment just detailed is sufficient to cure the issue. If insufficient, you may be a candidate for other procedures I perform such as low volume caudal epidural injections, pulsed radiofrequency ablation of the pudendal nerves, botox injections into the pelvic floor muscles, or spinal cord stimulation trial over a special area of the spinal cord called the conus meddularis.
Pudendal Neuralgia is a challenging condition to treat and diagnose, but there is certainly hope!
I am one of the few physicians in the world to routinely perform pulsed radiofrequency treatment of the pudendal nerve. It is a technically challenging procedure and time consuming. As I have performed many of them I have become proficient in this procedure and it is available to patients who are not responding to more conservative measures. Some literature on this procedure is below:
Pudendal Neuralgia FAQ
How do the symptoms differ in women vs. in men?
In women, the pain is commonly in the perineum and vulva. In men, the pain is more common in the perineum and glans penis (tip of the penis).
What conditions can pudendal neuralgia be mistaken for?
Unfortunately, pudendal neuralgia symptoms are mirrored by many, many other diseases and syndromes. Almost always, other disease states need to be “ruled out” prior to pursuing a diagnosis of pudendal neuralgia. In women, endometriosis, vaginitis, UTI, vaginismus, or other infections need to be ruled out. In men, prostatitis and bladder issues need to be ruled out. I always encourage my female patients to be fully evaluated by a gynecologist or urogynecologist prior to seeing me if they have genital pain. They should also see a colorectal surgeon if there is severe rectal pain. My male patients should be evaluated by a urologist if they have genital pain. They should also see a colorectal surgeon if there is severe rectal pain.
I would estimate that 90% of the patients I see in my clinic who are later conclusively proven to have pudendal neuralgia have been misdiagnosed by multiple prior physicians. I have seen many women sterilized (had a historectomy) for this condition. I have seen many women have many invasive surgeries and long courses of antibiotics for this condition. Unfortunately this worsens the underlying problem.
Almost 100% of the men I see have been misdiagnosed with “prostatitis,” in the past, and had multiple courses of antibiotics.
What causes it?
In roughly 50% of cases, there is no known cause in women and men. In women, the most common known causes are pelvic floor surgeries by far, particularly pelvic mesh placement. In men, the most common known cause is trauma, in particular bicycling, falling on the buttocks during skiing or snowboarding, or violent masturbation.
To what extent can it be prevented?
Avoid extreme bicycling, avoid pelvic sling/mesh placement if possible.
What are the risk factors?
See causes, above.
Is it hereditary?
Not to our knowledge. I have never had a patient mention pudendal neuralgia was present in any other family member.
Can pudendal neuralgia be treated?
Yes, there are many treatments!
Can it just go away by itself?
Yes, absolutely. However the longer you live with it, the less likely it is to go away by itself.
What are the treatment options?
The most conservative treatments include lifestyle modification, such as cessation of extreme bicycling. Other conservative options include pelvic floor physical therapy, in which a physical therapist places their fingers through the vagina and or rectum to stretch contracted pelvic floor muscles. Then medications can come into play, such has specially prepared vaginal or rectal suppositories with medications such as valium and baclofen which can help relax muscles and nerves in the pelvic floor. Oral medications such as muscle relaxants and nerve pain medications come next. Finally, invasive injection procedures enter the picture if needed. Such procedures include image-guided pudendal nerve blocks to diagnose the condition and hopefully gain some long term pain relief, image-guided pudendal nerve pulsed radiofrequency treatment, and image-guided botox injections of the obturator internus muscle to reduce pressure on the pudendal nerve as it passes through Alcock’s canal
We also are the only clinic in the pacific northwest to perform cryoablation treatment to the pudendal nerve, in which a special machine is used to create an ice ball at the tip of a specialized needle. This ice ball literally freezes the pudendal nerve, and interrupts the pain signals on a long term basis. The nerve grows back unharmed after 6-12 months, but oftentimes the pain does not return with it. This is a neurodestructive treatment, and therefore not a treatment we utilize unless necessary. We operate the “gold-standard” machine used for cryoablation, the EpiMed PainBlocker. You can learn more about this device by clicking here. You can also watch an outstanding lecture about cryoablation from the doyenne of this modality and outstanding Pain Medicine physician, Dr. Andrea Trescot, here. Dr. Trescot’s practice is in Alaska and can be contacted here.
Finally, the most invasive treatment I offer is called spinal cord stimulation, in which a special wire is placed along the spinal cord in the spine, and a small electrical current is applied to it. This blocks the pain signal from the pelvis to the brain. I use conventional spinal cord stimulator systems, as well as the newly released and very advanced St. Jude/Abbot DRG (dorsal root ganglion) stimulator, in which I can place these wires upon the S2-S4 nerve roots which form the pudendal nerve. This is a very powerful, expensive treatment, but one involving minor surgery, and thus I try save this option for last. You can read more about spinal cord stimulation in an interview I did with PudendalHope.
You can read about the St. Jude DRG stimulator here:
Oftentimes, particularly for patients traveling from foreign countries to see me, I will combine many of the procedures above in a single treatment. Therefore a patient may have pulsed radiofrequency treatement to the pudendal nerve, pulsed radiofrequency treatment of the pudendal nerve, and botox to the obturator internus muscles all in one session. The helps minimize the need to travel to my clinic multiple times to receive these treatments individually.
How does treatment work?
How long does the treatment take?
I treat nerve pain of all sorts all over the body. I want to be frank and state that pudendal neuralgia is one of the toughest to beat. Typically, treatment takes many months, when incorporating pelvic floor physical therapy, medications, injections, and lifestyle modifications. Patients typically will start with at least two diagnostic image-guided pudendal nerve blocks to confirm the diagnosis. They may then need to proceed to more advanced procedures such as pulsed radiofrequency treatement, botox, or in some cases spinal cord stimulation or dorsal root ganglion stimulation. Finally, surgical intervention may be needed in some cases.
Is there anyone who should not undergo treatment?
No, there is a treatment option of some sort for everybody.
What if I’m pregnant?
If you are pregnant, you are only eligible for pelvic floor physical therapy and lifestyle modification. I do not offer injection or medication treatments for pregnant patients.
That said, I have never met a pregnant patient with chronicpudendal neuralgia. If they do have it, it is very transient.
How should I prepare for treatment so it goes smoothly?
We have specific instructions to help get the most out of your treatments, and these are provided to you as you enroll.
Can you walk me through what happens on treatment day?
For an injection, typically you will arrive at my clinic for check in. We will then discuss the procedure and answer all your questions and obtain written consent from you. We then perform various injecitons as described above, almost all of which involve using an ultrasound or x-ray machine to very precisely guide a very thin needle through the skin of your buttock to the pudendal nerve, obturator internus muscle, or sacrotuberous ligament. In general, I can do all procedures through a single needle poke, as I can redirect the needle deeper in your body to various targets. The injections last anywhere from 5 minutes to 45 minutes depending on which injection(s) you will receive. You are then sent home with a driver.
Do I need multiple visits?
Typically, yes, multiple injections are needed, but not always.
What aftercare do I need to do?
We have special protocols for you to follow depending on the treatment you are receiving.
What are signs of a smooth recovery?
Gradual reduction or elimination in your pain, however the pain typically fluctuates up and down for the first few weeks after treatment, so do not expect your pain to go away immediately.
How can I prevent it from returning?
How much does the treatment cost?
Treatment cost is often covered by insurance. Many procedure however are not covered by any insurance, and therefore need to be paid directly by you. Costs range from $300 to $3000 per side, depending on the complexity of the procedure performed.
How can I find local help?
Unfortunately, rarely. There are very few physicians that treat pudendal neuralgia in the entire world. This is truly unfortunate. I would suggest you visit pudendalhope.info for local physicians that may help you.
How do I know whether a given doctor can actually help me?
Ask them how many patients with pudendal neuralgia they have treated in their career. If it is less than 10, it is unlikely they have the expertise to help you. Unfortunely, 99.9% of physicians have never (knowingly) seen a single case of pudendal neuralgia.