Category Archives: Pudendal neuropathy

Endometriosis & melatonin | Women and pain series

Women and pain | Part 1

‘As many as 50 million American women live with one or more neglected and poorly understood chronic pain conditions’ 

Generally I see more female patients than male. This observation supports the view that chronic pain is more prevalent in women than in men for some conditions – see the International Association for the Study of Pain fact sheet here. There are some ideas as to why this may be, including the role of the sex hormones and psychosocial factors such as emotion, coping strategies and roles in life. Additionally, experimental studies have shown that women have lower pain thresholds (this is a physiological reading) and tolerance to a range of pain stimuli when compared to men although this does not clarify that women actually feel more pain – see here. Pain is a subjective experience of course, and modulated by many factors.

A campaign for women’s pain | Chronic pain in women (2010) report

It is not uncommon for a female patient to tell me about her back pain and continue the narrative towards other body areas that hurt and cause problems. This may include pelvic pain, migraine, headache, irritable bowel syndrome, chronic knee pain, widespread sensitivity and gynaecological problems (including dysmenorrhoea, endometriosis and difficulty conceiving). These seemingly varied conditions are typically looked after by a range of medical and surgical disciplines: gynaecology, neurology, rheumatology, gastroenterology and orthopaedics. More recent science and thinking has started to join the dots on these problems, offering new insight into the underpinning mechanisms and more importantly approaches that can affect all the conditions in a positive way. This is certainly my thinking on this hugely significant matter.

Reconceptualising pain

Undoubtedly pain is complex. This is particularly the case when pain persists, disrupting and impacting upon life. Reconceptualising pain according to modern neuroscience is making a real difference to how we think and treat pain – see this video. Briefly, thinking of pain as an output from the brain as a result of a complex interaction of circumstance, biology, thought, emotion and memory begins to give an insight into the workings of the brain and body. Pain is individual, it is in the ‘now’ but so coloured by the past and what it may mean to the individual. The context or situation in which the pain arises is so very important. We talk about pain from the brain but of course we really feel it in our physical bodies, but the location is where the brain is projecting the sensation – see this video.

Neuroscience has shown us that the danger signals from the body tissues are significantly modulated by the brain before the end output is experienced. Factors that influence the messages include attention, expectation and the circustance in which the individual finds herself. We have powerful mechanisms that can both facilitate and inhibit the flow of these signals and these reside within the brain and brain stem. For this reason we must consider the person’s situation, their expectations, hopes, goals, past experiences and current difficulties, and how these can affect their current pain.

Stress & emotion

Any hugely emotive issue within someone’s life can impact enormously upon pain and sensitivity. This can be the stress of a situation including caring for a relative, losing someone close, work related issues and divorce. The problem of conception certainly features in a number of cases that I see, causing stress and turmoil for both partners but clearly in different ways. Fertility receives a great deal of attention in the media and there are a many clinics offering treatment and therapies, in effect raising awareness and attention levels towards the problem. The pain caused by difficulties having children can manifest physically through the stress that is created by the situation. Thoughts, feeling and emotions are nerve impulses in the brain like any other and will trigger physical responses including tension. Stress physiology affects all body systems, for example the gastrointestinal system (e.g./ irritable bowel), nervous system (e.g. headaches, back pain) and the immune system (e.g. repeated infections).


Lifestyle factors play a significant role in persisting pain. Modern technology and habits that we form easily may not be helpful when we have a sensitive nervous system. For example, sedentary work, the light from computer screens, pressures at work, limited exercise, poor diet, binge drinking and smoking to name but a few. All are toxic in some way as can be our own thinking about ourselves. When we have a thought, and we have thousands each day, and we pay attention, becoming absorbed in the process, the brain reacts as if we are actually in that situation. Consequently we have physical and emotional responses that can be repeated over and over when we dwell on the same thinking. This is rumination and is likely due to ‘hyper-connectivity’ between certain brain areas – see here. We can challenge this in several ways including by changing our thinking and using mindfulness, both of which will alter brain activity and dampen these responses. It does take practice but the benefits are attainable for everyone.

In summary, the underlying factors that must be addressed are individual and both physical and psychological. Pain is complex and personal, potentially affecting many different areas of life. How we live our lives, what we think and how we feel are all highly relevant in the problem of pain as borne out of sensible thinking and the neuroscience of pain. Understanding the pain, learning strategies to reduce the impact, receiving treatment that targets the underlying mechanisms, making healthy changes to lifestyle and developing good habits alongside the contemporary brain based therapies can make a huge difference and provide a route forwards.

For information on our ‘join the dots’ treatment programmes for chronic pain, contact us here or call 07932 689081



Pudendal Neuralgia & Pudendal Neuropathy

Pudendal Neuralgia & Pudendal Neuropathy

From Hopkins Medicine

Also termed pudendal nerve entrapment, this problem afflicts both men and women having immense effects upon quality of life. The pudendal nerve is a sensory, autonomic, and motor nerve that carries signals to and from the genitals, anal area, and urethra. There are three branches of the nerve on each side of the body: rectal, perineal and clitoral/penile. Pudendal neuropathy occurs when the nerve or one of its branches is damaged, inflamed, or becomes entrapped.

The symptoms can be on one side or bilateral, starting acutely or developing over time. They include:

  • Pain in the areas innervated by the pudendal nerve or one of its branches
  • Burning
  • Reduced or loss of sensation
  • Electric shock-like pain, stabbing pain, knife-like or aching pain
  • The sense of a lump or foreign body – increased sense of size of the affected area
  • Altered sense of temperature
  • Constipation with pain on straining with bowel movements
  • Urination causes a burning pain
  • Painful intercourse
  • Sexual dysfunction

Once diagnosed, treatment often involves a combination of medication, procedures such as a pudendal nerve block, and physical therapy to address the pelvic floor muscles.

A contemporary approach to pain

Similar to other persisting pain states, to think about the suffering individual as much as the condition is fundamental. The wide ranging affects of the pain, associated symptoms and subsequent limitations have to be carefully considered within the treatment programme. The underpinning neurobiology is the basis for the problem but the responses of the body and brain and the individual are key determinants upon the impact. Initially developing a good understanding of the pain and the problem through high quality education creates a strong platform for effective coping and engagement in the rehabilitation and training programme.

The neuroimmune system is designed to adapt and change. This is how we learn. On the basis of the plasticity characteristic of neurons and how they fire together, we believe that change is possible with the right strategies based upon the right understanding within a realistic time-frame. See here

When we are in pain we move differently. The brain and body changes the way that the muscles are used including increased tension to protect the affected area. This is called guarding. The fact that the muscles are overworking creates its own issues including soreness, tightness, difficulty moving and often pain. Trigger points can develop that refer pain into other areas. Tackling changes in the motor system, especially those in response to nerve injury, needs an approach that considers the top-end, the brain (motor cortices and the areas of the brain that communicate with the motor centres, e.g. visual areas, emotional areas). It is important to understand that the associated thoughts about pain and the situation affect the way in which we move. If our belief is that the pain is a sign of damage and danger, we are going to be more protective and hence feed back into guarded posturing and movement. This is how understanding pain and the influences upon pain can really help. Changing our thinking through deeper understanding uses the frontal cortex to change our perception of pain. This is because the frontal cortex is part of the matrix of brain cells (neurons) that underpins the experience of pain. Directly targeting the areas of the brain involved in pain is a logical and now scientifically demonstrated way of dealing with pain.

Certainly local treatment of the the superficial muscles about the lumbar spine and pelvis can be useful to ease tension. In fact, anything that relaxes the individual will help to ease tension. For example, watching a favourite film, laughing with a friend, listening to music or taking a bath. Going beyond the tissues is vital though in dealing with nerve related pain (neuropathy) because of the adaptations that occur in the neuroimmune system. In recent years the use of Graded Motor Imagery for pain and movement problems has provided us with a way of working with the higher centres (‘top-down’) alongside approaches that nourish and mobilise the tissues gradually and safely. Together with development of understanding and often mindfulness, this combined approach offers a tangible and effective way of bringing about change to reduce the impact factor, distress level, increase function and improve quality of life.

For further information upon our approach to pain please contact us here or call 07518 445493



Pain Med. 2012 Apr;13(4):596-603. doi: 10.1111/j.1526-4637.2012.01343.x. Epub 2012 Mar 5.

Response to pudendal nerve block in women with pudendal neuralgia.

School of Women and Children, University of New South Wales, Sydney, Australia. [email protected]


To examine the evolution of pain and the duration of numbness after neural blockade of the pudendal nerve in women with pudendal neuralgia and correlate with clinical and historical data.


Prospective, single arm, open label study.


University hospital and outpatient clinic.


Eighty-two adult female patients were recruited from November 8, 2008 to February 14, 2010. Patients were selected based on the presence of spontaneous or provoked pain in the distribution of the pudendal nerve.


Subjects underwent a standardized pudendal nerve block.


Visual analog pain scores and the presence of numbness were recorded before and for 64 hours after the pudendal nerve block. A complete clinical history and examination were documented.


Sixty-six patients completed the study. About 86.9% had a reduction in one or more pain symptom, while 44.3% found that more than one of their pain symptoms did not return. About 69.7% of patients reported numbness lasting up to 16 hours or longer. Previous gynecological surgery was recorded in 75.8%, previous traumatic obstetric events in 47.0% of cases. Prolonged history of pain correlated with a reduced chance of positive outcome of the pudendal nerve block.


In patients with pudendal neuralgia, the pudendal nerve block has a variable response, but may have a beneficial effect in a subset of women. Surgical and obstetrical trauma are common historical antecedents


World J Gastroenterol. 2011 Oct 28;17(40):4447-55.

Chronic proctalgia and chronic pelvic pain syndromes: new etiologic insights and treatment options.

This systematic review addresses the pathophysiology, diagnostic evaluation, and treatment of several chronic pain syndromes affecting the pelvic organs: chronic proctalgia, coccygodynia, pudendal neuralgia, and chronic pelvic pain. Chronic or recurrent pain in the anal canal, rectum, or other pelvic organs occurs in 7% to 24% of the population and is associated with impaired quality of life and high health care costs. However, these pain syndromes are poorly understood, with little research evidence available to guide their diagnosis and treatment. This situation appears to be changing: a recently published large randomized, controlled trial by our group comparing biofeedback, electrogalvanic stimulation, and massage for the treatment of chronic proctalgia has shown success rates of 85% for biofeedback when patients are selected based on physical examination evidence of tenderness in response to traction on the levator ani muscle–a physical sign suggestive of striated muscle tension. Excessive tension (spasm) in the striated muscles of the pelvic floor appears to be common to most of the pelvic pain syndromes. This suggests the possibility that similar approaches to diagnostic assessment and treatment may improve outcomes in other pelvic pain disorders


Neurourol Urodyn. 2008;27(4):306-10.

Diagnostic criteria for pudendal neuralgia by pudendal nerve entrapment (Nantes criteria).

Service d’Urologie, CHU Hôtel-Dieu, Nantes, France.


The diagnosis of pudendal neuralgia by pudendal nerve entrapment syndrome is essentially clinical. There are no pathognomonic criteria, but various clinical features can be suggestive of the diagnosis. We defined criteria that can help to the diagnosis.


A working party has validated a set of simple diagnostic criteria (Nantes criteria).


The five essentials diagnostic criteria are: (1) Pain in the anatomical territory of the pudendal nerve. (2) Worsened by sitting. (3) The patient is not woken at night by the pain. (4) No objective sensory loss on clinical examination. (5) Positive anesthetic pudendal nerve block. Other clinical criteria can provide additional arguments in favor of the diagnosis of pudendal neuralgia. Exclusion criteria are also proposed: purely coccygeal, gluteal, or hypogastric pain, exclusively paroxysmal pain, exclusive pruritus, presence of imaging abnormalities able to explain the symptoms.


The diagnosis of pudendal neuralgia by pudendal nerve entrapment syndrome is essentially clinical. There are no specific clinical signs or complementary test results of this disease. However, a combination of criteria can be suggestive of the diagnosis


Neurourol Urodyn. 2007;26(6):820-7.

Pudendal entrapment as an etiology of chronic perineal pain: Diagnosis and treatment.

Fort Bend Neurology, Sugar Land, Texas 77479, USA. [email protected]


This study was conducted to evaluate pudendal entrapment as an etiology of chronic pain, a diagnostic protocol for pudendal entrapment, and clinical response to surgical decompression.


A case series of 58 consecutive patients with a diagnosis of pudendal entrapment, based on clinical factors, neurophysiologic studies, and response to pudendal nerve infiltrations, is described. All patients were refractory to other treatment modalities. Patients were assessed before and after surgical decompression: degree of pain was assessed by visual analog scale (VAS) score, percent global overall improvement, and improved function and quality of life before surgery and 12 months or longer after surgery.


The primary presenting feature was progressive, chronic, intractable neuropathic pain in the perineum (ano-rectal and/or urogenital) that worsened with sitting. Other symptoms included urinary hesitancy, frequency, urgency, constipation/painful bowel movements, and sexual dysfunction. After surgical decompression, 35 (60%) patients were classified as responders, based on one of the following three criteria: a greater than 50% reduction in VAS score, a greater than 50% improvement in global assessment of pain, or a greater than 50% improvement in function and quality of life.


Pudendal entrapment can be a cause of chronic, disabling perineal pain in both men and women. Since symptomatic patients seek medical care from many different medical specialists, a reliable diagnostic protocol should be established. For patients refractory to conventional interventions, surgical decompression of the pudendal nerve can improve pain-related symptoms and disability. With ongoing work on this subject, which is a difficult disorder to accurately diagnose and treat, a better awareness of pudendal entrapment across specialties will emerge


J Minim Invasive Gynecol. 2010 Mar-Apr;17(2):148-53. Epub 2010 Jan 12.

Pudendal neuralgia.

Department of Obstetrics and Gynecology, St. Joseph’s Hospital and Medical Center, Phoenix, Arizona 85013, USA. [email protected]

Pudendal neuralgia is a painful, neuropathic condition involving the dermatome of the pudendal nerve. This condition is not widely known and often unrecognized by many practitioners. The International Pudendal Neuropathy Association ( estimates the incidence of this condition to be 1/100,000; however, most practitioners treating patients with this condition feel the actual rate of incidence may be significantly higher. Currently, there is fair paucity of medical literature and scientific evidence in the diagnosis and treatment of pudendal neuralgia. Diagnosis of this condition is based on the utilization of Nantes Criteria, in conjunction with clinical history and physical findings. CT-scan guided nerve blocks are also employed, by this author, to provide additional information. Subsequent treatment of pudendal neuralgia is medical and well as surgical, with Physical Therapy a key component to all aspects of treatment. The goal of this paper is to present evidence based information, as well as personal clinical experience, in treating approximately 200 patients with pudendal neuralgia.

Useful links (please note that on the home page is a video demonstrating a surgical procedure. If you are particulalry sensitised it maybe advisable to avoid watching the film currently although with graded exposure this could become a goal. Seek the advice of your health professional)