Pudendal Neuralgia and Endometriosis

Peripheral neuropathy can occur when there is damage to nerves located outside the brain or spinal cord. One of the symptoms of nerve damage, or, neuropathy is neuralgia, which is a sharp pain that occurs along the path of the nerve that due to the damage. This article explains how pudendal neuralgia and endometriosis may be linked.

Can endometriosis affect nerves?

One of the prominent symptoms of endometriosis is neuropathy involving the pelvic nerves directly or indirectly. Inflammation due to endometriosis within the pelvic cavity can affect or damage nerves. Usually, the small nerve fibers of the peritoneum are always involved. Larger nerve fibers can also be affected but this is rarer.

Endometriosis lesions and scars can pull or apply pressure on the nerves directly causing a sharp, constant pain that patients often describe as a throbbing or stabbing sensation. Neuropathy in endometriosis can manifest as pelvic pain, sciatica pain (affecting the back and legs), and hip pain radiating to the buttocks.

What is the pudendal nerve?

The pudendal nerve is a major nerve in the pelvis that runs through the pelvic floor muscles and sends information from the genital area. The pudendal nerve arises at the base of the spine in the sacral plexus and is present on both the left and right sides of the body. The functions of the pudendal nerve include controlling the movement of the anal and urethral sphincter muscles and sending sensory information from the vagina, anal canal, anus, and perineum (skin between the anus and the vagina).

What is pudendal neuralgia?

Pudendal neuralgia, associated with pudendal nerve entrapment (PNE) syndrome, is a highly debilitating, chronic neuropathic pain that can affect both men and women. Its prevalence is low at around 1 in 100,000 people. However, the prevalence may be substantially higher since many cases go unreported. Researchers know that PNE affects women twice as often as men.

Pudendal neuralgia can occur due to a variety of reasons such as postpartum pelvic pain, surgery, strained bowel movements, trauma, pelvic floor muscle spasms, and pressure on the pudendal nerve due to endometriosis lesions or scar tissue.

What are the symptoms of pudendal neuralgia?

The symptoms of pudendal neuralgia include:

• pain, numbness, and dysfunction along the pudendal nerve that affects the genitalia, perineum, rectum, and lower urinary tract
• increased pain while sitting down
• sexual dysfunction and dyspareunia
• issues with urinary urgency and frequency
• painful ejaculations in men
• sphincter dysfunction that results in constipation, dysuria, fecal incontinence, and urinary hesitancy
• the sensation of a foreign body in the anus, rectum, vagina, or urethra

How do doctors diagnose pudendal neuralgia?

Doctors often misdiagnose neuropathy due to endometriosis as a musculoskeletal issue mostly because of the lack of expertise in the treatment and diagnosis of endometriosis. However, early diagnosis of conditions such as pudendal neuralgia is very important to prevent further nerve damage and avoid serious physical and mental problems.

A confirmed diagnosis of pudendal neuralgia, and neuropathies in general, is not easy. Common ways include:

• vaginal and/or rectal examination
• MRI scan to detect compression of the pudendal nerve
• high-frequency ultrasonography
• Doppler ultrasound
• evaluation of pain relief with unguided diagnostic nerve blocks in the vagina
• pudendal nerve block injections directly into the Alcock’s canal using image guidance

Pudendal neuralgia coinciding with the onset of periods suggests that endometriosis is the most likely reason. In such cases, laparoscopic deep excision surgery followed by histology is the way to reach a definite diagnosis.

How can pudendal neuralgia due to endometriosis be treated?

Pudendal neuralgia can be managed by avoiding painful stimuli such as cycling, jogging, skiing, swimming, and sitting for too long. Physical therapy also works if the pain is the result of muscle spasms in the pelvic region.

Other known therapies include:

• pharmacologic therapy with analgesics, muscle relaxants, and anticonvulsants
• guided or unguided pudendal nerve block using a local anesthetic or steroid
• laparoscopic surgical decompression of the pudendal nerve in the Alcock’s canal
• sacral neuromodulation with the help of peripheral nerve stimulation
• pulsed radiofrequency ablation
• CT-guided percutaneous cryoablation
• lipofilling with adipose tissue along with stem cells into the Alcock’s canal

If endometriosis lesions are the reason for pudendal neuralgia, laparoscopic deep excision surgery is the only gold standard treatment. When performed by an experienced surgeon who can remove all lesions and scar tissue, symptoms can improve to a large extent. Performing excision surgery near the nerve requires advanced skills that very few surgeons have.

Dr. Seckin uses a multi-disciplinary approach that helps the patient understand all possible consequences before going ahead with the surgery.

Do you think you might have pudendal neuralgia linked to endometriosis? Please share your experience by leaving a comment on our post on Facebook or Instagram