Across all genders, we all have two pudendal nerves – one that serves the right side of the pelvis and one that serves the left. This nerve, when irritated, is hard to ignore. The pudendal nerve supplies sensory and motor signals to the perineum and genitals. More specifically, when someone is suffering from pudendal neuralgia (or pain associated with the pudendal nerve), they can experience the following:
• Numbness in the perineal or genital area
• Shooting or burning sensations in the perineal or genital area
• Sensation of swelling as if sitting on a tennis or golf ball
• Increased sensitivity where clothing can feel painful
• Pain during sex, difficulty reaching orgasm, or erectile dysfunction in men
• Pain worse with sitting
Where Exactly Is the Pudendal Nerve?
The pudendal nerve originates from the sacrum, which is located at the bottom of your spine and between your two large hip bones.
Your sacrum can be looked at in levels or segments, just like your spine. The pudendal nerve will originate from the sacral levels of S2, S3, and S4. From here, the nerve makes a rather complicated route through and/or around the pelvic floor muscles and ligaments. It exits just inside the ischial tuberosity or “sit bone” that we feel when we’re sitting. From here, the nerve splits into three different branches.
1. Inferior rectal or hemorrhoidal branch: supplies sensation to external anal sphincter
2. Perineal branch: supplies sensation to skin of posterior scrotum, labia majora, vagina, and perineal body; also has muscular/motor branches to pelvic floor muscles and penis in men.
3. Dorsal nerve to the clitoris or penis: supplies sensation to the clitoris and underside of the penis.
Pudendal Nerve Route As Seen With Female Anatomy
Pudendal Nerve Route As Seen With Male Anatomy
When we see how the pudendal nerve spans out into its three branches, we can begin to understand the symptoms associated with pudendal neuralgia. For example, the nerve exits just inside the ischial tuberosity (sit bone), and can become irritated with prolonged sitting and especially cycling. Another example is that men who feel pain, numbness, or burning in the shaft of their penis or scrotum can also be suffering from pudendal neuralgia. These symptoms, along with what was discussed above can all be related to pudendal nerve dysfunction.
What’s also important to note is that we don’t only have the pudendal nerve in this area. There are other nerves that innervate this space as well, so if you’re feeling burning, shooting, tingling, or numbness but it doesn’t sound exactly like the pudendal nerve distribution, it is most likely another nerve in this area. We will still be able to determine which nerve is involved and create a plan of action to help you receive relief.
Causes of Pudendal Neuralgia
A nerve injury is most likely caused by compression or traction to a nerve. Pudendal neuralgia is no different and typically prolonged sitting, cycling, or horseback riding can provoke this nerve irritation. Other possible causes can be chronic constipation, childbirth, surgery to the pelvic area, a pelvic fracture, or an internal tissue growth placing pressure on the pelvic floor muscles and therefore the pudendal nerve.
How to Treat Pudendal Neuralgia
As stated earlier, it is very difficult to ignore pudendal neuralgia symptoms and if you suffer from these symptoms, it can be quite debilitating. We, as pelvic floor physical therapists, help to relieve the muscular tension along the pathway of the pudendal nerve. We also assist in improving the space around the nerve so it can glide and move more freely in its route.
We also believe in the importance of a collaborative care team. This usually involves your PCP, gynecologist, urologist, or urogynocologist in prescribing suppositories or injections to relieve the pain. Studies have also shown the importance of mindfulness and an anti-inflammatory diet in healing nerve injuries and re-mapping chronic pain cycles.
Nerve injuries take time and as we assist you through this journey, it’s important to try and have patience as your body heals. However, your body can and will heal with the proper treatment and care team around you.