Medicines for Pudendal neuralgia

What it is

Pudendal neuralgia is a type of long-term (chronic) pain that affects the area supplied by the pudendal nerve — the nerve that carries sensation from the lower pelvic area, including the genitals, the area between the genitals and anus (the perineum), and around the back passage. In pudendal neuralgia, this nerve becomes irritated, compressed, or damaged, causing pain in this area. It can affect both men and women. The pain of pudendal neuralgia is typically felt in the pelvic, genital, perineal, or anal area, and is often described as a burning, aching, stabbing, or shooting pain, or a feeling of pressure, discomfort, or numbness; it may affect one or both sides. A characteristic feature is that the pain is often worse when sitting, and may be relieved by standing up, lying down, or sitting on a toilet seat (which takes pressure off the area) — though this is not the case for everyone. The pain can be constant or come and go, and can be significant and distressing, affecting daily activities, sitting, sexual function, and quality of life. There can be various causes or contributing factors, including compression or irritation of the nerve (for example from prolonged sitting or cycling, or from the surrounding tissues), injury or damage to the nerve (for example from trauma, surgery, or childbirth), or other factors; sometimes no clear cause is found. Because pelvic pain can have many causes, and because pudendal neuralgia can be difficult to diagnose, assessment is important to consider the diagnosis and exclude other causes. There is no single cure for pudendal neuralgia, but a range of treatments can help manage the pain and improve quality of life — including measures to reduce pressure on the nerve, medicines for nerve pain, physiotherapy, nerve blocks or injections, and, in some cases, other treatments — and specialist and multidisciplinary input (such as pain specialists) is often helpful, particularly for persistent or difficult cases. The key messages are that pudendal neuralgia is long-term pain in the pelvic and genital area caused by irritation or damage to the pudendal nerve (often worse when sitting), and that a range of treatments and specialist care help manage it.

How it is treated

Pudendal neuralgia is managed with a range of treatments to reduce the pain and improve quality of life — including reducing pressure on the nerve, nerve pain medicines, physiotherapy, and, in some cases, injections or other treatments — often with specialist and multidisciplinary input; there is no single cure, but it can be managed. Because pelvic and genital pain can have many causes, and pudendal neuralgia can be difficult to diagnose, assessment is important to consider the diagnosis, look for any contributing cause, and exclude other conditions — this may involve a careful history and examination, and sometimes tests or specialist assessment; the characteristic features (such as the pain being worse when sitting) help suggest it. Management is usually a combination of approaches, tailored to the individual, and may include: measures to reduce pressure on and irritation of the nerve — such as avoiding prolonged sitting where possible, using a specially shaped cushion (for example one that takes pressure off the affected area when sitting), avoiding activities that worsen it (such as cycling, for some people), and modifying activities; nerve pain medicines — as this is a type of nerve pain, medicines specifically used for nerve pain (rather than ordinary painkillers, which are often less effective for nerve pain) may be prescribed and adjusted to help control the pain; physiotherapy — particularly specialist pelvic floor physiotherapy, which can help by addressing muscle tension and other factors around the nerve and pelvis, and is an important part of care for many people; and nerve blocks or injections — injections around the pudendal nerve (for example with local anaesthetic and/or steroid) can help reduce the pain in some people, and can also help with diagnosis. For persistent or difficult cases, other treatments may be considered, guided by specialists — such as other pain management approaches, and, in selected cases where nerve compression is identified and other treatments have not helped, surgery to release the nerve (decompression) may be an option, though this is considered carefully. Because pudendal neuralgia can be persistent and distressing, a multidisciplinary approach — often involving pain specialists, physiotherapists, and others — and support for the impact on daily life, activities, and wellbeing (including any effects on mood, given that chronic pain can affect this) are important. Managing any contributing factors, and a combination of the above tailored to the individual, give the best chance of controlling the pain and improving quality of life. The reassuring messages are that pudendal neuralgia, although it can be a persistent and distressing type of nerve pain, can be managed with a range of treatments — reducing pressure on the nerve, nerve pain medicines, physiotherapy (particularly pelvic floor physiotherapy), and injections or other treatments — and that specialist and multidisciplinary care help, particularly for difficult cases; so assessment, a tailored combination of treatments, and specialist input are the keys to managing pudendal neuralgia.