PNE Paradox

Pudendal Nerve Entrapment (PNE) is diagnosed primarily on the patient’s symptoms.

· Persistent pain in the specific nerve distribution: genital area; around the anus tail-bone sometimes into the gluteal (buttock) muscles

· Pain may be described as: dull, burning, tearing, sharp, aching, or “pressure”

· Pain is much worse with sitting, can be all or partially relieved with standing, significantly relieved with sitting on a toilet seat, or any seat with a cutout that takes pressure off the pudendal nerve.

Patients with these symptoms are often misdiagnosed with chronic prostatits (in the male) and vulvodynia or vestibulitis (in women). In both sexes these symptoms may get you a diagnosis of Interstitial Cystitis (IC) or Chronic Pelvic Pain Syndrome (CPPS). There is a really great article in Urology Times by Penny Allen that discusses these differential diagnoses. The problem with diagnosing all of these conditions is that one does not necessarily rule out the other. You may have PNE, and also have IC. Once you are positively diagnosed with one, your healthcare professionals may stop looking for other conditions that contribute to your pain. Getting the diagnosed condition under control before looking for other factors may be the best course of action; but, if you are showing significant improvement with some symptoms, and other symptoms are no better (or worse), it is time to start digging deeper.

Your pudendal nerve exits your sacrum and travels between two ligaments and your piriformis muscle through a half circle opening (called Adcock’s canal) in your pelvis down to the area it innervates around your genitals. Realize this explanation is very simplified, and I have not figured out how to put graphics onto this blog. There are great images all over the net – follow this link to an article with a nice little schematic and a great picture of the nerve as it travels through the pelvis. (PNE pics) The primary site of entrapment is in Adcock’s canal, and many treatments are focused on this area. Nerve injections are done here; surgical releases are performed at Adcock’s canal, particularly if calcium deposits are found.

Sometimes injections and surgical treatments do not work. This is because there are other ways that the nerve can become irritated, and other ways that pain may show up in your genital and anal area. Trigger points are something I post about a lot. Many trigger points (TP’s), will refer to the external genitals. Common TP’s that I look for are in the adductor (inner thigh) muscles, obdurator internus (which can be accessed externally, or through the vagina), and muscles of the pelvic floor, which are accessed through the rectum or vagina. Often stretching the piriformis muscle and the ligaments involved in PNE will take some of the pressure off the nerve. There is some evidence that hyper-irritation of abdominal organs can cause the PNE to become over active, irritated and painful.

Many physicians that are well versed in treating PNE have begun trying conservative, non-invasive treatments before surgical interventions or injection therapy. Sometimes, if the symptoms are very severe, injections are still the best first-line treatment. If you have these symptoms and your doctor recommends surgery right away, or after only trying injection therapy, ask about physical therapy and other non-invasive treatments first. And Always, Always, get a second opinion before undergoing a surgical procedure, even if your doctor is the best doctor in the field.

Weiss J; Prendergast S; Pitfalls in the Effective Diagnosis and Treatment of Pudendal Nerve Entrapment. The International Pelvic Pain Society. Vision.

Antolak S; Pudendal Neuralgia. Internatioan Pelvic Pain Society. Symposium. Banff, AB, CA. 2003