Pudendal neuralgia and osteopathy

Pudendal neuralgia is a chronic, often disabling condition caused by damage to the pudendal nerve, a mixed nerve that innervates the external genitalia, anus, perineum and part of the pelvic floor. This condition is still largely under-diagnosed, despite being a source of great physical and psychological suffering. It can affect men and women of any adult age, with a peak between the ages of 30 and 60.

The pudendal nerve arises from the sacral roots S2, S3, S4. It leaves the pelvis via the greater ischial incisure, bypasses the ischial spine and re-enters the pelvis via the lesser ischial incisure, then travels through Alcock's canal (or pudendal canal) with the pudendal artery and vein.

It has three main branches:

1. The inferior rectal nerve

2. The perineal nerve

3. The dorsal nerve of the clitoris or penis

The pudendal nerve is therefore both motor (sphincters) and sensory (perineum, external genitalia). Its proximity to bony, ligamentous and muscular structures makes it vulnerable to compression.

Pudendal neuralgia (or pudendal neuropathy) is chronic pain caused by irritation, inflammation or compression of the pudendal nerve along its course.

It differs from "simple" chronic pelvic pain in that it meets specific diagnostic criteria, defined by the Nantes group in 2006, which is a reference in the medical world.

• Pain in the pudendal nerve territory (from the anus to the clitoris or penis, often in a "bicycle saddle" pattern)

• Pain aggravated by sitting

• No nocturnal pain (patient can sleep)

• No objective sensory deficit on neurological examination

• Partial relief after anesthetic infiltration of the pudendal nerve

• Burning, throbbing, numbness or electric sensations

• Urinary or anal disorders (dysuria, post-micturition pain, false desire)

• Sexual discomfort (dyspareunia, pain after ejaculation)

• Pain during ejaculation or defecation

• Perineal hypersensitivity

Pudendal neuralgia can have multiple origins. In some cases, it is said to be idiopathic, i.e. no precise cause is identified. More often, however, it is secondary to compression, irritation or inflammatory damage to the pudendal nerve along its course.

Mechanical factors include :

• Prolonged or repeated sitting (cyclists, drivers, office workers)

• Pelvic, gynaecological or proctological surgery

• Traumatic or instrumental delivery

• A fall on the sacrum or coccyx

• Chronic muscle spasms or contractures of the pelvic floor

• Scar fibrosis (particularly post-surgical)

• Prolapse or pelvic static disorders

These mechanical causes are sometimes compounded by underlying medical conditionswhich can alter nerve conduction or cause perineural inflammation:

• Diabetes

• Multiple sclerosis

• Lyme disease

• Genital herpes

• Recurrent urinary tract infections

Pudendal neuralgia most often begins between the ages of 50 and 70, with a slightly higher prevalence in women (around 6 women for every 4 men). This predominance is partly explained by gyneco-obstetrical factors and the anatomical configuration of the female pelvis.

It is based on expert clinical analysis. No examination is pathognomonic, but some are useful in ruling out other causes and assessing the impact:

• Pelvic MRI focused on Alcock's canal (to find a conflict)

• Endoperineal or endocavitary ultrasound

• Electroneuromyogram (EMG) of perineal muscles

• Diagnostic infiltration test (local anesthesia of the pudendal nerve)

A urodynamic, gynaecological, proctological or sexological check-up may be indicated, depending on the associated symptoms.

Treatment must be multimodal, progressive and focused on pain reduction, functional recovery and improved quality of life.

• Reducing sitting time

• Use of U-shaped or hollowed-out cushions to relieve pressure on the perineum

• Postural rehabilitation

• Treatment by a specialized physiotherapist or osteopath

• Work on relaxing pelvic floor muscles (trigger points, breathing, stretching)

• Biofeedback, electrostimulation, myofascial techniques

In some cases, your GP or specialist may prescribe medication. Here are a few examples:

• Level 1 or 2 analgesics

• Anti-epileptics (gabapentin, pregabalin)

• Tricyclic antidepressants or serotonin and norepinephrine reuptake inhibitors

• Muscle relaxants

• Under ultrasound, scanner or electrostimulation guidance

• Corticoids + anesthetics

• Purpose: diagnosis + therapy

• Renew if partial response

It is indicated when other treatments have failed.

• Sacral neuromodulation (S3)

  • This is the technique most frequently used when conservative treatments have failed.

  • It may have an effect on pudendal pain by influencing sacral neurological circuits (S2-S4).

  • Implantation of an electrode close to the sacral root (usually S3), with a test phase before the final implant.

• Neuromodulation of the pudendal nerve directly

  • More technically complex, but currently being evaluated in some centers.

  • Transforaminal or via the Alcock canal.

• Cryoneurolysis is an innovative neuromodulation technique involving the application of intense, controlled cold to temporarily interrupt conduction of the nerve fibers responsible for pain. Unlike surgery or radiofrequency, it does not permanently destroy the nerve, but rather puts it at rest by blocking painful impulses.

• Rare, reserved for resistant cases

• Approaches: transgluteal, transischiorectal, laparoscopic

• To be considered in an expert center, after a complete workup and a conclusive infiltration test

Manual therapies, and in particular osteopathy, play a central role in the overall management of pudendal neuralgia, particularly when the pain is linked to mechanical compression of the nerve along its path, postural imbalances, or myofascial dysfunction of the pelvis and perineum.

Osteopaths trained in pelviperineology can explore and treat pelvic mobility restrictions (sacroiliac, sacro-coccygeal, pubic), deep ligament tensions (sacrospinous, sacro-tuberous), scar adhesions (post-episiotomy, caesarean section, pelvic surgery), as well as pelvic floor muscle spasms, particularly of the obturator internus, elevator ani or piriformis muscles, often involved in impingement syndromes.

Work on the visceral system (uterus, rectum, bladder), thoracic diaphragm and overall postural chain also helps to reharmonize intra-abdominal pressures, restore deep-tissue mobility and reduce central sensitization phenomena.

Techniques are always non-invasive, progressive and adapted to the patient's tolerance, with the aim of providing lasting rather than immediate relief. In many cases, patients report a reduction in pain intensity and frequency, improved tolerance to sitting, and a reappropriation of their body, all of which help to break the vicious circle of chronic pain.

Osteopathy is ideally integrated into a multidisciplinary approach, complementing perineal re-education, drug treatments and postural adaptations. It can play a decisive role in non-surgical forms, or in pre- and post-operative support when nerve decompression is envisaged.

The prognosis depends on :

• Early diagnosis

• The origin of compression

• Comprehensive and specialized care

Pain that is neglected becomes chronic and has major repercussions: social isolation, depression, sleep disturbances, alteration of intimate and professional life.

Hence the importance of multidisciplinary support: pain doctor, physiotherapist, osteopath, psychologist, sex therapist...

Pudendal neuralgia is a complex pathology, still little known, but whose management has improved considerably in recent years. It requires attentive listening, accurate diagnosis and a comprehensive, patient-centred therapeutic approach.

When practised by a professional trained in pelvic-perineal disorders, osteopathy offers invaluable tools to help patients achieve lasting well-being. By working on the mechanical, postural and tissue causes of pain, osteopathy plays a key role in freeing the pudendal nerve and restoring balance to the body and its functions.

Because there is no single solution, but rather a personalized path to recovery, it is essential not to be left alone in the face of pain. A multidisciplinary approach, integrating osteopathy, rehabilitation, medical care and psychological support, can often transform an impasse into an effective and hopeful course of treatment.