PUDENDAL NEURALGIA (AKA THE MOST IMPORTANT CAUSE OF PELVIC PAIN THAT YOU HAVE NEVER HEARD OF)

I learn a lot from my patients. Sometimes, more than I would like to admit.

Yes, we doctors may disparage our patients who consult Dr. Google before seeing us and there is a lot of misinformation out there. But sometimes we are reminded that most of our medical education happens long after medical school or even residency.

Five years ago, I had a 30-something patient who presented with intense vulvar pain. She explained to me that she had rough (consensual) sex a month prior and ever since then, she had a burning sensation. She had done her research online and concluded that this might be Pudendal Neuralgia. I nodded knowlingly, implying that of course I had heard of this, being a board-certified gynecologist. While I left the room to have her undress, I quickly ran to my laptop to google “What the heck is Pudendal Neuralgia?”

Her exam confirmed that pressure on her pudendal nerve reproduced her pain, I gave her a prescription for Amitryptiline and had her follow-up with me a month later. Had I been more experienced with this disorder, I would have also referred her for Pelvic Floor therapy. Fortunately, the medication worked and her symptoms slowly resolved.

What is Pudendal Neuralgia (PN)? PN is a nerve pain caused by damage, inflammation or entrapment of the Pudendal Nerve. In women, this supplies innervation to the vulva, perineum and lower buttocks. It travels through a small space deep in the pelvis called “Alcock’s Canal,” named after Dr. Benjamin Alcock, an Irish anatomist in the early 1800s who dissected a lot of pelvises.

Quick anatomy lesson: the vulva is outside of the vagina and includes both the labia minora (thin flappy inner lips) and the labia majora (soft pads on the outside of the thin flappy lips). It also includes the perineum, which an old friend described as the “taint,” as in “taint the vagina and taint the anus.” End of lesson.

In the aforementioned patient, she likely damaged her Pudendal Nerve during rough sex. Another common cause is bicycling–the pressure on the perineum can cause nerve damage. However, I have seen many women since that first patient who have no known precipitating factors. Like so many other undesireable medical conditions, it just sometimes happens.

Fast forward three years: a 40 year old woman was referred to me after going to Urgent Care and then seening two other gynecologists. She had been having months of itching near her clitoris and had self-diagnosed a yeast infection. The Urgent Care provider gave her a prescription medication for yeast, not really knowing what else it could be. The other gynecologists informed her that it wasn’t yeast, but that she must be allergic to something and to stop using scented detergents. When she finally saw me, she mentioned that it was an “itchy-burny pain” that was not relieved with scratching. Did it get worse if she was sitting for a long time? Yes! Long story long, I diagnosed Pudendal Neuralgia and referred her to Pelvic Floor therapy. She had almost immediate relief.

Pelvic nerves are a complex web and PN pain can mimic yeast infections or even bladder infections, causing a constant urge to urinate. Other associated symptoms include numbness, sharp stabbing pain, and pain with sex. As mentioned above, prolonged sitting and even tight clothing can make symptoms worse.

So why do more gynecologists not know about PN? It is because PN is more of a neurological issue disguised as a gynecologic problem. We gynecologists typically do not learn about this in residency, and it is by sheer luck (and a smart patient) that I learned about this. Since then, I have treated dozens of women with this disorder, most of whom have been misdiagnosed by other providers. Fortunately treatment is effective, but only if one knows the diagnosis.

By Cynthia McNally MD 5-27-2021