A pinched nerve causes pain in the bladder. How to treat the pudendal nerve? Exercises for pinched sciatic nerve: video

It is responsible for the innervation of the pelvic floor muscles, and when this bundle is pinched, people experience chronic pain in the pelvic area. This phenomenon usually occurs due to compressive neuropathy. It represents compression (pinched nerve). In men, this problem occurs 2-3 times more often than in women due to anatomical features.

Features of the anatomy of the pudendal nerve

The pudendal nerve tract begins significantly above the innervated zones, which is why doctors often call it the femoral-genital nerve. It passes through the muscles of the lower back and over the ureter, and then extends to the groin area. At this point it is divided into 2 branches:

The femoral-genital nerve, passing into the inguinal branch, has 2 options for continuation depending on the gender of the person:

Male. It exits through the canal along with the spermatic cord and follows into the scrotum;
Female. In the case of the weaker sex, the pudendal nerve leaves the canal along with the round ligament of the uterus and smoothly passes into the skin of the labia majora.

The inguinal nerve in women and men innervates the following tissues:

Muscle tissue of the anus;
The outer skin of the anus and genitals;
Anal sphincter;
Musculature of the perineum;
Female clitoris;
Male cavernous bodies of the penis;
Bladder sphincter.

The pudendal nerve pathway is responsible not only for the sensations experienced during intercourse, but also directly for defecation and urination.

It performs the last two functions thanks to the vegetative fibers in its composition. It is the autonomous (vegetative) part of the nervous system that is responsible for many systems that are not controlled by the human mind, for example, constriction of the pupils, heart rhythm, etc.

Damage to this nerve is caused by pinching of the piriformis muscle, ligaments, etc. Sometimes the cause of such compression lies in the resulting injury, as a result of which the pelvic bones were crushed or ligaments were torn. This type of neuralgia is usually accompanied by a feeling of tension and inflammation.

Causes of inflammation

Traction-compression neuropathy of the left or right nerve pathway occurs in Alcock's canal. Therefore, a pinched pudendal nerve that occurred in this area is called Alcock's syndrome. Among other varieties of neuropathy characteristic of this nerve pathway, one can distinguish the femoral-genital form. It manifests itself mainly due to groin injury or the development of an inguinal hernia. Ilioinguinal nerve neuropathy also falls into this group. It occurs due to the appearance of scars on the muscle tissue, which are the result of surgical intervention.

Infringement of the pudendal nerve occurs mainly due to the following factors:

Trauma sustained during childbirth;
Spasm of the muscle tissue of the anus;
pelvic fracture;
Development of malignant oncological diseases;
High tone of the piriformis muscle;
Complications of herpes;
Spasm of the obturator internus muscle;
Compression of the pudenda due to riding a horse or bicycle.

Symptoms

Compressive neuropathy of the pudendal nerve has many symptoms, but their severity is rather weak. For this reason, it is extremely difficult to diagnose pathology. Among the main manifestations of the disease are the following:

Aching pain in the pelvic area;
Genital dysfunction;
Constant feeling of discomfort in the anal area;
Involuntary urination;
False sensation of a foreign object in the groin area;
Feeling of burning and slight tingling in the groin area;
Excessively high sensitivity of the skin in the groin area.

In the female, severe itching and burning in the genital area can be added to the main symptoms of neuropathy. In a sitting position, these symptoms intensify significantly.

In more rare cases, the following symptoms are observed:

Abnormal bowel movements (constipation);
Numbness of the genitals;
Pain during sexual intercourse and when urinating.

Diagnostics

The doctor identifies the presence of a problem, focusing on the symptoms that appear and the results of an ultrasound scan. With neuropathy, it will indicate impaired blood flow in the pudendal artery, which goes through the Alcock canal. From this we can conclude that with it there was a compression of the pudendal nerve pathway.

An effective diagnostic method is blockade of the pudendal nerve tract. If the discomfort disappears, then all the blame lies with neuropathy. Typically, in such a situation, a course of therapy is prescribed, which includes glucocorticoid injections, vaginal suppositories and other methods of restoring pinched nerve fibers.

Course of therapy

Treatment of neuropathy should consist of a set of measures aimed at eliminating inflammation, relieving pain and restoring nerve conduction. Typically it includes the following treatment methods:

Elimination of pain with the help of anticonvulsants (Gebapentin);
The use of physiotherapeutic procedures (phonopharesis, electropheresis, etc.);
Blocking the nerve pathway with a solution of hormones and anesthetics;
Use of muscle relaxants (Mydocalm);
The use of vitamin complexes (Neuromultivit).

Neuromultivit vitamins and their analogues can be taken both as a component of a blockade solution and in the form of tablets. If the discomfort is severe, then suppositories for rectal or vaginal use based on Diazepam and special sets of exercises are used. The essence of physical therapy for neuropathy of the pudendal nerve is to compress and relax the muscles of the perineum.

If there is no point in continuing to treat medically damaged nerve tissue due to lack of results, then surgery will be required to decompress the compressed nerve. Such operations are extremely effective, but have a long recovery period.

With prolonged absence of treatment, the consequences of the pathology may develop. The disease can become chronic and some symptoms will be extremely difficult to eliminate. There have been cases of impotence and decreased libido, as well as increased involuntary urination and defecation.

Pudendal neuropathy is an unpleasant condition, but some people live with it for years. This is usually associated with vague symptoms and a chronic course. You can avoid such discomfort, but to do this you will have to undergo an examination and follow all the doctor’s recommendations.

The information on the site is provided solely for popular informational purposes, does not claim to be reference or medical accuracy, and is not a guide to action. Do not self-medicate. Consult your healthcare provider.

Possible pinching of the pudendal nerve. How to treat a pinched nerve?

Good afternoon! I am a man, 44 years old. I have the following problem: for the last 15 years I have had sudden sharp shootings from the groin to the stomach, for a few seconds, about once a month. And they immediately went away.

I worked all this time at hard physical work associated with lifting weights. Then I moved on to a much more physically easy job. 2.5 years ago I had a repair, I carried heavy things alone.

The loads were very heavy. After the repair was completed, I suddenly had a problem - difficulty urinating and defecating. I went to the urologist.

After the examination, he said that I had an exacerbation of chronic prostatitis and wrote out the appropriate course of treatment. At the same time, I suddenly had pain in my anus, right in the center. Pain appears after lifting weights and after defecation, especially when it passes with attempts.

Also, shootings became more frequent when getting up from a sitting position, from the groin to the lower abdomen. In a sitting position, there was often a feeling that you were sitting on a tubercle. Consistently passed: treatment by the same urologist, in the end, he stated that my prostatitis went into remission, a thorough examination by a proctologist and a gastroenterologist, with the delivery of all conceivable tests and examinations

None of them found any pathology in their part, especially that could cause such symptoms. Those. doctors completely ruled out urology, proctology and gastroenterology. And only when he did an MRI of the lumbosacral region, did at least some new “hook” appear - osteochondrosis of the spine, disc herniation L2-3 (6 mm), protrusion of the disc L5-L6 ( 4 mm), S1 lumbaization. I did an electroneuromyography, which says that no pathological changes in the sciatic nerve were detected.

From the treatment: I received medication from my local neurologist. There was no effect. I went to exercise therapy, massage and magnetic therapy. There was no effect. Only milgamma injections helped, but only for one day. And only when I began to do exercise therapy for the lumbosacral spine every day at home, exercising for PIR of the piriformis muscle (which, as I know, also unload the spine) and underwent 10 sessions with a chiropractor, then the pain in the anus has decreased and reminds itself less often and not so strongly.

Simultaneously with pain relief, after these exercises. My stool, urination, erection and libido are improving. But still the pain does not go away completely, although more than 2 years have passed. It is localized in the anus, as if inside. Defecation, basically, goes away with pushing and irregularly. My exercises for the pyriformis help almost immediately, but for about half a day. In the evening I have to do them again.

I wanted to ask: what do you think I have? The chiropractor suggested that my hernia or protrusion pinched some nerve, perhaps the pudendal (genital). I looked on the Internet, according to descriptions of pinched pudendal nerve - this is very similar to my case, almost one to one.

The chiropractor told me to come to him again in half a year, but I couldn’t and now I regret it. I wanted to ask: do my symptoms look like pinched nerve (neuropathy) of the pudendal nerve and if so, how and where to treat it?

The problem is really related to damage to the lumbosacral spine, so I recommend that you undergo periodic courses of manual therapy as prescribed by your doctor until you achieve a more stable remission.

There may be several such courses. The disease is chronic, so it may take time to achieve lasting results. Sincerely, osteopathic chiropractor Evdokimov A.A.

Ask a question to osteopathic doctor Evdokimov A.A.

Possible contraindications. Consult your doctor.

Pinched pudendal nerve in men and women

The “pudendal” or pudendal nerve (n. Pudendus) is very often the cause of chronic pelvic pain that occurs in adults. The most common cause of this is compression neuropathy. Moreover, “pinching” of the pudendal nerve is three times less common in men than in women.

A little anatomy

The pudendal nerve is small in length, but a very important nerve of the latter, if you go from the brain, the sacral plexus. It lies in the pelvic cavity, along the way it goes around the ischium. It further divides into three branches - the rectal, perineal and dorsal nerve of the penis (clitoris). Its functions are varied:

it innervates the levator ani muscle;

innervates the anal sphincter;

sphincter

gives branches to the muscles of the perineum;

innervates the genital organs: cavernous bodies of the penis in men, clitoris in women;

gives sensitivity to the skin of the external genitalia and anus;

innervates the sphincter of the urethra.

As you can see, this nerve plays a big role not only in a person’s intimate life, but also in urination and defecation. The pudendal nerve contains a large number of autonomic fibers, which ensure the “unconscious work” of the sphincters. After all, a person never thinks, does not control and consciously compresses the muscles so as not to accidentally defecate or urinate in broad daylight. This is done by autonomic nerve fibers that enter the lumen of the pudendal nerve.

The pudendal nerve in the male body (in yellow)

This nerve can be pinched by the piriformis muscle, which is located in the pelvic cavity, or be sandwiched between two ligaments.

In addition, the nerve can be damaged, for example, due to a car accident, a fall from a great height, in which the pelvic bones are fractured. A fairly common cause of chronic pelvic pain is nerve damage during childbirth, as well as the involvement of the nerve trunk in the growth of a malignant neoplasm.

In addition, activities such as riding a horse or cycling can also lead to pudendal compression neuropathy over time.

Symptoms of pudendal neuropathy

As with any neuropathic lesions, all symptoms are made up of pain, sensory disturbances, autonomic disorders and muscle weakness. A pinched pudendal nerve is manifested by the following symptoms:

painful sensations in the perineum;

discomfort in the anus and genitals;

burning tinge of pain;

decreased skin sensitivity in these areas, “crawling goosebumps”;

an unpleasant feeling of a foreign body in the urethra and anus;

fecal and urinary incontinence. It may be incomplete, and manifest as fecal smearing or drip incontinence;

sexual disorders: impotence, anorgasmia.

Pinched pudendal nerve in women causes the above symptoms also in the lower third of the vagina.

Pinched pudendal nerve in men, in addition to the above, can cause pain during intercourse.

The very nature of the pain becomes burning, touching the skin becomes excruciatingly unpleasant. There are sensations of electric shocks, a sensation of either a hot or cold foreign body, problems with urination and defecation, and other various and unpleasant symptoms.

About diagnosing neuropathy

With such unpleasant and painful sensations, a person is not inclined to endure for a long time, as, for example, with pain in an arm or leg. Therefore, most often he turns to a neurologist, or a proctologist, in the event that violations of the anal sphincter are expressed and there are problems with the retention of urine and feces.

Less often, a patient turns to a sexopathologist, but a competent specialist should, with the help of an elementary question, identify organic disorders and refer the patient to a specialist. Neuropathy of the pudendal nerve is diagnosed on the basis of the following complaints and studies;

patient complaints, which were discussed in detail above;

the nature of the pain, which indicates neuropathic changes (burning, crawling, all kinds of itching, unpleasantness when touched);

a trial therapeutic and diagnostic novocaine blockade of this nerve reliably reduces the severity of symptoms, or completely relieves the patient of suffering for the period of action of novocaine - from 12 hours to 3 days;

When performing an ultrasound of the perineum and pelvis with Doppler ultrasound, almost always with compression-ischemic neuropathy of the pudendal nerve, a decrease in the volumetric velocity of blood flow in the nearby pudendal artery is observed. This happens “for company”: the pudendal artery passes along with the nerve in the same canals, and its narrowing indirectly confirms the compression of the pudendal nerve;

An important diagnostic criterion is that the pain increases if the person sits, and the pain decreases if the person lies on his back. Also, neuropathy of the pudendal nerve is characterized by unilateral damage. Disorders occur on the same side;

patients often note that if they apply cold to the perineum, it causes relief and burning pain decreases. This symptom indicates the neuropathic nature of the nerve damage.

In addition to these diagnostic criteria, it is possible to palpate the perineum to identify characteristic pain points that reflect spasm in the piriformis muscle.

It is important that the pathology of this nerve has a deep connection with the progression of myofascial syndrome. This syndrome is more difficult to treat because the muscles are deeply located.

In addition, pudendal neuropathy worsens depression, anxiety, and makes people more susceptible to negative events.

Treatment of neuropathy

As in all other cases, therapy for this disease must be comprehensive. The basic principles of treatment are as follows:

impact on the neuropathic nature of pain with the help of gabapentin (Tebantin, Lyrica);

conducting regular nerve blocks with anesthetics and hormones;

physiotherapeutic effects: phonophoresis, Amplipulse therapy, electrophoresis;

centrally acting muscle relaxants (Mydocalm). Allows you to relax muscles, including reducing the tone of the piriformis muscle;

B vitamins included in the blockade, as well as tablet forms.

Sometimes treatment requires the support of a psychologist, correctional therapy is performed, and antidepressants are prescribed. Sometimes it is necessary to prescribe rectal or vaginal suppositories with diazepam, as well as perform special exercises. Their meaning is gradual relaxation - compression of the muscles of the perineum.

You should find out what exercises you need to do when the pudendal nerve is pinched

If conservative treatment is ineffective, then decompressive surgical operations are performed, which are performed in centers for the treatment of chronic pelvic pain.

It should be remembered that treatment of pudendal nerve neuropathy is a long process, and you need to follow all the instructions of specialists for at least 6 months.

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This site contains information about such a complex and fairly common disease as neuralgia. All articles on the site were written by qualified and active neurologists - those who deal with this disease every day in their practice.

Pinched and neuropathy of the pudendal nerve in women and men

Does the pudendal (genital) nerve and its damage differ from similar pathologies in other “regions” of the body?

Yes, the nature of the pathology is different in that the pudendal nerve serves the pudendal area - the genital area, the structure of which is different in men and women. The words of one very concentrated boy from the film “Kindergarten Policeman” immediately come to mind, with which he stopped everyone entering the door of the kindergarten: boys have a penis, girls have a vagina.

In men, the concept of external genitalia includes much more structures in terms of number, volume, and area, therefore the pudendal nerve has a more complex and branched structure, while in women, due to the greater “compactness” of the external genitalia, its length is much shorter.

The pudendal nerve is a paired structure formed on both sides of the body also by the paired branches of the sacral spinal nerves, which provides innervation to organs present in both sexes: the perineum, sphincters of the bladder and rectum, as well as the levator ani muscle, but then they begin differences in structure: in women it provides sensitivity and vegetative function of the labia majora and minora and the clitoris, in men it provides the same functions in relation to the cavernous bodies of the penis and scrotum.

In the photo, the same painful area in women is highlighted in yellow.

About the causes and symptoms of functional disorders

For the etiology of damage, the proximity to the ischium, which the nerve goes around entering the pelvic cavity, as well as the relatively shallow depth of the terminal branches under the surface of the skin and mucous membranes of the pelvic organs, are important. Therefore, dysfunction can occur as a result of:

injuries to the perineal area;

Perineal trauma can lead to more serious consequences

Provoking factors may be:

horse riding or cycling (frequently or professionally);
prolonged labor;
fracture of the pelvic bones (from a fall from a height, in a car or plane accident).

To understand that something is wrong with the genitofemoral nerve is made possible by dysfunctions of the organs located in the pelvis. These may be sensitivity disorders or autonomic disorders.

Deviations in the vegetative system are expressed by violations of the functioning of the glands and other structures containing smooth muscle fibers, in particular, disorders of the mechanism of blood filling of the cavernous bodies of the penis or clitoris.

Trophic disorders of the skin of the perineum, scrotum and perianal zone can also be a sign of disorders.

In addition to physical factors of influence, general somatic diseases can also be the cause of the pathology:

tuberculosis;
collagenoses;
circulatory disorders due to endocrine disorders and vascular accidents or for another reason.

Infringement of rights, or neuralgia

It has long been observed that the disenfranchised either yell loudly about this fact or grumble about it in an undertone until no one hears.

Provoking factors

The situation is exactly the same if the pudendal nerve is pinched in the enclosing canal. A channel with a narrowed diameter for some reason (due to bone growths, bone fractures, or for another reason) puts pressure on the nerve, which leads to predominantly pain sensations of varying intensity.

Compression of the nerve can be caused by its “swelling”, accompanied by an increase in diameter, which causes its discrepancy with the diameter of the enclosing canal.

But the structure of the affected pudendal nerve does not change during neuralgia. Movement disorders do not occur in the same way as loss of sensitivity.

Therefore, neuralgia is exclusively pain of varying nature and intensity.

And pinching of the pudendal nerve can occur in the inguinal canal:

with varicose veins of the spermatic cord in men;
due to pathology of the round ligament of the uterus in women;
due to an inguinal hernia or the occurrence of cicatricial changes after hernia repair.

Pelvic neuralgia, which often accompanies pinched pudendal nerve, can also occur due to:

trauma during childbirth;
muscle spasm in the area of the anus, hypertonicity of the piriformis muscle or obturator internus muscle;
development of oncopathology in the pelvic organs;
the onset of complications of herpes.

Features of symptoms

The symptomatology of this form of neuralgia is chronic pain in the pelvic region, which has the character:

aching;
feelings of burning and itching, especially strong in women and especially in a sitting position;
excessively high sensitivity of the skin of the groin and perineum area;
sensations of constant discomfort in the area of natural orifices of the body;
false-obsessive sensation of a foreign body in the genital area.

Against the background of chronic stress from long-term sensations, the following may appear:

urination disorders (involuntary act) or pain when urinating;
dysfunction of the genital organs (pain during coitus);
bowel disorders (constipation).

Diagnostic criteria and treatment

For diagnosis, symptoms are important - the sensations of the patient, as well as the absence of external manifestations of pathology.

The use of:

In the first case, a violation of blood flow through the genital artery is detected, in the second case, the disappearance of discomfort after manipulation.

In treatment, the main goals are: pain relief, elimination of inflammation and restoration of nerve conduction.

Therefore, it is advisable to use:

anticonvulsants (Gabapentin), providing pain relief;
muscle relaxants (Mydocalm), used to relax muscles;
blockade of the pudendal nerve with a combination of solutions of anesthetics and hormones;
vitamin complexes (Neuromultivita class);
physiotherapeutic techniques (electro-, phonophoresis and the like).

To reduce the symptoms of discomfort, vaginal or rectal suppositories with Diazepam and exercise therapy techniques are used (for massaging the muscles of the perineum).

With the ineffectiveness of therapeutic methods, surgical decompression is used, which relieves infringement and symptoms.

Surgical decompression is sometimes the only option

Since there is no limit to indignation, or about neuropathy

In addition to neuralgia, the genital nerve can also become the scene of an inflammatory process, then they talk about neuropathy (neuropathy), or pudendal neuritis (a term rarely used today).

Neuropathy differs from neuralgia by the presence of structural changes in the pudendal nerve, as well as motor disorders and the possibility of loss of sensitivity, which causes indignation and grief of the patient, because we are talking about neither more nor less about the genitals.

What could be the reason?

The cause of the pathology (also called pudendoneuropathy) is the implementation of two mechanisms:

compression-squeezing of the nerve trunk in the “scissors” of the sacrospinous ligament-piriformis muscle;
traction due to overstretching of the nerve in the zone of its transfer over the ischial spine.

The first is illustrated by the consequences of long-term or unsuccessful horse riding or cycling (compression by a hard saddle), and the second by the consequences of surgical intervention - for example, when traction of the hip with the use of a perineal fixator, tension occurs on the nerve pressed to the pubic region.

Features of symptoms

The clinic may consist of lesions of the main nerve trunk or signs of involvement of various branches of the pudendal nerve.

When a surgical fixation is used in the perineal area, isolated damage to the dorsal nerve of the penis occurs with anesthesia of the penis and complete disruption of the previously normal erection.

Full restoration of sensitivity can occur within 6 to 18 months after surgery, but restoration of erection can be only partial.

When compressed by a hard saddle, the disorder is felt as transient numbness or the appearance of paresthesia in the genital area.

Both unilateral and bilateral loss of sensitivity may be observed, not limited to the penile area, but continuing to manifest itself also in the scrotum area.

Neuropathies of the pudendal nerve can signal themselves by pain in the lower buttock and in the anus, short-term urinary retention or a disorder of the imperatives to urinate, accompanied by sharp pain when palpated in the projection of the ischium.

In men, an inflamed pudendal nerve manifests itself with characteristic symptoms - paresthesia or hypoesthesia and pain in the peri-anal area, in the area of the penis and scrotum.

Diagnosis and treatment methods

The main diagnostic criterion is that the pull of the knee towards the opposite shoulder causes pain in the buttock (due to stretching of the sacrospinous ligament).

A simple diagnostic method is to pull the knee towards the shoulder

The clinic is confirmed by electromyography, noting the lengthening of the anal reflex, which closes on the pudendal nerve trunk, as well as a test blockade with the introduction of a novocaine solution into the area of the ischial spine.

The choice of treatment method depends on whether the process is advanced or in an acute stage.

Thus, all the symptoms disappeared in a group of cyclists on their own, after they agreed to refrain from cycling for a month. In case of chronic neuropathy, long-term restorative therapy is necessary.

In chronic cases, methods of drug therapy in combination with rational exercise therapy and physiotherapy are applicable.

Drug therapy includes the use of anti-inflammatory drugs (glucocorticoids Prednisolone, Triamcinolone, Hydrocortisone) in combination with anesthetics (Novocaine 0.5 or 1%) in the form of blockades. A case of relief of pain that had been observed for 14 years after a course of perineural administration of Triamcinolone is described.

Blockade is an effective method, the injection point is indicated with a finger

Pure novocaine blockades are usually less effective.

In order to relieve pain, suppositories of a combined formulation with anesthetics, sedatives and antispastic compounds, both rectal and vaginal, are used.

Vitamin therapy (administration of vitamin C and group B in adequate doses) is especially effective in combination with physiotherapy techniques (various methods of heat therapy), while exercise therapy allows you to increase the capabilities of muscles spasmed by pain and helps to increase the overall tone of the body.

Surgical intervention is applicable if there is no effect from treatment with therapeutic methods.

You should be extremely careful in the case of neuropathy of oncogenic etiology.

Preventive measures

When riding a bicycle or horse professionally, you should take precautions and follow a routine with mandatory breaks.

Implementing traction for a hip fracture requires the use of a perineal fixator with an adequate support area (up to 9 cm) with a mandatory softening pad.

Intramuscular injections of Magnesium sulfate solution in large doses require caution to prevent the occurrence of ischemic necrosis of the gluteal muscles.

If painful sensations in the pelvis, perineum and genitals appear, and even more so if they increase, you must immediately seek help from a neurologist.

This section was created to take care of those who need a qualified specialist, without disturbing the usual rhythm of their own lives.

Incontinence due to damage to the pudendal nerve

The pudendal nerve is responsible for sensation in the external genitalia, lower rectum, and perineum. The perineum is the space between the genitals and the anus. Neuropathy occurs due to disease or damage to the nerves, and pudendal neuropathy can cause symptoms in these areas.

Pudendal nerve entrapment is often misdiagnosed as a prostate disease, such as prostatodynia or nonbacterial prostatitis. Unknown causes of vaginal pain, ovarian pain, rectal pain, penile pain, tailbone pain and buttock pain can occur as a result of pudendal nerve neuropathy. About 2/3 of patients with pudendal nerve entrapment are women.

Pudendal nerve entrapment can occur suddenly or develop over time. Prolonged sitting, cycling. Repetitive movements and leg exercises can lead to pinching of the pudendal nerve.

Some people have primarily rectal pain, sometimes with problems with bowel movements. For others, pain predominates in the perineum or genitals. Symptoms may include stabbing, cramping or burning pain, tingling, numbness or sensitivity. Symptoms are usually worse when sitting and better when standing or lying down. There may be a feeling that the person is sitting on a bump.

Damage to the pudendal nerve is identical to Carpal Tunnel syndrome, which is also a form of nerve entrapment. However, damage to the pudendal nerve is much more difficult to treat due to its location.

Pudendal nerve entrapment is a condition that causes pain without any apparent cause in the area innervated by the pudendal nerve. There is no dominant pain pattern. The pain can be localized in one area, several, or all. It can be one-sided, two-sided or in the middle. Problems in the urinary, rectal and reproductive systems are also common.

Pudendal neuropathy is often caused by inflammatory injury or chronic mechanical compression of the pudendal nerve.

Damage to the pudendal nerve can occur suddenly as a result of trauma, such as pelvic surgery, falls, bicycle accidents or childbirth, and sometimes severe constipation. It can also occur from repeated trauma over a long period of time, such as cycling, or aggressive lifting of heavy objects that strains the pelvic muscles. It can also be caused by diseases such as diabetes or multiple sclerosis. Trauma may directly stretch or compress the nerve, or fibrosis may impinge on the nerve.

Treatment for neuropathy of the pudendal nerve should be comprehensive.

The course of therapy is prescribed individually by the attending physician and includes:

taking special medications that affect neuropathic and chronic pain;
physiotherapeutic procedures (neuromodulation, acupuncture);
pudendal nerve blockade - droppers using anesthetics and glucocorticoids;
massage;
physical therapy

Massage, IVs and blockades are the most effective ways to relieve pain. They significantly improve treatment results. Physiotherapeutic procedures will help restore impaired nerve function. Also, for this purpose, a specialist can prescribe appropriate exercises to strengthen the pelvic floor muscles. The duration of treatment is at least 6 months.

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Damage to the pudendal (genital) nerve often causes chronic pain in adults, localized in the pelvic area. In men, this pathology occurs three times less often than in women. The anatomy of the pudendal nerve can explain this phenomenon.

Structural features

The described element is small in size. The pudendal nerve originates from the sacral plexus, exits through the subpiri-shaped foramen, along with the internal pudendal artery, goes around the sciatic spine behind and through the small sciatic foramen enters the ischiorectal fossa. There it lies on the surface of the obturator muscle and passes through the Alcock canal (it is formed by the split fascia of the obturator internus muscle). Then diverge into three branches:

rectal;
perineal;
dorsal

They innervate the muscle that lifts and holds the anus, the anal sphincter, the urethral sphincter, the muscles of the perineum, the genitals - the cavernous bodies of the penis in men and the clitoris in women. The branches provide sensitivity to the skin of the external genitalia and anus. Any damage to the nerve can provoke disruption of sexual life, bowel movements and bladder processes.

The main causes of pinched pudendal nerve in men and women

The main etiological factor that can provoke sexual neuropathy is pinching of the pudendal nerve. It can happen due to the formation of a hernia or injuries to the groin area received in an accident, while carelessly riding a bicycle or riding a horse. This phenomenon can be caused by:

repetitive movements and intense exercises performed with the legs;
pelvic bone fractures;
hypertonicity of the piriformis muscle;
tension in the obturator internus muscle;
growth of malignant tumors in the pelvic area;
spasm of the muscles located in the anus.

Pinching can occur as a complication of the development of herpes infection. This version is supported by the fact that treatment with acyclovir gives persistent positive results. In women, pinching of the pudendal nerve occurs during a protracted, difficult labor.

Clinical manifestations

Symptoms of pinched genitofemoral nerve in men and women are vague and unexpressed, so the manifestations of the disease are often mistaken for other pathologies. Patient complaints:

the appearance of mild aching pain in the genital area, anus or perineum: localized mainly on one side, intensifies in a sitting position, does not disturb sleep and does not cause the patient to wake up at night;
burning and tingling in the groin;
a feeling of the presence of a foreign body in the anus or in the urethra - in women, such manifestations can form in the vagina;
dysfunction of the genital organs;
hypersensitivity of the skin in the pubic area.

In the fairer sex, with a pinched nerve, itching and burning in the clitoris may appear. Such manifestations intensify in a sitting position. Men are bothered by a feeling of numbness in the penis and scrotum. Patients of both sexes often have problems with defecation, urinary incontinence, and sharp shooting pain occurs during sexual intercourse. In everyday life, a person may feel as if he is sitting on a tubercle.

Diagnostics

If you have these symptoms, you should consult a neurologist. Identification of the disease begins with a thorough history taking. The presence of a triad in the system of complaints - pain, burning and sensory disturbances - makes it possible to make a preliminary diagnosis and determine the range of additional studies.

An ultrasound Doppler scan is required, which helps to identify a slowdown in the speed of blood flow in the pudendal artery. The presence of such a pathology indirectly indicates a possible pinching of the vessel, and therefore the nerve located along its course.

During the examination, the branches of the pudendal trunk are blocked. If it helps to completely relieve pain, the diagnosis is confirmed.

Therapy methods

Treatment of genitofemoral nerve neuropathy in women and men begins with drug therapy. Patients are prescribed:

regular blockades with injections of glucocorticoids with local anesthetics;
enhancement of neuromuscular transmission by antiepileptic rectal drugs that contain diazepam;
decreased tone of the piriformis muscle with muscle relaxants;
nutrition of nervous tissue with vitamins B and C: they can be taken separately in the form of tablets or used as a component of a solution for blockade;
physiological effects to restore impaired functions: phonophoresis, electrophoresis.

Experts have found that the development of neuropathy contributes to increased anxiety, and in especially severe cases it becomes the cause of deep depression. In such cases, correctional therapy is used, antidepressants are prescribed, and work is carried out with a psychologist. Many people are helped by physical exercises, the meaning of which is to gradually compress and relax the muscles of the perineum. Full recovery takes time. The indicated course is long - stretches for six months.

If conservative therapy does not cure the neuropathy, surgery is prescribed to eliminate the cause of the pinched pudendal nerve. Radical measures are always effective, but any surgical intervention has a long recovery period.

Ignoring the problem can lead to unwanted complications. The disease can become chronic, in which case it will be extremely difficult to eliminate the main symptoms with medication.

Clinical practice knows of cases where patients with the described diagnosis became impotent and completely lost control over bowel movements and urination.

Preventive measures

Pinched pudendal nerve is a recurrent disease. If the patient does not follow certain rules after completing the therapeutic course, a re-exacerbation is possible. It is characterized by increased symptoms, which are difficult to treat with medication. You can avoid relapse by strictly following the following recommendations:

It is necessary to protect the groin area from injuries, direct blows, and prolonged exposure to cold.
Professional equestrians and cyclists should take frequent breaks from exercise.
In case of a hip fracture, traction should be carried out using a perineal fixator, the support area of which is no more than 9 cm (a softening pad should be placed under it).
If you plan to intramuscularly administer a solution of magnesium sulfate, this must be done extremely carefully to prevent the formation of ischemic necrosis of the gluteal muscles.

If the triad characteristic of a pinched pudendal nerve reappears, it is important to immediately seek medical help.

Pathology develops in both men and women of different ages. Despite the prevalence of this problem, neuropathy is diagnosed extremely rarely. This is due to the fact that only a small percentage of patients pay attention to the symptoms of the disease and seek medical help.

Genital neuropathy can affect various nerve fibers surrounding the genital organs (genital femoral, ilioinguinal nerve).

Causes of the disease

The main etiological factor provoking pudendal neuropathy is pinching of the pudendal nerve, which occurs in the Alcock canal. Due to the affected area, the disease is also called “Alcock canal syndrome.”

This type of pathology, such as femoral genital neuropathy, progresses due to injury to the groin area or the formation of a hernia. Damage to the ilioinguinal nerve is the result of the formation of muscle scars that appear after surgery or injury.

Pudendal nerve neuropathy also develops for the following reasons:

labor (obstetric neuropathy);
hypertonicity of the piriformis muscle;
spasm of the anus muscle;
tension in the obturator internus muscle;
fracture of the pelvic bones;
malignant formations in the pelvic cavity;
herpes virus;
nerve damage caused by horse riding or cycling.

Main symptoms

Pudendal neuropathy manifests itself with multiple but mild symptoms. It is precisely because the symptoms are vague that this disease is difficult to diagnose. Patients have complaints about the following phenomena:

aching pain in the perineum, anus and genitals;
burning and tingling in the groin;
discomfort in the anus;
sensation of the presence of a foreign body in the rectum, urethra or vagina (in women);
dysfunction of the genital organs;
urinary incontinence;
hypersensitivity of the skin in the pubic area.

In women, the development of pathology is accompanied by itching and burning in the clitoris, labia, and vagina. The discomfort becomes more intense when sitting.

Often patients are bothered by a feeling of numbness in the genitals, problems with bowel movements (constipation), discomfort when urinating, pain during sexual intercourse.

Diagnosis and treatment

When patients complain of symptoms of pudendal nerve neuropathy, the specialist makes a diagnosis based on a compiled medical history containing signs characteristic of the disease (pain, burning, sensory disturbance). Patients are also prescribed an ultrasound Doppler scan, during which a slowdown in the speed of blood flow in the pudendal artery can be detected, indicating possible pinching of this vessel. And since this artery passes together with the pudendal nerve through the Alcock canal, we can conclude that the cause of the disorder is compression processes. The method of diagnosing the disease is the blockade of the pudendal nerve. If after its implementation the pain syndrome weakens, then this indicates the development of neuropathy.

Treatment of pathology is based on the use of the following medications:

Pregabalin;
vaginal suppositories with diazepam;
injections of glucocorticoids with local anesthetics.

If the pinched nerve is quite complex and does not respond to pharmacological therapy, then patients may be prescribed surgical treatment.

All about stress and depression

Injury to the pudendal or genitofemoral nerve

There are many nerve pathways in the human body, each of which innervates a specific area. Among them, one can single out the pudendal nerve, which in medicine is called the genital. It is responsible for the innervation of the pelvic floor muscles, and when this bundle is pinched, people experience chronic pain in the pelvic area. This phenomenon usually occurs due to compressive neuropathy. It represents compression (pinched nerve). In men, this problem occurs 2-3 times more often than in women due to anatomical features.

Features of the anatomy of the pudendal nerve

The femoral-genital nerve, passing into the inguinal branch, has 2 options for continuation depending on the gender of the person:

Male. It exits through the canal along with the spermatic cord and follows into the scrotum;
Female. In the case of the weaker sex, the pudendal nerve leaves the canal along with the round ligament of the uterus and smoothly passes into the skin of the labia majora.

The inguinal nerve in women and men innervates the following tissues:

Muscle tissue of the anus;
The outer skin of the anus and genitals;
Anal sphincter;
Musculature of the perineum;
Female clitoris;
Male cavernous bodies of the penis;
Bladder sphincter.

The pudendal nerve pathway is responsible not only for the sensations experienced during intercourse, but also directly for defecation and urination.

Causes of inflammation

Infringement of the pudendal nerve occurs mainly due to the following factors:

Trauma sustained during childbirth;
Spasm of the muscle tissue of the anus;
pelvic fracture;
Development of malignant oncological diseases;
High tone of the piriformis muscle;
Complications of herpes;
Spasm of the obturator internus muscle;
Compression of the pudenda due to riding a horse or bicycle.

Symptoms

Aching pain in the pelvic area;
Genital dysfunction;
Constant feeling of discomfort in the anal area;
Involuntary urination;
False sensation of a foreign object in the groin area;
Feeling of burning and slight tingling in the groin area;
Excessively high sensitivity of the skin in the groin area.

In the female, severe itching and burning in the genital area can be added to the main symptoms of neuropathy. In a sitting position, these symptoms intensify significantly.

In more rare cases, the following symptoms are observed:

Abnormal bowel movements (constipation);
Numbness of the genitals;
Pain during sexual intercourse and when urinating.

Diagnostics

Course of therapy

Treatment of neuropathy should consist of a set of measures aimed at eliminating inflammation, relieving pain and restoring nerve conduction. Typically it includes the following treatment methods:

Elimination of pain with the help of anticonvulsants (Gebapentin);
The use of physiotherapeutic procedures (phonopharesis, electropheresis, etc.);
Blocking the nerve pathway with a solution of hormones and anesthetics;
Use of muscle relaxants (Mydocalm);
The use of vitamin complexes (Neuromultivit).

Femorogenital nerve

The genitofemoral nerve is a nerve formed from the plexus of the upper lumbar spinal nerves. Its path runs along the anterior surface of the psoas major muscle, piercing its thickness. Passing behind the ureter, the nerve rushes to the inguinal canal. The femoral genital nerve branches deep into the muscle and forms two branches: the femoral branch and the inguinal branch.

The femoral branch is located at the external iliac vessels, located posterior and lateral to them. The branch stretches behind the iliac fascia, goes around it in front and goes already into the vascular lacuna. Here the femoral branch is located anterior and external to the femoral artery. It then passes through the fascia lata of the thigh, which is located in the subcutaneous opening and forms a network of branches in the skin of this area. A separate part of the nerve network penetrates under the inguinal ligament and, passing through the lata femoral fascia, divides again. The division into other branches occurs here in the skin of the femoral triangle. The path of the femoral branch can be considered completed in the form of reunification with the ilioinguinal nerve and with the anterior cutaneous branches of the femoral nerve.

The genital branch of the genital femoral nerve is located in the region of the psoas major muscle, on its anterior surface. The genital branch passes next to the femoral branch along an identical path, that is, in relation to the external iliac vessels - outward from them. Further, her path lies in the inguinal canal - to the superficial ring. In men, the genital branch comes out in union with the spermatic cord; in women, along with the round ligament of the uterus.

In the male body, the genital branch of the femoral-genital nerve innervates the skin of the scrotum and, branching, directs its network to the muscle that elevates the male testicle. Also, the branching nerve pathways go in the skin of the scrotum, the fleshy shell of the scrotum, and then to the middle upper parts of the thigh.

In the female body, the reproductive branch multiplies in the round ligament of the uterus, on the skin of the inguinal ring and in the area of the labia majora. Next, the genital branch fuses with the femoral branch.

Nerve diseases

A characteristic syndrome with damage to the genital femoral nerve: intense pain, aching and tingling in the area of the gluteal region and anogenital. Pain occurs on the inner and front surface of the thigh - on 1/3 of it.

The intensity of the pain increases when the patient walks, sits, and also suffers when performing bowel movements. During the diagnostic test, in which the patient tries to touch the opposite shoulder with his knee, severe pain occurs. As a rule, when the genitofemoral nerve is damaged, there is an absence of the cremasteric reflex, or a decrease in it. The disease can cause a slight disruption of the external sphincters of the pelvic organs. The prerequisites for the occurrence of neuropathy of the nerve is the impact on it in the area of \u200b\u200bthe bend through the ischial spine, or through the sacrospinous ligament. Another cause of neuropathy may be compression of the nerve by the piriformis muscle when it is tense.

The causes of damage to the genitofemoral nerve can be not only compression factors, which are also responsible for damage to the iliohypogastric nerve and ilioinguinal nerve. Also, the formation of the disease can be facilitated by compression on the femoral branch, which is located under the inguinal ligament in the vascular space, or compression of the genital branch in the inguinal canal. The disease can be acquired as a result of heavy physical work, after surgery in the groin area. Local adhesive-scarring processes can also provoke the disease.

Signs and symptoms of genital femoral nerve damage:

paresthesia and pain in the groin area
pain in the external genitalia
pain with abdominal tension and hip flexion-extension
pain in the testicle, with pain radiating to the upper part of the inner femoral surface when the patient stands
pain occurs when palpating the lower region of the Poupart ligament towards the outer side of the femoral artery
sensation of pain when palpating the inguinal ring area
clear Wasserman's sign
formation of hypoesthesia

Similar symptoms manifest themselves neuropathy of the ilioinguinal nerve and iliohypogastric nerve. In rare cases, neuropathy of the genitofemoral nerve contributes to the development of damage to the inguinal nerve. The reason is the close anatomical proximity of the nerves. The signs and culprits of damage to these nerves are identical, however, sensory dysfunctions are aggravated in the proximal and medial genital areas.

Consultation with a doctor is required!

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Pinched pudendal nerve in men and women

A little anatomy

it innervates the levator ani muscle;

innervates the anal sphincter;

sphincter

gives branches to the muscles of the perineum;

innervates the genital organs: cavernous bodies of the penis in men, clitoris in women;

gives sensitivity to the skin of the external genitalia and anus;

innervates the sphincter of the urethra.

The pudendal nerve in the male body (in yellow)

This nerve can be pinched by the piriformis muscle, which is located in the pelvic cavity, or be sandwiched between two ligaments.

In addition, activities such as riding a horse or cycling can also lead to pudendal compression neuropathy over time.

Symptoms of pudendal neuropathy

As with any neuropathic lesions, all symptoms are made up of pain, sensory disturbances, autonomic disorders and muscle weakness. A pinched pudendal nerve is manifested by the following symptoms:

painful sensations in the perineum;

discomfort in the anus and genitals;

burning tinge of pain;

decreased skin sensitivity in these areas, “crawling goosebumps”;

an unpleasant feeling of a foreign body in the urethra and anus;

fecal and urinary incontinence. It may be incomplete, and manifest as fecal smearing or drip incontinence;

sexual disorders: impotence, anorgasmia.

Pinched pudendal nerve in women causes the above symptoms also in the lower third of the vagina.

Pinched pudendal nerve in men, in addition to the above, can cause pain during intercourse.

About diagnosing neuropathy

patient complaints, which were discussed in detail above;

the nature of the pain, which indicates neuropathic changes (burning, crawling, all kinds of itching, unpleasantness when touched);

a trial therapeutic and diagnostic novocaine blockade of this nerve reliably reduces the severity of symptoms, or completely relieves the patient of suffering for the period of action of novocaine - from 12 hours to 3 days;

When performing an ultrasound of the perineum and pelvis with Doppler ultrasound, almost always with compression-ischemic neuropathy of the pudendal nerve, a decrease in the volumetric velocity of blood flow in the nearby pudendal artery is observed. This happens “for company”: the pudendal artery passes along with the nerve in the same canals, and its narrowing indirectly confirms the compression of the pudendal nerve;

An important diagnostic criterion is that the pain increases if the person sits, and the pain decreases if the person lies on his back. Also, neuropathy of the pudendal nerve is characterized by unilateral damage. Disorders occur on the same side;

patients often note that if they apply cold to the perineum, it causes relief and burning pain decreases. This symptom indicates the neuropathic nature of the nerve damage.

In addition to these diagnostic criteria, it is possible to palpate the perineum to identify characteristic pain points that reflect spasm in the piriformis muscle.

It is important that the pathology of this nerve has a deep connection with the progression of myofascial syndrome. This syndrome is more difficult to treat because the muscles are deeply located.

In addition, pudendal neuropathy worsens depression, anxiety, and makes people more susceptible to negative events.

Treatment of neuropathy

As in all other cases, therapy for this disease must be comprehensive. The basic principles of treatment are as follows:

impact on the neuropathic nature of pain with the help of gabapentin (Tebantin, Lyrica);

conducting regular nerve blocks with anesthetics and hormones;

physiotherapeutic effects: phonophoresis, Amplipulse therapy, electrophoresis;

centrally acting muscle relaxants (Mydocalm). Allows you to relax muscles, including reducing the tone of the piriformis muscle;

B vitamins included in the blockade, as well as tablet forms.

You should find out what exercises you need to do when the pudendal nerve is pinched

If conservative treatment is ineffective, then decompressive surgical operations are performed, which are performed in centers for the treatment of chronic pelvic pain.

It should be remembered that treatment of pudendal nerve neuropathy is a long process, and you need to follow all the instructions of specialists for at least 6 months.

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How to treat the pudendal nerve?

The pudendal nerve, which is called the genital, is the cause of chronic pain in the pelvic region. The disease occurs due to a pinched nerve. Despite the fact that this problem is common in men and women, neuropathy is diagnosed extremely rarely. If the pudendal nerve is pinched, only a specialist will prescribe treatment.

Causes of the disease

The main factor in the occurrence of this disease is the pinching of the pudendal nerve, which occurs in the Alcock canal. Pudendal nerve neuropathy occurs in the following cases:

All these reasons cause pain in the pelvic area.

Symptoms of pathology

Pudendal nerve neuropathy is characterized by many symptoms. Patients complain of the following:

Pain of a aching nature that occurs in the anus or genitals.

When a disease occurs, women feel itching and pain in the region of the labia, clitoris and vagina.

Diagnosis and treatment of pathology

When patients turn to a specialist with signs of infringement of the pudendal nerve, the diagnosis is established according to the characteristic features. Patients undergo Doppler ultrasound scanning. As a result, a slowdown in the speed of blood flow in the penile artery is determined.

"Gabapentin." The drug helps reduce pain.

If you experience discomfort caused by a pinched pudendal nerve, you must urgently seek help from a specialist.

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Incontinence due to damage to the pudendal nerve

Pudendal nerve entrapment can occur suddenly or develop over time. Prolonged sitting, cycling. Repetitive movements and leg exercises can lead to pinching of the pudendal nerve.

Pudendal neuropathy is often caused by inflammatory injury or chronic mechanical compression of the pudendal nerve.

Treatment for neuropathy of the pudendal nerve should be comprehensive.

The course of therapy is prescribed individually by the attending physician and includes:

taking special medications that affect neuropathic and chronic pain;
physiotherapeutic procedures (neuromodulation, acupuncture);
pudendal nerve blockade - droppers using anesthetics and glucocorticoids;
massage;
physical therapy

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Pinched and neuropathy of the pudendal nerve in women and men

Does the pudendal (genital) nerve and its damage differ from similar pathologies in other “regions” of the body?

In the photo, the same painful area in women is highlighted in yellow.

About the causes and symptoms of functional disorders

injuries to the perineal area;

Perineal trauma can lead to more serious consequences

Provoking factors may be:

horse riding or cycling (frequently or professionally);
prolonged labor;
fracture of the pelvic bones (from a fall from a height, in a car or plane accident).

To understand that something is wrong with the genitofemoral nerve is made possible by dysfunctions of the organs located in the pelvis. These may be sensitivity disorders or autonomic disorders.

Trophic disorders of the skin of the perineum, scrotum and perianal zone can also be a sign of disorders.

In addition to physical factors of influence, general somatic diseases can also be the cause of the pathology:

tuberculosis;
collagenoses;
circulatory disorders due to endocrine disorders and vascular accidents or for another reason.

Infringement of rights, or neuralgia

It has long been observed that the disenfranchised either yell loudly about this fact or grumble about it in an undertone until no one hears.

Provoking factors

Compression of the nerve can be caused by its “swelling”, accompanied by an increase in diameter, which causes its discrepancy with the diameter of the enclosing canal.

But the structure of the affected pudendal nerve does not change during neuralgia. Movement disorders do not occur in the same way as loss of sensitivity.

Therefore, neuralgia is exclusively pain of varying nature and intensity.

And pinching of the pudendal nerve can occur in the inguinal canal:

with varicose veins of the spermatic cord in men;
due to pathology of the round ligament of the uterus in women;
due to an inguinal hernia or the occurrence of cicatricial changes after hernia repair.

Pelvic neuralgia, which often accompanies pinched pudendal nerve, can also occur due to:

trauma during childbirth;
muscle spasm in the area of the anus, hypertonicity of the piriformis muscle or obturator internus muscle;
development of oncopathology in the pelvic organs;
the onset of complications of herpes.

Features of symptoms

The symptomatology of this form of neuralgia is chronic pain in the pelvic region, which has the character:

aching;
feelings of burning and itching, especially strong in women and especially in a sitting position;
excessively high sensitivity of the skin of the groin and perineum area;
sensations of constant discomfort in the area of natural orifices of the body;
false-obsessive sensation of a foreign body in the genital area.

Against the background of chronic stress from long-term sensations, the following may appear:

urination disorders (involuntary act) or pain when urinating;
dysfunction of the genital organs (pain during coitus);
bowel disorders (constipation).

Diagnostic criteria and treatment

For diagnosis, symptoms are important - the sensations of the patient, as well as the absence of external manifestations of pathology.

The use of:

In the first case, a violation of blood flow through the genital artery is detected, in the second case, the disappearance of discomfort after manipulation.

In treatment, the main goals are: pain relief, elimination of inflammation and restoration of nerve conduction.

Therefore, it is advisable to use:

anticonvulsants (Gabapentin), providing pain relief;
muscle relaxants (Mydocalm), used to relax muscles;
blockade of the pudendal nerve with a combination of solutions of anesthetics and hormones;
vitamin complexes (Neuromultivita class);
physiotherapeutic techniques (electro-, phonophoresis and the like).

To reduce the symptoms of discomfort, vaginal or rectal suppositories with Diazepam and exercise therapy techniques are used (for massaging the muscles of the perineum).

With the ineffectiveness of therapeutic methods, surgical decompression is used, which relieves infringement and symptoms.

Surgical decompression is sometimes the only option

Since there is no limit to indignation, or about neuropathy

In addition to neuralgia, the genital nerve can also become the scene of an inflammatory process, then they talk about neuropathy (neuropathy), or pudendal neuritis (a term rarely used today).

What could be the reason?

The cause of the pathology (also called pudendoneuropathy) is the implementation of two mechanisms:

compression-squeezing of the nerve trunk in the “scissors” of the sacrospinous ligament-piriformis muscle;
traction due to overstretching of the nerve in the zone of its transfer over the ischial spine.

Features of symptoms

The clinic may consist of lesions of the main nerve trunk or signs of involvement of various branches of the pudendal nerve.

When a surgical fixation is used in the perineal area, isolated damage to the dorsal nerve of the penis occurs with anesthesia of the penis and complete disruption of the previously normal erection.

Full restoration of sensitivity can occur within 6 to 18 months after surgery, but restoration of erection can be only partial.

When compressed by a hard saddle, the disorder is felt as transient numbness or the appearance of paresthesia in the genital area.

Both unilateral and bilateral loss of sensitivity may be observed, not limited to the penile area, but continuing to manifest itself also in the scrotum area.

In men, an inflamed pudendal nerve manifests itself with characteristic symptoms - paresthesia or hypoesthesia and pain in the peri-anal area, in the area of the penis and scrotum.

Diagnosis and treatment methods

The main diagnostic criterion is that the pull of the knee towards the opposite shoulder causes pain in the buttock (due to stretching of the sacrospinous ligament).

A simple diagnostic method is to pull the knee towards the shoulder

The choice of treatment method depends on whether the process is advanced or in an acute stage.

In chronic cases, methods of drug therapy in combination with rational exercise therapy and physiotherapy are applicable.

Blockade is an effective method, the injection point is indicated with a finger

Pure novocaine blockades are usually less effective.

In order to relieve pain, suppositories of a combined formulation with anesthetics, sedatives and antispastic compounds, both rectal and vaginal, are used.

Surgical intervention is applicable if there is no effect from treatment with therapeutic methods.

You should be extremely careful in the case of neuropathy of oncogenic etiology.

Preventive measures

When riding a bicycle or horse professionally, you should take precautions and follow a routine with mandatory breaks.

Implementing traction for a hip fracture requires the use of a perineal fixator with an adequate support area (up to 9 cm) with a mandatory softening pad.

Intramuscular injections of Magnesium sulfate solution in large doses require caution to prevent the occurrence of ischemic necrosis of the gluteal muscles.

If painful sensations in the pelvis, perineum and genitals appear, and even more so if they increase, you must immediately seek help from a neurologist.

This section was created to take care of those who need a qualified specialist, without disturbing the usual rhythm of their own lives.

Recently, especially in French- and Spanish-speaking medical circles, the approach to the pathogenesis, diagnosis and treatment of diseases of the pelvic organs has changed significantly.
First of all, it has become complex or, as they say in Europe, “multimodal”, since the pelvic organs are closely interconnected and often have common efferent and efferent innervation, blood circulation, and musculo-ligamentous apparatus. Thus, damage to one organ often involves others in the pathological process.
An example is the occurrence of painful bladder syndrome (not interstitial cystitis - these are different things, why will be explained below) in patients with adenomyosis or IBS.
This is due to the phenomenon of the so-called. cross-sensitization. Most of the pelvic organs receive sensory and motor innervation through the n.pudendus. In addition, in some cases, these organs have representation in the same or neighboring centers of the brain. This issue will also be discussed in more detail below.
Secondly, the increasingly dominant point of view is that the role of inflammatory diseases in the pathogenesis of chronic pelvic pain syndrome is decreasing. Currently, the main role, according to French colleagues, is played by myofascial (spastic) syndromes of the pelvic floor muscles and neuropathy of the pudendal nerve, which is informally called the king of perineum - “king of the perineum”. Thirdly, the terminology has changed: increasingly, instead of the term “chronic pelvic pain syndrome,” the term “chronic perineal-pelvic pain and dysfunction syndrome” is used.
We hope that at the 1st International Congress on Pelvic Pain and Dysfunction, which will be held in Amsterdam, a common terminology will be adopted.

Within the framework of this article, it is not possible to consider all pain syndromes and dysfunctions of the pelvic organs, so we suggest paying attention to syndromes of the female pelvic organs that are relevant to practice, that is, urogynecological syndromes.

Pain syndromes:

painful bladder syndrome;
pudendal nerve neuropathy;
myofascial syndromes.

Disorders of the storage and evacuation function of the bladder:

overactive bladder with detrusor overactivity;
overactive bladder with increased bladder sensitivity;
and men under stress.

As for painful bladder syndrome, this, according to G. Amarenco, is a condition caused precisely by cross-sensitization of the bladder due to damage to neighboring organs, for example, the colon (IBS) or the uterus with adenomyosis. In this case, the number of C-fiber receptors also increases, and central sensitization occurs - but this is a consequence of a pathological process in another organ. Pathological changes in the lamina propria can cause umbrella cell damage similar to IC - but in this case it will be secondary.

Clinical case

The patient is 38 years old and has never given birth. She applied for long-term (3 years) dysuria, pollakiuria, nocturia, pain localized in the urethra, irradiating to the right lower limb. Repeated courses of antibiotic therapy were carried out for U. urealitycum. Urine cultures are sterile, general urine tests are unchanged. Cystoscopy revealed visual signs of leukoplakia in the area of Lieto's triangle.
Pathomorphological examination: no evidence of leukoplakia was found.
The patient underwent TUR of the altered area in the area of Lieto's triangle. After the operation, the condition improved somewhat, but after a month it returned to the situation before the intervention. At the time of examination, completion of the voiding diary demonstrated 41 voiding movements per day, with an average voided volume of 37 ml.
The patient was examined together with Professor E. Botrand (L’Avancee Perinneal-Pain Clinic, Aixen-Provence).
The examination revealed adenomyosis, increased tone of the right internal obturator muscle, pain in the trigger point m. obturatorius int.

According to the expert opinion of Professor Botran, in this case there is a painful bladder syndrome caused by cross-sensitization due to adenomyosis and aggravated by the myofascial reaction of the right internal obturator muscle. In addition, due to neurogenic inflammation in the lamina propria of the urothelium caused by cross-sensitization, the patient has urothelial damage.
The pathogenesis of this condition may be as follows. Adenomyosis, like any other condition that causes chronic pain, leads to a decrease in the threshold of pain sensitivity. This is well demonstrated in an experiment on rats called the pressure paw vocalization test.
Its essence is as follows: two groups of rats were taken, in one a chronic pain syndrome was induced by introducing a chemical reagent under the skin of the back, the other group remained intact. A month later, a test was carried out by squeezing the paw of rats in both groups with a special device. The vocalization threshold was determined, i.e. when the rats started squeaking. So, before the start of the study, the threshold in rats of both groups was the same. But after a month, in the group of rats with chronic pain, vocalization occurred with much weaker pressure on the paw compared to intact rats. This seems quite logical. Pain is a signal of tissue damage. If the pain has become chronic, it means that the brain has not taken action sufficient to eliminate the cause of the pain. Therefore, it is necessary to reduce the pain threshold in order to motivate the central nervous system to take more active actions.

The next stage is peripheral sensitization. In the affected organ, the production of nerve growth factor (NGF) increases. This leads to an increase in the number of receptors affiliated with demyelinated C-fibers. The main role of C-fibers is the transmission of chronic pain impulses. Accordingly, an increase in their number leads to an increase in pain in the affected organ. However, as we have already discussed, the pelvic organs have cross-innervation, and in this case, the number of receptors for C-fibers increases not only in the endo- and myometrium, but also in the urothelium.
In addition, this patient was diagnosed with myofascial reaction m. obturatorius int. dext. Muscle contraction is a normal response to pain. However, long-term pain leads to spastic contractions, which, in turn, cause pain due to the accumulation of lactate in the muscle and compression of nerve fibers. As an example, we can cite piriformis-syndrome, when m. piriformis causes compression of n. Pudendus.

Returning to the examined patient - for the treatment of adenomyosis, she was sent to. In addition, for the purpose of treating painful bladder syndrome, it was recommended:

katadolon 200 mg - to relieve pain and central sensitization;
pregabalin - 75 mg 2 times a day with gradual dose titration - to eliminate peripheral sensitization;
injection of 100 units of botulinum toxin into the right obturator muscle under electromyographic (EMG) control;
intravesical electrophoresis 200 units of botulinum toxin;
intravesical administration of sodium hyaluronate (URO-HYAL) in order to restore the urothelium.

You should pay attention to the effectiveness, albeit short-term, of the TUR of the Lieto triangle. As is known, the main afferent innervation of the bladder is localized in the region of Lieto's triangle - apparently TUR temporarily disabled the endings of the afferent fibers.

Pudendal neuropathy

The main symptom of neuropathy of the pudendal nerve is pain in one or more areas innervated by n. pudendus or its branches.
These are the areas of the rectum, anus, urethra, perineum and genitals. One of the typical symptoms is increased pain while sitting and progression during the day.
The causes of neuropathy are still debated, but the best known is compression of the pudendal nerve in the Alcock canal.
Other causes are: piriformis-syndrome, damage to the pudendal nerve during childbirth, pelvic trauma and malignant neoplasms. Therefore, for any chronic pelvic pain, an MRI is advisable.
The role of the herpes virus is also actively discussed - indirect evidence is the effectiveness of acyclovir and valaciclovir in some cases of PN.

There are so-called Nantes criteria for PN, which were developed by J.J. Labat, R. Robert, G. Amarenco. Five main criteria have been identified:

pain in the area innervated by the pudendal nerve;
Predominant pain in the sitting position;
the pain does not cause sleep disturbance (i.e. does not cause the patient to wake up at night);
the pain does not cause serious sensory impairment;
blockade of the pudendal nerve relieves pain.

Typically, patients describe pain during PN as neuropathic, i.e. burning, paresthesia. Most often, the pain is localized on one side. The sensation of a foreign body in the rectum is very typical.
A few words about the anatomy of n. Pudendus. The pudendal nerve contains both afferent and efferent fibers, which causes sensory and motor disorders of the corresponding organs.
The pudendal nerve enters the pelvis at the level of S2-S4 and passes through f. piriformis, then through Alcock's canal and divides into 3 branches.
It is assumed that dysfunction of the pudendal nerve can lead to symptoms of an overactive bladder of predominantly sensory origin, due to an increase in the number of C-fibers in the bladder, as well as due to cross-sensitization, which we have already mentioned, in organs that receive the same innervation for a reason. convergence of sensory pathways in the pelvis.
Diagnosis of PN is based on the above Nantes criteria; in addition, it is necessary to palpate trigger points m. piriformis and m. obturatorius for the diagnosis of myofascial syndromes.
Transvaginal ultrasound with assessment of blood flow in a. can help in diagnosing compression of the pudendal nerve in the Alcock canal. pudenda and v. pudenda, because when the nerve is compressed, these vessels are also compressed and the speed of blood flow on the affected side decreases.

Treatment of pudendal nerve neuropathy

Drug treatment usually includes pregabalin, starting at 75 mg twice daily, titrated up to 600 mg/day. To relax the muscles, vaginal suppositories with diazepam are used, injections of local anesthetics with glucocorticoids into the muscles concerned. In the case of a positive effect, botulinum toxin is injected under EMG control.
For diagnosis and treatment, pudendal nerve blockade is used under X-ray or ultrasound control. Typically, 5 ml of 0.5% bupivacaine with 80 mg of triamcinolone is administered - 3 injections.
Surgical treatment is carried out only with proven compression of the pudendal nerve, resistant to drug therapy. Significant improvement is achieved only in 44% of cases. Other authors report 62% effectiveness (E. Botrand), 70% (R. Robert).
Indications for pudendal nerve decompression and its technique require further discussion and study.

Myofascial syndromes of the pelvis

Myofascial syndromes or chronic myofascial pain are chronic pain syndromes and dysfunctions caused by chronic spasm of the musculo-ligamentous apparatus of the small pelvis.
These syndromes are quite widespread, but rarely diagnosed in urological practice. For example, Skootsky S. reports 30% of patients with chronic pelvic pain who were diagnosed with myofascial syndromes in specialized pain clinics, while Bartoletti R. published data on 5540 patients suffering from CPPS examined in 28 Italian urological clinics - myofascial syndromes were detected only in 13.8% of cases.
Therefore, it is necessary to more carefully examine patients with chronic cystitis, chronic prostatitis, urethritis, etc. in order to identify neuropathic and myofascial syndromes.

Types of iofascial pelvic syndromes:

levator syndrome;
internal obturator muscle syndrome;
piriformis syndrome;
bulbocavernous syndrome.

Levator syndrome

Localization of pain:

pain in the anorectal area;
vaginal pain;
hypogastric pain;
pollakiuria and imperative urge to micturate;
increased pain when sitting.

According to J. Rigaud, this syndrome occurs in 100% of cases in patients with CPPS of both sexes.

Internal obturator syndrome:

feeling of a foreign body in the rectum;
pain in the urethra;
pain in the vulva area.

Piriformis syndrome:

lower back pain;
pain in the perineum;
dyspareunia;
erectile disfunction;
pain in the buttock and hip joint;
pain during bowel movements.

Bulbocavernous syndrome:

pain in the perineum;
dyspareunia;
sexual arousal syndrome without sexual stimulation;
erectile disfunction;
pain at the base of the penis.

analgesics (catadolon);
gabapentins;
benzodiazepines (if possible - vaginal suppositories);
antidepressants (trazodone);
transcutaneous electrical stimulation (TENS);
injections of anesthetics and glucocorticoids into the involved muscles (naropin 0.5% + diprospan);
injections of botulinum toxin under EMG control (Porta M.A, Grabovskiy C.);
sacral neuromodulation.

Overactive bladder with detrusor overactivity

Enough has been written about this type of OAB; effective diagnostic and treatment methods have been developed.
The drugs of choice are M-anticholinergics, but quite often there are cases of insufficient effectiveness of these drugs. This may be due to the combination of OAB with DO and OAB with increased sensitivity of the bladder, which will be discussed below.

Overactive bladder with bladder sensitivity

Clinically, this type of OAB (which is sometimes called “OAB without OAB”) is manifested by a frequent or even constant feeling of the urge to urinate, but without urgency and episodes of urgency, as in women. M-anticholinergics are usually ineffective.

Urodynamic manifestations:

decrease in the volume of the first sensation of bladder filling;
decreased volume of the first urge to urinate;
decrease in maximum cystometric capacity;
absence of detrusor overactivity and episodes of urinary incontinence;
positive cold water test;
positive test with lidocaine.

Etiology:

pudendal nerve neuropathy;
myofascial syndromes;
cross-sensitization of the urothelium in adenomyosis, IBS, adexitis;
damage to the GAG layer of the urothelium.

Pathogenesis

Just as with painful bladder syndrome, there is an increase in the number of C-fibers and receptors affiliated with them. Moreover, sometimes the clinical and urodynamic manifestations of both conditions are identical. Perhaps these are manifestations of the same process that differ in severity.
Central sensitization also plays an important role. This is why the use of tibial neuromodulation is effective - the tibial nerve and the pudendal nerve have the same representation in the central nervous system.

pregabalin;
intravesical use of anesthetics, oxybutynin;
intravesical electrophoresis of anesthetics, glucocorticoids, botulinum toxin;
intravesical application of vanilloids (resiniferatoxin, capsaicin);
transcutaneous electrical stimulation (TENS) with placement of electrodes at the S2-S4 level, (for example, Neurotrack Pelvitone, mode 10 Hz, 200 ms, 30 - 40 minutes a day);
sacral neuromodulation;
tibial neuromodulation;
treatment of pudendal nerve neuropathy and myofascial syndromes;
laser or electroablation of Lieto's triangle (A.I. Neimark, V. Gomberg);
hydrobougation of the bladder.

Stress urinary incontinence (stress incontinence)

Pathology deserves consideration in a separate article, so we will only touch on its relationship with pelvic dysfunctions and pain syndromes.
We are talking about complications of implantation of synthetic slings by transobturator access. Quite often (2-8%) after this procedure, pain syndrome occurs associated with the conduction and persistence of the implant in the obturator muscle, with compression of the branches of the obturator nerve and the occurrence of myofascial obturator syndrome. Sometimes, in addition to the pain syndrome, OAB symptoms occur, which are very difficult to stop.

A possible solution to the problem is the use of new types of slings:

minislings of the new generation (“JUST-SWING”) - they are fixed with a titanium anchor in the obturator membrane without involving the muscle;
biodegradable mini-slings (for example, polylactic acid matrix obtained by electrospinning technology) impregnated with fibroblast growth factors.

For the treatment of pain syndromes after TVT-O surgery, it is possible to use injections of mixtures of anesthetics and glucocorticoids into the obturator muscle. If ineffective, remove the implant.

Conclusion

Diagnosis and treatment of pelvic pain syndromes and dysfunctions seems to be a very relevant and promising area in urology. The active introduction of a modern approach to the tactics of managing patients with such syndromes will improve the quality of medical care and reduce the cost of treatment.
The possibility of organizing specialized rooms or departments within the leading urological medical institutions should also be considered.

I.A. Apolikhina, Ya.B. Mirkin, D.A. Bedretdinova, I.A. Eisenach, O.Yu. Malinina.
Scientific Center of Obstetrics and Perinatology named after. Academician V.I. Kulakova, Research Institute of Urology of the Ministry of Health and Social Development of the Russian Federation, Moscow, NMTC International, New Medical Technologies LLC. Diabetes mellitus – laser treatment

Diabetes mellitus is a dangerous chronic disease that can develop in both children and adults. The number of patients doubles every 15 years, and experts are looking for more and more effective methods for treating this disease.

A little anatomy

it innervates the levator ani muscle;

innervates the anal sphincter;

gives branches to the muscles of the perineum;

innervates the genital organs: cavernous bodies of the penis in men, clitoris in women;

gives sensitivity to the skin of the external genitalia and anus;

innervates the sphincter of the urethra.

The pudendal nerve in the male body (in yellow)

This nerve can be pinched by the piriformis muscle, which is located in the pelvic cavity, or be sandwiched between two ligaments.

In addition, activities such as riding a horse or cycling can also lead to pudendal compression neuropathy over time.

Symptoms of pudendal neuropathy

As with any neuropathic lesions, all symptoms are made up of pain, sensory disturbances, autonomic disorders and muscle weakness. A pinched pudendal nerve is manifested by the following symptoms:

painful sensations in the perineum;

discomfort in the anus and genitals;

burning tinge of pain;

decreased skin sensitivity in these areas, “crawling goosebumps”;

an unpleasant feeling of a foreign body in the urethra and anus;

fecal and urinary incontinence. It may be incomplete, and manifest as fecal smearing or drip incontinence;

sexual disorders: impotence, anorgasmia.

Pinched pudendal nerve in women causes the above symptoms also in the lower third of the vagina.

Pinched pudendal nerve in men, in addition to the above, can cause pain during intercourse.

About diagnosing neuropathy

With such unpleasant and painful sensations, a person is not inclined to endure for a long time, as, for example, with pain in an arm or leg. Therefore, most often he turns to a proctologist, or a proctologist, if disorders of the anal sphincter are severe and there are problems with continence of urine and feces.

patient complaints, which were discussed in detail above;

the nature of the pain, which indicates neuropathic changes (burning, crawling, all kinds of itching, unpleasantness when touched);

a trial therapeutic and diagnostic novocaine blockade of this nerve reliably reduces the severity of symptoms, or completely relieves the patient of suffering for the period of action of novocaine - from 12 hours to 3 days;

When performing an ultrasound of the perineum and pelvis with Doppler ultrasound, almost always with compression-ischemic neuropathy of the pudendal nerve, a decrease in the volumetric velocity of blood flow in the nearby pudendal artery is observed. This happens “for company”: the pudendal artery passes along with the nerve in the same canals, and its narrowing indirectly confirms the compression of the pudendal nerve;

An important diagnostic criterion is that the pain increases if the person sits, and the pain decreases if the person lies on his back. Also, neuropathy of the pudendal nerve is characterized by unilateral damage. Disorders occur on the same side;

patients often note that if they apply cold to the perineum, it causes relief and burning pain decreases. This symptom indicates the neuropathic nature of the nerve damage.

In addition to these diagnostic criteria, it is possible to palpate the perineum to identify characteristic pain points that reflect spasm in the piriformis muscle.

It is important that the pathology of this nerve has a deep connection with the progression of myofascial syndrome. This syndrome is more difficult to treat because the muscles are deeply located.

In addition, pudendal neuropathy worsens depression, anxiety, and makes people more susceptible to negative events.

Treatment of neuropathy

As in all other cases, therapy for this disease must be comprehensive. The basic principles of treatment are as follows:

impact on the neuropathic nature of pain with the help of gabapentin (Tebantin, Lyrica);

conducting regular nerve blocks with anesthetics and hormones;

physiotherapeutic effects: phonophoresis, Amplipulse therapy, electrophoresis;

centrally acting muscle relaxants (Mydocalm). Allows you to relax muscles, including reducing the tone of the piriformis muscle;

B vitamins included in the blockade, as well as tablet forms.

You should find out what exercises you need to do when the pudendal nerve is pinched

If conservative treatment is ineffective, then decompressive surgical operations are performed, which are performed in centers for the treatment of chronic pelvic pain.

It should be remembered that treatment of pudendal nerve neuropathy is a long process, and you need to follow all the instructions of specialists for at least 6 months.

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