By Kelly Sammis, DPT, CLT and Aaron Castonguay, DPT, OCS, CSCS
Pudendal neuralgia (PN) is a diagnosis which describes neuropathy along the distribution of the pudendal nerve1. PN can be hard to diagnose in the medical community and, no doubt, severely affects the quality of life of those affected. While the clinical presentation of PN does include pain along the distribution of the nerve, it is also typically accompanied by sexual dysfunction, bowel dysfunction, and/or bladder dysfunction2.
This is a very common diagnosis in cyclists and triathletes secondary to the increased time spent in the bike saddle. The friction created in the pudendal canal from the repetitive nature of pedaling and/or direct compression of the nerve between the nose of the bicycle seat and the ischiopubic region makes these athletes susceptible to pathology of the pudendal nerve and its terminal motor and sensory branches3.
Before we dive further into the diagnosis, dysfunctions, and treatment options, let’s first understand the anatomy.
Anatomy of the Pudendal Nerve
The pudendal nerve is a major branch of the sacral plexus and is derived from the sacral nerve roots of S2, S3, and S4. The nerve exits the greater sciatic foramen, travels over the sacrospinous ligament and re-enters the pelvis through the lesser sciatic foramen. It then traverses through the pudendal canal (aka Alcock’s canal) and emerges inferior to the pubic bone to innervate the perineum and genitalia4.
Inside the pudendal canal, the pudendal nerve divides into three main branches. First, it gives off the inferior rectal nerve which services the anorectal region5. Second, the perineal nerve which services the muscular branches to the superficial and deep perineal muscles (including the external urethral sphincter) and the sensory branches to the posterior scrotum and labia5. Third, the dorsal nerve to the penis in men or the dorsal nerve to the clitoris in women servicing each structure respectively5.
The pudendal nerve is a mixed nerve which contains autonomic, sensory, and motor functions6. The nerve carries sympathetic fibers which cause it to respond when our “fight or flight” system is activated. It supplies sensation to the penis and posterior scrotum in men; the clitoris, posterior labia, and vaginal canal in women; and the perineum and anorectal canal in both genders. Additionally, it innervates the muscles of the perineum and pelvic floor, which are largely responsible in supporting normal function of the bowel, bladder, and sexual systems7.
Pudendal Nerve Entrapment in Cycling
The pudendal nerve is predisposed to entrapment at the level of the ischial spine in the pudendal canal8,9. The most common sites of entrapment occur in the space between the sacrospinous and sacrotuberous ligaments at the ischial spine and at the medial ischium by the obturator internus muscle10,11. Heavy and prolonged cycling on an inappropriately shaped or incorrectly positioned saddle can increase the compression on the pudendal nerve. This, paired with the friction created in the pudendal canal from the repetitive nature of pedaling, can exacerbate the symptoms associated with PN3.
Pudendal Neuralgia Clinical Presentation
Pudendal neuralgia is caused by inflammation, compression and/or traction of the pudendal nerve1. It may be associated with pelvic trauma secondary to childbirth, surgical procedures, cancer treatment, or other traumatic events and/or may be provoked secondary to strenuous or repetitive exercise, repetitive stress or strain during defecation, poor posture, anatomical anomalies or systemic disease related mechanisms such as diabetes and multiple sclerosis2.
As mentioned before, PN symptoms typically include dysfunctions of the bowel, bladder and sexual systems and oftentimes are marked by the presence of pelvic pain. Let’s examine these symptoms and common client complaints further:
- Pelvic pain: pain in the penis, scrotum, labia, clitoris, perineum, or anorectal region; pain stemming from the pudendal nerve is typically exacerbated with sitting, driving, cycling, exercise, defecation and/or a full bladder and is relieved by standing, lying recumbent or when sitting on a toilet seat6.
- Bladder dysfunction: pain with bladder filling, painful urination, urethral pain, urinary frequency, urinary urgency, nocturia, incontinence, hesitancy of urination, slow or inconsistent urinary stream, sensation of incomplete bladder emptying6.
- Bowel dysfunction: pain prior to or during defection, straining during defecation, constipation, incontinence, loss of feeling of fullness or urge to defecate6.
- Sexual dysfunction: painful intercourse, pain during or after ejaculation, pain with sexual thoughts or arousal, reduced sexual pleasure, erectile dysfunction, persistent arousal6.
With the breadth of symptoms pudendal nerve dysfunction is associated with, it’s easy to see why the diagnosis is oftentimes very difficult for clinicians. Misdiagnosis is common and can be very frustrating for clients who are searching for relief from these high impact symptoms.
Getting A Diagnosis
In general, the conundrum of chronic pelvic pain includes at least 22 syndromes in both genders12. Clients are often referred to physical therapy with medical diagnoses such as: chronic pelvic pain syndrome (CPPS), interstitial cystitis, irritable bowel syndrome, endometriosis, dyspareunia, bowel and urinary incontinence, and chronic prostatitis, among others13-15. Specifically for male clients with PN, it is common to come in with a diagnosis of prostatitis, as the symptoms of pudendal nerve entrapment overlap considerably with those ascribed to chronic nonbacterial prostatitis-pelvic pain syndrome10, a syndrome that has never been scientifically shown to be a primary disease of the prostate or the result of an inflammatory process18.
It is important to seek out a pelvic health provider who has the education and knowledge base to perform tests and measures that will support an accurate diagnosis. An accurate diagnosis can help determine the most appropriate treatment strategies. As a client, navigating healthcare professionals in this area can be a frustrating and time consuming process. It can take months, or even years, to find the right provider with the right tools to help improve your overall quality of life.
A multidisciplinary approach is crucial to tailor a treatment plan that is specific to each client’s pathology, symptomatology, and clinical presentation. Your team should be comprised of a medical doctor who specializes in pelvic pain (typically obstetrics and gynecology, urology, urogynecology or gastroenterology) as well as a physical therapist or chiropractor who specializes in pelvic health and pelvic floor dysfunction. For PN as it relates to cyclist’s syndrome, it is also crucial to have a professional bike fitter assess your saddle and riding posture.
Pudendal neuralgia can be debilitating, but it’s also quite treatable. To begin our treatment approaches, we must first identify the symptoms and root cause, then employ a custom regime specific to each client.
Current approaches from medical doctors include, but are not limited to: drug therapy via oral medication, topical medication or suppositories, pudendal nerve injections or blocks, regenerative medicine via stem cell or other orthobiologic injections, pudendal nerve decompression, radiofrequency ablation, or pudendal nerve or spinal cord neuromodulation1,19.
Physical Medicine Approach:
As a physical therapist, I recommend conservative treatment approaches prior to the exploration of more aggressive treatments. Unfortunately, this is not always how the sequence of events unfolds for each client. Conservative treatments by a physical therapist might include: client education on the cause of your symptoms and pain, manual therapy to address muscle tone abnormalities, dry needling to address neuromuscular dysfunction, restoration of muscle balance via appropriate exercises and stretches, postural modifications, activity modifications, stress management techniques, and/or discussion surrounding dietary impacts on the pelvis. Treatment availability will depend on each clinician’s skill set, knowledge base, and particular treatment style.
Regardless of the treatment approach utilized, the goal for clinicians is typically to reset the dysfunction and restore the tissues to a homeostatic baseline. Personally, when the tissue dysfunction is one that involves the peripheral nerves, which is the case with PN, I tend to choose a treatment modality that directly influences the nerve itself to achieve the reset. I have found that utilizing dry needling is the most effective and efficient treatment approach in this realm. The power of the tissue reset that dry needling provides has changed my clinical practice and how I approach nerve dysfunction. It has also positively impacted and changed the lives of many of my clients.
The thought process behind this approach is to desensitize the pudendal nerve and its branches by utilizing neuromodulation with an indwelling needle electrode. It has been shown that sacral or pudendal neuromodulation are effective treatment approaches for PN1,10,19,20; however, these non-conservative options involve a surgical procedure to place the electrodes in the pelvis.
One way neuromodulation is achieved is by delivering electrical agents directly to the target area, so why not utilize a conservative approach via dry needling first? We are able to place the needle electrode near the perineurium of the pudendal nerve and/or in the surrounding musculature that may be contributing to the compression. We can then add electrical stimulation, or neuromodulation, to help achieve the tissue reset by affecting central processing in the brain and via restoration of normal signaling from the nerve itself as the stimulation produces a natural biologic response to either inhibit pain signals or by stimulating neural impulses where they were previously absent21.
To learn more about this technique, consider attending the pelvic floor course offered by KinetaCore. We would love to see you there!
Equipment and Performance Approach:
As mentioned previously, for cyclist’s syndrome, it is integral to have a professional bike fitter assess your saddle and body position. Let me take a moment to introduce the readers to Aaron Castonguay, DPT, OCS, CSCS. Aaron is a physical therapist by discipline with specialties in orthopedics, strength and conditioning and medical bike fitting. Here are his recommendations in relation to making sure you have the proper saddle and posturing for your ride:
The general culture of pain while cycling is, you strictly press on. Discussion, openness, and education are key. Any pain while on your bike that is sharp, sustaining after a ride, or causes you to frequently shift while riding, is not exercise specific pain. These painful situations can come from an abnormal movement pattern, or an inappropriate pressuring or lengthening of a tissue based on the primary contact points between the rider and their bike. There should never be prolonged or continuous numbness and pain in your genitals or perineum while riding. If you are experiencing the constant need to stand or hunch away from the pain, then it may be time to consult a specialist. Each person has uniquely different dimensions, which means that there is no ‘one-size fits all’ bike position or saddle.
Pudendal neuralgia (PN) is just one of many repetitive stress injuries that a cyclist is prone to, and may be one of the most debilitating. It is difficult to pin-point just one root cause of pudendal nerve injury in a cyclist since there are many factors in play surrounding this modified closed-kinetic chain sport. The most direct cause in many cases, however, is an abnormal rider interaction with the keystone of the bike: the saddle.
Usually, this is due to the saddle being too narrow for the rider and not providing an appropriate amount of support where it is needed beneath them. Current best practice is to encourage decompression of the perineum by positioning the body with primary contact between the saddle and the rider’s ischial tuberosities. While this is the exact opposite of boney compression that is avoided in acute and subacute settings with wheelchair positioning, cycling’s main difference is the rider’s natural hip sway with each pedal stroke. During the loading phase of the foot with the pedal, the contralateral ischial tuberosity will ideally lift slightly from the saddle, providing a brief decompression moment before shifting during the reciprocal loading phase. This happens quickly as most cyclists pedal between 80-100 times per minute and is subtle, but is enough to prevent tissue breakdown.
The next challenge is, what is the best saddle for your client? This is not an easy answer and is dependent on the client. With hundreds of saddles currently on the market, there are several prominent leaders with different theories and structures. Saddles vary in width, density, and in the amount of curve across the face of the saddle. Some people prefer a flatter feel while others feel less tension sitting on a contoured curved saddle. The best way to know if it fits well and feels good is to try it, as it is nearly impossible to guess just by looking at a saddle through a screen.
The general rule of thumb for saddle selection is the saddle should fully support the measured width of the rider’s ischial tuberosities to lift the perineum away from direct saddle contact. Without full boney support, the entire upper body weight with push down on the soft tissue, allowing compression and neural and vascular occlusion. Secondly, with an active case of PN, the client should try a saddle with a middle cut-out to allow for appropriate pressure relief along the midline of the perineum. Most of this research has been done with male riders and there is a debate over if women riders benefit from the same kind of cut-out. Specialized has recently released a women’s specific saddle that has a modified cut-out with a soft lining, aimed at preventing labia compression from natural swelling which occurs 30-45 minutes into a ride. Again, this does not mean that all women will or will not benefit from a cut-out, only that each rider’s anatomy and feel needs to be taken into account.
The above saddle specifications cover the majority of the cycling communities with road, mountain, and recreational bikes. Triathlete, time trial, and track bikes put the rider in a more forward flexed position, requiring increased pressure over the pelvic rami. The pelvic rami cannot be measured directly, so consulting the ischial width measurement first is still best practice.
Quick tips for saddle placement: Make sure your saddle is mostly level to the ground, with only a small variance of 2-3 degrees at most in either the tipped up or down position. Be sure that the forward and back position of the saddle in relation to the seat post keeps the client’s hips a comfortable distance toward the handlebars (without compromise to the knees, but that’s an another discussion on plumb line). Saddle height is also key, to try to maintain a bottom knee position between 25 and 40 degrees of flexion. Moving one contact point of the handlebars, pedals and/or saddle position can make all the difference for a good or bad feel.
Having an appropriate bike fit is just the first step to returning to getting on the bike after an episode of PN. Keeping an appropriate posture while on the bike is also vital to minimizing perineum pressures. As shown below in the saddle mapping image, keeping an active core can help decrease midline pressure while riding. The image on the left side shows a final fit during pedaling with a woman rider with increased midline pressure. Although not high in peak pressure, a lasting pressure will cause occlusion. The image to the right is after cueing for subtle traverse abdominal activation while pedaling. The pressures are then taken from the soft tissue and redistributed to the ischial structures.
Although this discussion focuses on the saddle and the interaction with the rider, all portions of a bike fit influence each other. An increased reach length can prevent a rider from staying back on the saddle, or a non-corrected leg length difference can hinder the rider’s ability to stay centered on the bike.
If you feel that you are having increased back, knee, neck or perineum complications, then it may be time to follow up with a specialist in your area. Usually, the local bike shop will have a connection to a fitter in the area who can help with general orthopedic complications. For PN based complications with a bike fit, a medical fitter is the best choice for consultation.
Regardless of where you currently find yourself on your journey with pudendal neuralgia, know that treatment exists for this dysfunction. There is hope to live an active life that is free of pain and free of dysfunctions of the sexual, bowel, and bladder systems.
About the Authors
Kelly Sammis, DPT, CLT: Kelly is a physical therapist, continuing eduction instructor with KinetaCore, and Pilates instructor living and working in and around Denver, Colorado. Her passion for treatment in the PT discipline is pelvic health and wellness. Her specialties are male and female pelvic floor dysfunction (Herman and Wallace), oncology rehabilitation, lymphedema (Klose Training), dry needling (KinetaCore), herbal medicine (in progress with Aviva Romm) and Pilates (BASI). Her formal education took place at Ohio University (2007) and The University of St. Augustine for Health Sciences (2010). When she is not treating clients or teaching a dry needling course, you can find her spending time with her family and exploring the beautiful mountains of Colorado!
Aaron C. Castonguay, DPT, OCS, CSCS: Aaron is a physical therapist and medical bike fitter working and living in Denver, Colorado. His philosophy within the profession of PT is to encourage an active lifestyle through biomechanical awareness, safe strengthening, and outdoor participation. Aaron specializes in orthopedic treatment and assessments (APTA), return to sport progression and dynamic rehabilitation (Gray Institute and NSCA), medical bike fitting (CU Sports Medicine and Specialized Bike Components University), biomechanical movement analysis (RETUL, DARI, Geobiomized Saddle Mapping), and dry needling (KinetaCore). He attended Ithaca College in upstate New York for both his undergraduate and graduate degrees, where he competed in collegiate football and track & field. Outside of the clinic and bike lab, Aaron is usually climbing mountains with his skis or touring on his bike with friends and family.
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