(646) 355-8777

Herman & Wallace Blog

Pudendal Nerve: Caught in the Space Between

My 6 year old girl (going on 13) asks “Alexa” to play the Descendants II soundtrack over and over again. So the song, “Space Between,” was lingering in my head while reading the most recent articles on pudendal neuralgia, particularly when pudendal entrapment is to blame. After all, entrapment, by medical standards, describes a peripheral nerve basically being caught in between two surrounding anatomical structures.

Ploteau et al., (2016) presented 2 case studies highlighting the warning signs when pudendal nerve entrapment does not follow the Nantes criteria. A brief summary of those 5 criteria follows:

  • Pain in the region of the pudendal nerve innervation from anus to penis or clitoris.
  • Pain most predominant while sitting.
  • The patient does not wake at night from the pain.
  • No sensory impairment can be objectively identified.
  • Diagnostic pudendal nerve block relieves the pain.

The case studies of a 31 and a 68 year old female revealed endometrial stromal sarcoma and adenoid cystic carcinoma in the ischiorectal fossa, with night pain was noted in both patients, as well as no pain with sitting or defecation, respectively. Clinicians must always be mindful to resolve red flags in patients.

In 2016, Florian-Rodriguez, et al., studied cadavers to determine the nerves associated with the sacrospinous ligament, focusing on the inferior gluteal nerve. Fourteen cadavers were observed, noting the distance from various nerves to the sacrospinous ligament (from a pelvic approach) and to the ischial spine (from a gluteal approach). The S3 nerve was closest to the sacrospinous ligament, and the pudendal nerve was the closest to the ischial spine. In 85% of subjects, 1 to 3 branches from S3/S4 nerves pierced or ran anterior to the sacrotuberous ligament and pierced the inferior part of the gluteus maximus muscle. The authors concluded the inferior gluteal nerve was less likely to be the source of postoperative gluteal pain after sacrospinous ligament fixation; however, as the pudendal nerve branches from S2-4, it was more likely to be implicated in postoperative gluteal pain.

A study by Ploteau et al. (2017) explored the anatomical position of the pudendal nerve in people with pudendal neuralgia. In 100 patients who met the Nantes criteria, 145 pudendal nerves were surgically decompressed via a transgluteal approach. At least one segment of the pudendal nerve was compressed in 95 of the patients, either in the infrapiriform foramen, ischial spine, or Alcock’s canal. In 74% of patients, nerve entrapment was between the sacrospinous ligament and the sacrotuberous ligament. Anatomical variants were found in 13% of patients, often with a transligamentous course of the nerve.

When the pudendal nerve is caught in the narrow space between ligaments in the pelvis, diagnosing the source of pain is paramount. Research supports a gluteal approach in releasing the entrapped nerve. Post-surgical care falls into the hands of pelvic floor therapists, so taking “Pudendal Neuralgia and Nerve Entrapment: Evaluation and Treatment” may be something to consider in order to provide optimal care.


Ploteau, S, Cardaillac, C, Perrouin-Verbe, MA, Riant, T, Labat, JJ. (2016). Pudendal Neuralgia Due to Pudendal Nerve Entrapment: Warning Signs Observed in Two Cases and Review of the Literature. Pain Physician. 19(3):E449-54
Florian-Rodriguez, ME, Hare, A, Chin, K, Phelan, JN, Ripperda, CM, Corton, MM. (2016). Inferior gluteal and other nerves associated with sacrospinous ligament: a cadaver study. American Journal of Obstetrics and Gynecology. 215(5):646.e1-646.e6. doi: 10.1016/j.ajog.2016.06.025
Ploteau, S, Perrouin-Verbe, MA, Labat, JJ, Riant, T, Levesque, A, Robert, R. (2017). Anatomical Variants of the Pudendal Nerve Observed during a Transgluteal Surgical Approach in a Population of Patients with Pudendal Neuralgia. Pain Physician. 20(1):E137-E143

Continue reading

Pudendal entrapment or a tumor?

In the comedy, Kindergarten Cop, Detective John Kimble may only have had a headache, not a tumor, but sometimes our patients do have a tumor. One of my patients was actually just diagnosed with a brain tumor after responding poorly to a cortisone injection for her neck pain. Tumors in other areas of the body, even in the pelvis, can be the source of symptoms that may seem like a nerve entrapment. This is a serious consideration to be given when diagnosing pudendal neuralgia.

In 2008, Labat et al. published the “Diagnostic Criteria for Pudendal Neuralgia by Pudendal Nerve Entrapment” in Neurourology and Urodynamics . A group in Nantes, France, established criteria in 2006, since the diagnosis is primarily clinical in nature. The results of this paper concluded the five essential diagnostic criteria (Nantes criteria) are as follows:

  • Pain located in the anatomical region of the pudendal nerve.
  • Pain worsened with sitting.
  • Pain does NOT awaken the patient at night.
  • Negative sensory loss upon clinical exam.
  • Pain is relieved with an anesthetic pudendal nerve block.

A recent study by Waxweiler, Dobos, Thill, & Bruyninx explored the Nantes criteria as related to choosing surgical candidates for pudendal neuralgia from nerve entrapment. They looked at how a patient’s response to the anesthetic block corresponded to appropriate selection of patients for a successful surgical outcome. Six of 34 patients in the study had a negative anesthetic pudendal nerve block, and 100% of those patients had no symptom relief after surgery. In contrast, 64% of the patients who met all five of the Nantes criteria responded positively to surgery. The authors concluded confirmation of the 5th criteria as essential for predicting success of surgery for pudendal neuralgia by pudendal nerve entrapment.

In Pain Physician in 2016, Ploteau et al. present two case studies where consideration of the Nantes criteria helped diagnose rare tumors in patients who demonstrated red flags during examination. Warning signs such as nocturnal awakening, point-specific pain, pain of a neuropathic nature, and neurological deficits cannot be overlooked when a patient presents with pudendal neuralgia. In the case studies presented, the 31 year old woman did not have pain exacerbated with sitting and woke at night with pain, and the 62 year old woman was awakened at night with pain. Each patient had magnetic resonance imaging performed, and rare diagnoses of endometrial stromal sarcoma and adenoid cystic carcinoma were made, respectively. The tumors arose in the ischiorectal fossa and compressed the pudendal nerve, presenting as pudendal neuralgia in atypical forms requiring careful clinical examination and referral for MRI for accurate diagnosis.

Although a tumor rarely exists, it is our duty to recognize signs and symptoms that do not follow established criteria. Paying attention to what your patients say just may be lifesaving. Proper diagnosis of pudendal neuralgia is essential and sometimes falls in our hands.


Labat, JJ., Riant, T., Robert, R., Amarenco, G., Lefaucheur, JP., Rigaud, J. (2008). Diagnostic criteria for pudendal neuralgia by pudendal nerve entrapment (Nantes criteria). Neurourology and Urodynamics. 27(4):306-10. doi: 10.1002/nau.20505.
Waxweiler, C., Dobos, S., Thill, V., Bruyninx, L. (2016). Selection criteria for surgical treatment of pudendal neuralgia. Neurourology and Urodynamics. doi:10.1002/nau.22988.
Ploteau, S., Cardaillac, C., Perrouin-Verbe, M. , Riant, T., & Labat, J. (2016). Pudendal Neuralgia Due to Pudendal Nerve Entrapment: Warning Signs Observed in Two Cases and Review of the Literature. Pain Physician. 19:E449-E454.

Continue reading

Living with Hypermobility and Ehlers-Danlos

One of my dear patients was recently diagnosed with Ehlers-Danlos sydrome (EDS). The diagnosis brought a sense of relief for sweet Katie who for years struggled with numerous health problems and was often misunderstood and under cared for by the medical community. Katie was referred to me 2 years ago at 28 for pelvic pain, endometriosis and IC. Upon exam we also discovered a significant elimination disorder and paradoxical elimination. Katie regularly timed her elimination and was spending at times up to 2 hours trying to empty her bowels. As we worked together we uncovered bilateral hip dysplasia, left hip labral tear, ilioinguinal and pudendal neruralgia and POTS (Postural Orthostatic Hypotension Syndrome). Katie already had a history of anxiety and depression but managed well with good family and friend support. When the diagnosis of EDS came, she finally felt like she had an explanation for why her body is like it is. This brought great relief as well as the knowledge that her condition was genetic and her conditions needed to be managed as best as possible to give her the most function, but would likely never be fully resolved.

In her book "A Guide to Living with Ehler's Danlos Syndrome" Isobel Knight does a beautiful job outlining the various genetic subtypes of Ehlers Danlos but also highlighting the fact that EDS hypermobility type (Type III) does not just affect the connective tissue in the musculoskeletal sytem leading to joint instability and hypermoblity, muscle tears, dislocations, subluxations, hip dysplasia and flat feet. EDS can also affect the body's systemic collagen leading to increased risk for endometriosis, POTS, Renauds, bladder problems, fibromyalgia, headaches, restless legs, ashtma, consitpation, bloatedness, prolapse, IBS symptoms, anxiety, depression and learning difficulties. She notes that some people have only a few of these systemic symptoms while others may be more affected. Per Isobel: "it is important that all symptoms are treated seriously and not ridiculed and that the appropriate medical support is given to them when necessary."

It seems that EDS is becoming more widely recognized. As rehabilitation specialists we should be alert to problems stemming from joint hypermobility when we notice how our patients position themselves. Often legs are curled up or double crossed. Upon questioning we might find that the patient has a history of being "double jointed" or was able to do "party tricks" with their bodies. The Bighton scale is a test of joint hypermobility which we should all be familiar with. It is also important to note that a patient may have hypermobility without having EDS, and that EDS is usually associated with pain. A rheumatologist, or in Katie's case a geneticist, can help confirm a suspected EDS diagnosis.

If you have a patient with hypermobliiy or with EDS, know that their ability to know where their body is in space is limited as their joints have much more range of motion than normal. The proprioceptors do not fire well at mid range and the patient will have to be trained to become accustomed to neutral joint positions. This was really painful for Katie and it took a huge mental and physical effort. She is getting stronger now and it is becoming easier to achieve.  Stretching and soft tissue massage can feel really good when your muscles have to work so hard to maintain your joints in healthy positions. Patients should be instructed to not stretch into end range and also not "hang out" on their ligaments. Some patients may have to begin just with isometrics. I used Sara Meeks' program for safe and effective floor exercise with Katie. The floor gave her support while she strengthened her core muscles. Then she was able to progress to seated and seated on a ball as well as standing exercises. She loves the body blade! Yoga, Pilates, exercise in water can be effective for strength, propriception and movement reeducation. Mirrors are helpful for increasing position sense.
It is also helpful to note that even patients with EDS may be hypermobile in some joints and hypomobile in others. Isobel reports that her SI joints were extremely unstable while her thoracic spine was very rigid to the point that her lung capacity was affected. Having her therapist work on the hypomobility and doing breath work was life changing.

As pelvic health therapists and rehabilitation providers we may be the first professional to suspect EDS in a patient. There is a great deal that we and the greater medical and holistic community can do to help patients with EDS lead lives with less pain and dysfunction.

Continue reading

Why you should learn about Pudendal Neuralgia

Herman & Wallace are pleased to announce a new course! Pudendal Neuralgia and Nerve Entrapment will be presented by Michelle Lyons in Freehold, NJ on June 17/18, 2017. We chatted with Michelle about this new course to hear her thoughts and get an overview of the contents

There are a number of courses which I teach for Herman & Wallace including Pelvic Floor Level 2A, my Male Oncology and Female Oncology and the The Athlete and the Pelvic Floor courses. They all have sections on pudendal dysfunction and it’s an area that participants always want more information on. There’s no other nerve that elicits the same interest, discussion and confusion! Nobody really talks about iliohypogastric or ulnar neuralgia with the same intensity as pudendal neuralgia, and no other nerve dysfunction provokes the same amount of controversy and mystery.

When I was approached about developing this course for the Institute, I jumped at the opportunity. For those who don’t know me, I really like to bring an integrative approach to my work, both clinically and educationally. I have experience and training in nutrition, coaching, yoga, Pilates and mindfulness as a therapeutic intervention and I think these fit really well alongside traditional pelvic rehab approaches. Manual therapy and bespoke exercise prescription will always be the bedrock of my approach, but sometimes our patients, especially those with chronic pain, need some extra support. I’m also a bit of an anatomy nerd, so the chance to delve deep into pelvic neuroanatomy and neurodynamics was too much to resist!

I think this is a Golden Age in pelvic health – there are so many great learning opportunities and resources available to us to help serve our patients better. Another area that I find fascinating to explore is the huge leap we have made in understanding neuroscience and the role of pain education when it comes to chronic pelvic pain. I’m a big fan of the work done by Moseley and Butler in Australia, and I love how authors like Hilton, Vandyken and Louw have transferred that to the world of pelvic pain in their book "Why Pelvic Pain Hurts". The language that we use is very important when discussing how the brain responds to chronic pain and the changes that occur with central sensitization. We never want our patients to feel as if we think their pain is ‘all in their heads’ but at the same time, we need to be able to incorporate strategies such as motor imagery and graded exposure and to demonstrate to our patients that"…it is important to acknowledge that chronic pain need not involve any structural pathology" (Aronoff 2016).

Those are some of the discussions we’ll be having in Freehold, NJ next June – I hope you’ll come and join the conversation!


"What Do We Know About the Pathophysiology of Chronic Pain? Implications for Treatment Considerations" Aronoff, GM Med Clin North Am. 2016 Jan;100(1):31-42
"Why Pelvic Pain Hurts: Neuroscience Education for Patients with Pelvic Pain" Hilton, Vandyken, Louw, International Spine and Pain Institute (May 28, 2014)

Continue reading

A Patient's Pelvic Rehab Journey

The following comes from a male patient who wanted to share his story about finding care for his pelvic floor dysfunction. His story highlights the important role pelvic rehab practitioners can play, and why we need to continue training more therapists in this field.

I’m 65 year old male and I developed pudendal neuralgia and pelvic floor issues as a result of an accident about four years ago. Shortly after my accident I started to experience pain in my testicles and perineum.  At the time, I did not think that one had anything to do with the other. I made an appointment with my urologist who did an ultrasound and assured me that there was nothing physically wrong. I don’t think my testicles quite believe that but mentally I felt relieved. But the pain persisted and started to spread. Now it was also in my groin and penis.  I was also having problems with chronic constipation, urinary retention and erectile dysfunction. Since I did have back surgery years ago I started to suspect my low back was causing the problem. I made an appointment with a well-respected orthopedic surgeon in New York. While he gave me his analysis with regards to my back problems he clearly avoided addressing the pelvic issues. I left there feeling lost. Suffice it to say that over the course of the next couple of years I saw several other specialists who either skirted around the issue or told me that nothing was wrong. A couple of years passed but the pelvic issues just continued to get worse and worse. I started seeing a new primary care physician who indicated that perhaps the source of the pelvic pain was coming from the pudendal nerve and felt that physical therapy might help. She gave me a prescription for physical therapy to evaluate for pudendal nerve.

Well, I have a diagnosis now so I start researching pudendal neuralgia and land on the Pudendal Hope website. Wow! What an eye opener that was.  I’m reading the information on the website and it was like I had an epiphany.  I realized that I was not going crazy and that Pudendal Neuralgia and pelvic pain are very real issues.

OK, so where do I go from here? With prescription in hand I’ll make an appointment with a physical therapist that deals with pudendal neuralgia. Ha, I thought getting a diagnosis was tough but finding a physical therapist that treats pudendal neuralgia and pelvic issues was no easy task. To make things even more challenging, finding a physical therapist who treats men was even harder. I made a few calls and kept looking online without much success.  Desperate to find a physical therapist that treats men, I sent an email off to a therapist in California asking if by some chance she could recommend a physical therapist here in New Jersey. As luck would have it, I got both a response and a referral. With that, I called Michelle Dela Rosa at Connect Physical Therapy. I had to wait about six weeks for an appointment but finally the day arrived.  OK, so now, I had set my expectations. I’ll go for a few weeks of physical therapy, the pain will go away and it will be back to a normal life. Well, not so much… the journey and education were just getting started.

There are days when I am in so much pain that I ask myself if the pelvic therapy is really doing me any good. But then I reflect back to how things were before I started the therapy. Funny thing about pain… often times it makes us forget how things were in the past and shift our focus to the here and now. That being said, I quickly realize how much I have truly progressed since starting therapy.

So what have I learned?  Well, the first thing is to understand the anatomy and how all the pelvic muscle groups and nerves are integrated. After all you can’t fix what you don’t know is broken. Therapy has certainly helped educate me in that respect; I’ve learned the importance of proper breathing and strengthen the core muscles.  I know that when I was in pain I would tighten up the pelvic muscles and hold my breath which would only make things worse, as the muscles would get into a knot, and make it even more difficult to get relief.  I’ve learned a whole new set of exercises that I now have in my arsenal to help fight this battle. To help me deal with the chronic constipation I’ve learned how to massage my abdomen to help move things along. For those folks dealing with chronic constipation, well, we all know what happens when we push just a little too hard… flare time! I could go on and on. I learned to use tools, such as the TheraWand, to help break the tension for those internal pelvic muscles. Pelvic therapy has taught me the importance and benefits of the proper use of cold packs, glides, exercise, breathing, relaxing the pelvic floor and on and on and on.

I was a bit embarrassed getting started but the prospect of relieving some of the pelvic pain and the professionalism of my therapist quickly turned my embarrassment into a non-issue.

I want to express my thanks and gratitude to all those physical therapists who have the courage and vision to take on this problem. You are truly making a difference in the lives of the people you are helping.

Continue reading

Pelvic Dysfunction in Female Cyclists

Blog by Holly Tanner

A US study published in the International Society for Sexual Medicine last year reports on the available evidence linking cycling to female sexual dysfunction. In the article, some of the study results are summarized in the left column of the chart below. On the right side of the column, we can consider ideas about how to potentially address these issues.

 

 


 

Examples of Research Cited
Ideas for Addressing Potential for Harm
dropped handlebar position increases pressure on the perineum and can decrease genital sensation encourage cyclists to take breaks from dropped position, either by standing up or by moving out of drops temporarily
chronic trauma can cause clitoral injury encourage cyclists to wear appropriately padded clothing, to apply cooling to decrease inflammation, and to use quality shocks or move out of the saddle when going over rough roads/terrain when able
saddle loading differs between men and women women should consider specific fit for bike saddles
women have greater anterior pelvic tilt motion is pelvic motion on bike demonstrating adequate stability of pelvis or is there a lot of extra motion and rocking occurring?
lymphatics can be harmed from frequent infections and from groin compression patients should be instructed in positions of relief from compression and in self-lymphatic drainage
pressure in the perineal area is affected by saddle design, shape female cyclists with concerns about perineal health should work with a therapist or bike expert who is knowledgeable about a variety of products and fit issues
unilateral vulvar enlargement can occur from biomechanics factors therapists should evaluate vulvar area for size, swelling, and evidence of imbalances in the tissues from side to side, and evaluate bike fit and mechanics, encouraging women to create more symmetry of limb use
genital sensation is frequently affected in cyclists, indicating dysfunction in pudendal nerve therapists should evaluate female cyclists for sensory or motor loss, establishing a baseline for re-evaluation

Because women tend to be more comfortable in an upright position, the authors recommend that a recreational (more upright) versus a competitive (more aerodynamic and forward leaning) position may be helpful for women when appropriate. Although saddles with nose cut-outs and other adaptations such as gel padding in seats are discussed in the article, the authors caution against making any distinct recommendations due to the paucity of literature that is available. The paper concludes that more research is needed, and particularly for considering the varied populations of riders ranging from recreational to racing.

 

Within a pelvic rehabilitation setting, applying all orthopedic and specific pelvic rehabilitation skills is necessary for women cyclists who present with pelvic dysfunction. Because injury to the perineal area including the pudendal nerve can have negative impact on function such as bowel, bladder, or sexual health, skills in helping a patient heal from compressive or traumatic cycling injuries is very valuable. To learn more about pudendal nerve health and dysfunction, the Institute offers a 2-day course titled Pudendal Neuralgia Assessment, Treatment and Differentials: A Brain/Pain Approach. This course is offered next in Salt Lake City in April, so sign up soon!

Continue reading

Upcoming Continuing Education Courses

Dec 6, 2019 - Dec 7, 2019
Location: Swedish Covenant Hospital

Dec 6, 2019 - Dec 8, 2019
Location: Swedish Covenant Hospital

Dec 6, 2019 - Dec 8, 2019
Location: Franklin Pierce University

Dec 6, 2019 - Dec 8, 2019
Location: Florida Hospital - Wesley Chapel

Jan 10, 2020 - Jan 12, 2020
Location: Dominican Hospital - Physical Therapy

Jan 17, 2020 - Jan 19, 2020
Location: Spooner Physical Therapy

Jan 17, 2020 - Jan 19, 2020
Location: Banner Physical Therapy and Rehabilitation

Jan 17, 2020 - Jan 19, 2020
Location: Our Lady of the Lake Children's Hospital

Jan 24, 2020 - Jan 26, 2020
Location: Nova Southeastern University

Jan 24, 2020 - Jan 26, 2020
Location: UCLA Health

Feb 1, 2020 - Feb 2, 2020
Location: Evergreen Hospital Medical Center

Feb 1, 2020 - Feb 2, 2020
Location: Ochsner Health System

Feb 7, 2020 - Feb 9, 2020
Location: FunctionSmart Physical Therapy

Feb 22, 2020 - Feb 23, 2020
Location: Pacific Medical Centers

Feb 28, 2020 - Mar 1, 2020
Location: Inova Alexandria Hospital

Feb 28, 2020 - Mar 1, 2020
Location: University of North Texas Health Science Center

Feb 28, 2020 - Mar 1, 2020
Location: Novant Health

Mar 6, 2020 - Mar 8, 2020
Location: 360 Sports Medicine & Aquatic Rehabilitation Centers

Mar 6, 2020 - Mar 8, 2020
Location: Heart of the Rockies Regional Medical Center

Mar 6, 2020 - Mar 8, 2020
Location: University of Missouri-Smiley Lane Therapy Services

Mar 6, 2020 - Mar 8, 2020
Location: Princeton Healthcare System

Mar 6, 2020 - Mar 8, 2020
Location: Ochsner Health System

Mar 7, 2020 - Mar 8, 2020
Location: Veterans Administration - Salt Lake City

Mar 7, 2020 - Mar 8, 2020
Location: GWUH Outpatient Rehabilitation Center

Mar 13, 2020 - Mar 15, 2020
Location: Sentara Therapy Center - Princess Anne

Mar 13, 2020 - Mar 15, 2020
Location: Thomas Jefferson University

Mar 14, 2020 - Mar 15, 2020
Location: Park Nicollet Clinic--St. Louis Park

Mar 20, 2020 - Mar 22, 2020
Location: Allina Hospitals and Clinics

Mar 20, 2020 - Mar 22, 2020
Location: Comprehensive Therapy Services

Mar 20, 2020 - Mar 22, 2020
Location: Shelby Baptist Medical Center