For women
Pudendal neuralgia in women.
Women with pudendal neuralgia are routinely told they have vulvodynia, interstitial cystitis, or 'pain that will settle after birth'. The nerve is rarely examined. This is what the condition actually looks like in women — and how it is confirmed.
How it presents
The pain follows the pudendal nerve territory and is provoked by pressure on the perineum.
- Burning or electric pain in the vulva, clitoris, perineum or rectum
- Worse with sitting, better standing or lying on one side
- Foreign-body sensation in the vagina or rectum
- Pain with or after intercourse (dyspareunia)
- Urinary urgency, frequency or painful voiding
- Painful bowel movements and post-defecation flare
- Clitoral hypersensitivity or persistent genital arousal
Common triggers in women
Female pudendal neuralgia usually has a mechanical or surgical history behind it.
- Prolonged or instrumental vaginal delivery, significant tearing
- Pelvic mesh, sacrospinous fixation or prolapse surgery
- Hysterectomy or repeated endometriosis surgery with scarring
- Falls onto the buttocks, coccyx injury
- Long-term pelvic floor overactivity and chronic constipation
- Cycling, spinning and rowing
Why vulvodynia is often the wrong label
Vulvodynia is a diagnosis of exclusion. Pudendal neuralgia is a positive diagnosis with defined criteria: pain in the nerve territory, worse when sitting, not waking the patient at night, no objective sensory loss, and relief after a pudendal nerve block.
If those criteria are met, the treatment pathway is completely different — and includes an operable option.
Treatment pathway
Assessment against the Nantes criteria, pelvic-floor physiotherapy focused on down-training, neuropathic medication for sleep and sensitisation, MR neurography when the picture is unclear or surgery is contemplated, and an image-guided diagnostic block.
Where a genuine anatomical entrapment is confirmed, pudendal nerve decompression removes the mechanical cause. Where it is not, we say so and treat the pain medically rather than operate.
Common questions
What does pudendal neuralgia feel like in women?
Women typically describe burning or stabbing pain in the vulva, clitoris, perineum or rectum, worse the longer they sit and relieved by standing or lying down. A foreign-body sensation in the vagina or rectum, pain with intercourse, and urinary urgency are common accompaniments.
Is pudendal neuralgia the same as vulvodynia?
No, though they overlap and are frequently confused. Vulvodynia describes vulval pain without an identified cause. Pudendal neuralgia is pain in a defined nerve territory, provoked by sitting and relieved by a pudendal nerve block. Many women labelled with vulvodynia have unrecognised pudendal involvement.
Can childbirth cause pudendal neuralgia?
Yes. Prolonged second stage, instrumental delivery, a large baby or significant perineal tearing can stretch or injure the pudendal nerve. Many post-partum cases improve over the first year; those that do not deserve nerve-specific assessment rather than being accepted as normal after birth.
Can endometriosis cause pudendal neuralgia?
Endometriosis can involve or irritate pelvic nerves directly, and repeated pelvic surgery can produce scarring around the pudendal nerve. Women whose pain persists after otherwise successful endometriosis surgery should be assessed for a neuropathic component.
Does pudendal neuralgia get worse around my period?
Frequently. Hormonal shifts change nerve sensitivity and pelvic floor tone, so many women report a predictable premenstrual flare. Tracking symptoms against your cycle is useful clinical information to bring to a consultation.
Speak with a pudendal nerve specialist.
Dr Renaud Bollens leads a specialist practice dedicated to chronic pelvic pain, with centers in Dubai and Belgium.