Symptom guide
Pudendal neuralgia symptoms.
Pudendal neuralgia is one of the most commonly missed causes of chronic pelvic pain. The symptom pattern is distinctive — once you know what to look for. This is the checklist we work through in a specialist consultation.
The core symptom pattern
Pudendal neuralgia produces neuropathic pain in the territory of the pudendal nerve: the perineum, penis or clitoris, scrotum or labia, and the anal region. Patients most often describe it as burning, stabbing, electric or crushing.
The defining feature is positional: pain increases with sitting and decreases with standing, lying down, or sitting on a toilet seat (where the perineum is unsupported).
- Burning or electric pain in the perineum, genitals or rectum
- Pain that worsens minute by minute while sitting
- Relief when standing, walking or lying on one side
- Foreign-body sensation — a golf ball, stone or lump in the rectum or vagina
- Pain that builds through the day and is mildest on waking
Urinary, bowel and sexual symptoms
Because the pudendal nerve controls the sphincters and genital sensation, symptoms frequently spread well beyond pain — which is exactly why the condition is so often labelled as something else.
- Urinary urgency, frequency, hesitancy or incomplete emptying
- Pain during or after urination
- Constipation, pain with bowel movements, or post-defecation flare
- Persistent genital arousal, loss of sensation, or painful orgasm
- Erectile dysfunction or post-ejaculatory pain in men
- Dyspareunia (pain with intercourse) in women
What pudendal neuralgia is usually misdiagnosed as
Most patients we see have already been given two or three other labels. If antibiotics, bladder instillations or pelvic floor physiotherapy have not helped after months of treatment, the nerve itself deserves assessment.
- Chronic prostatitis / chronic pelvic pain syndrome (CPPS)
- Interstitial cystitis or painful bladder syndrome
- Vulvodynia or vestibulodynia
- Proctalgia fugax or 'levator ani syndrome'
- Coccydynia or sciatica
- Endometriosis with persistent pain after surgery
When symptoms mean you should see a specialist
Book a specialist evaluation if pain has lasted more than three months, is clearly worse when sitting, has not responded to physiotherapy or medication, or is spreading into urinary and sexual function.
A structured evaluation includes clinical examination against the Nantes criteria, targeted MR neurography where indicated, and a diagnostic pudendal nerve block. Only after that can anyone honestly tell you whether decompression surgery would help.
Common questions
What are the first symptoms of pudendal neuralgia?
The earliest symptom is usually burning, aching or electric pain in the perineum, genitals or rectum that gets worse the longer you sit and eases when you stand or lie down. Many patients also describe a foreign-body sensation — as if sitting on a golf ball or a folded sock.
Does pudendal neuralgia hurt all the time?
Not always. Early on the pain is typically provoked by sitting, cycling or long car journeys and settles overnight. As the condition becomes chronic, the pain-free windows shrink and background pain persists even at rest.
Can pudendal neuralgia cause urinary and bowel symptoms?
Yes. The pudendal nerve supplies the urethral and anal sphincters, so patients often report urinary urgency, hesitancy, incomplete emptying, painful urination, constipation or pain with bowel movements — frequently misdiagnosed as prostatitis, interstitial cystitis or IBS.
Is numbness a symptom of pudendal neuralgia?
Numbness, pins and needles, or a strange cold/wet sensation in the saddle area can occur alongside the pain. Complete saddle numbness with loss of bladder or bowel control is a red flag for cauda equina and needs emergency assessment, not an outpatient referral.
What are the Nantes criteria?
The Nantes criteria are the accepted diagnostic standard: pain in the pudendal nerve territory, worse with sitting, not waking the patient at night, no objective sensory loss on examination, and relief after a pudendal nerve block. Meeting these criteria supports the diagnosis even when imaging is normal.
Speak with a pudendal nerve specialist.
Dr Renaud Bollens leads a specialist practice dedicated to chronic pelvic pain, with centers in Dubai and Belgium.