Chronic Pelvic Pain Caused by the Pudendal Neuralgia

The pudendal nerve runs through the gluteus muscles (the buttocks) and into the perineum (think of the perineum as any part of the body that touches a bicycle seat). Pudendal neuralgia (also known as pudendal neuropathy) is a disorder of the pudendal nerve that can lead to chronic pelvic pain. This condition may be caused by pudendal nerve entrapment, when the nerve becomes compressed, or by damage to the pudendal nerve itself and is also known as pudendal neuropathy.

Causes of Chronic Pelvic Pain From Pudendal Neuralgia

Chronic pelvic pain from pudendal neuralgia can be caused by any of the following:

• Diabetic neuropathy
• Trauma to the buttocks or pelvis including childbirth
• Excessive sitting (cyclists often have pudendal nerve entrapment)
• Thickening of ligaments around the pudendal nerve
• Bony formations pushing against the pudendal nerve

Cyclist’s Syndrome

Prolonged sitting on hard surfaces, such as a bicycle seat, can cause pelvic nerve compression, which can lead to chronic pelvic pain over time. In fact, this happens so frequently that pudendal neuralgia, a type of chronic pelvic pain caused by entrapment or compression of the pudendal nerve, is often referred to as Cyclist’s Syndrome.

Sitting on some types of bicycle seats for long periods of time puts pressure on the pudendal nerve. Such pressure can cause swelling around the nerve, which causes nerve pain, and may even lead to nerve trauma over time. Nerve compression and swelling often cause pain described as burning, stinging or feeling like pins and needles.

For most people with pudendal neuralgia caused by cycling, symptoms appear after prolonged biking, sometimes months or years later. In other words, by the time you realize there is a problem, the damage may have already been done.

Symptoms

Pudendal nerve pain may be described as burning, numbness, or pins and needles, stabbing, or cramping. It may present in any of the following ways:

• Pain in the perineum or anal region
• In men, pain in the penis or scrotum
• In women, pain in the labia or vulva
• Pain during intercourse
• Pain when urinating or having a bowel movement
• Pain in sitting that goes away when standing

Because the symptoms are often hard to distinguish, pudendal neuropathy can often be hard to differentiate from other types of chronic pelvic pain, such as prostatitis and vulvodynia.

Preventing Cyclist's Syndrome

A review of studies published in 2021 offered the following recommendations for preventing Cyclist's Syndrome:

• Rest: Take breaks of at least 20–30 seconds after each 20 minutes of cycling. While you are riding, change positions often and stand up to pedal periodically. Consider taking time off between races to “rest” the pelvic nerves; breaks of 3–10 days can promote recovery. If you are starting to develop pelvic pain symptoms, take a rest and see your healthcare provider as soon as you can.
• Saddle: Use a soft, wide seat with a short nose. Make sure the seat is level or tilted slightly forward rather than backward. Surprisingly, seats with cutout holes put more pressure on the perineum, so seats without holes may help if you experience numbness or pain.
• Bike fit: Adjust your seat height so that your knee is slightly bent at the bottom of the pedal stroke. Your weight should rest on your "sit bones" (ischial tuberosities). Keeping the handlebar height below the seat can reduce pressure, but the extreme forward position of a triathlon bike should be avoided. Mountain bikes were associated with a higher risk of erectile dysfunction than road bikes. A more upright posture is better.
• Shorts: Wear padded bike shorts while cycling.

Treatment Options

If the cause is excessive sitting or cycling, pudendal neuralgia can be treated with rest. Nerve blocks may help relieve pain caused by pudendal nerve entrapment. Certain muscle relaxers, antidepressants, and anticonvulsants may be prescribed for pudendal neuropathy pain, sometimes in combination, though there's little research on their effectiveness. Nerve decompression surgery may be required.

Another option is a rehabilitation program including rest, stretches, and specific exercises to release the nerve entrapment. The active release technique (ART) involves applying pressure to muscles in the area while you stretch and tense them.

If you have chronic pelvic pain caused by pudendal neuropathy, your healthcare provider may use any combination of these treatments.

Coping

Because pudendal neuralgia is so difficult to diagnose and treat, learning to cope can be key to increasing your quality of life. Try these techniques:

• Keep a pain journal.
• Avoid stress when possible.
• Try distraction techniques, such as reading a book or listening to music.
• Talking to someone can help.