The topic of this blog article isn’t a particularly common one. While you may have heard of it, it’s quite possible this one may not yet have crossed you path. Pudendal Neuralgia (PN) is a form of peripheral nerve entrapment that causes numbness or pain in the pelvis or genitals. Occurring in just 1 in 100,000 people, it is not very common and can often go either unrecognised or misdiagnosed. Many patients also struggle to find an effective treatment. Current treatment options include surgical decompression, nerve blocks, injections of anaesthetic, medications, and physical and manipulative therapies.
The efficacy between the more and less invasive options is negligible and often only relieve symptoms for a short time. Nerve entrapments occur due to a force causing the compression of areas of a nerve, such as a change in the tissue surrounding the nerve. In the case of Pudendal Neuralgia, there are entrapments along the Pudendal Nerve which runs along the back of the pelvis to the base of the genitals, before separating into other nerves.
Peripheral nerve entrapments can cause debilitating pain that has the potential to derail an individual’s normal life. As there are minimal effective treatments available for patients to pursue, it is important to talk about the research emerging in this area. The following case report describes the management of an individual with Pudendal Neuralgia using multimodal chiropractic therapy.
The case
A highly active 25-year-old male presented for chiropractic care. He sustained an injury while working as a dance instructor and maintaining a regular exercise schedule. The symptoms began as tingling and stabbing pain, which was initially localised to his left gluteus muscles, extending to the anus, scrotum, and groin. At the time of presentation, the patient had a 10-year history of symptoms related to Pudendal Neuralgia. He also reported symptoms of constipation and abnormal sexual function that coincided with the pain.
Physical activity also exacerbated the symptoms. Cauda equina syndrome (CES), considered a medical emergency, shares similar symptoms with PN and led the patient to visit a hospital during the onset of symptoms 10 years prior. CES was confidently ruled out by multiple doctors and the patient was then referred to a neurologist, resulting in the diagnosis of Pudendal Neuralgia. The patient tried different treatments, including pharmacological interventions including gabapentin, steroid prescriptions and supplements, as well as physical therapy – all with varying levels of success.
At the time of the initial chiropractic visit, the patient had minimal tingling or painful symptoms as he had been avoiding aggravating activities for many months. He had stopped dancing due to worsening symptoms – a factor significantly impacting his quality of life. Maintaining a sedentary lifestyle outside of work was the only way to prevent chronic pain. Even while remaining sedentary, the patient reported experiencing mild flare-ups on a weekly basis. The patient’s aims were to reduce pain intensity, decrease symptom frequency, and to be able to dance and exercise again.
The chiropractors were able to reproduce symptoms in the office with deep palpation. A sensory examination was performed over the L1-S1 dermatomes on both sides and was determined to be within normal limits. He self-reported left-sided scrotal paraesthesia (abnormal sensation such as pins and needles or no sensation at all). However, he requested no examination due to the sensitivity. The chiropractor noted fluid motion restriction of the sacrum on both sides.
Management included spinal manipulation of the lumbosacral region, soft tissue manipulation, neuromobilization, and corrective exercises. The perineum and deep external rotator muscles of the hip were the main focus areas for care. Following his initial presentation, the patient started a treatment plan of 8 visits over four weeks.
“The aim of specific care modalities included soft tissue treatment focused toward muscular hypertonicity of the external rotators of the hip and adductors. Corrective exercises were prescribed to build strength in the chronically taut and tender hip musculature. Hip strengthening was focused on single leg stance position working on hip stability and balance”
The patient reported an intense flare-up of his symptoms following the first session, but with each subsequent visit, he found there was gradual improvement. Usually, a flare-up would take 2-4 months to resolve. But by the fourth visit, he reported an improvement in constipation through neuromobilization, and was pain-free for the first time since beginning treatment.
The care was concomitant with improvement in his scrotal and groin paresthesia to the point of it only being present 20% of the time he was awake. Following a re-evaluation, the initial care plan was extended, and improvement continued. The patient was then able to play soccer again and perform at-home exercises while only provoking mild symptoms – a significant improvement on his initial presentation.
At this point, the patient decided to take a B12 supplement to try and resolve the remaining symptoms. He did this with good success and continued taking the supplement and performing corrective exercises following cessation of care. In total, he attended 14 visits over 56 days for a full resolution of symptoms.
The case report includes an interesting discussion around the development of nerve entrapments and Pudendal Neuralgia diagnosis criteria, referencing helpful resources for further information. While the usual limitations involved with case reports apply here, the full resolution of symptoms in a highly sensitive, rare and under-represented condition makes this case an interesting one for consideration.
REFERENCES
- Olson, H., Gouveia, C., & Petersen, C. (2023). PUDENDAL NEURALGIA: A CASE FOR CHIROPRACTIC INTERVENTION. Journal of Contemporary Chiropractic, 6(1), 79–83
