Pudendal Neuralgia Risk Factors and Common Comorbidities

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Risk factors: 

• Prolonged sitting especially on a hard surface. A lot of my patients are actually competitive cyclists who train, and then, of course, compete over very long distances. Horseback riding is also quite common as far as activities that people participate in that fall under prolonged sitting and at risk. I also see this relatively often in people who drive for a living, particularly long-haul truckers, but I have also seen it in individuals who drive school buses or deliver packages.
• Pelvic fracture-History of the pelvic fracture does increase the risk for this as well.
• Surgery around the pudendal nerve pathway 
• Sedentary lifestyle ▪ Higher BMI
• Prolonged history of constipation-significant correlation from a prolonged history of constipation.
• Other neurologically driven pain. If the person has had a history of another type of neurologically driven pain, radiculopathy, for example, having those radiating symptoms, even if it wasn't diagnosed as radiculopathy is a potential risk factor. We know that some people's nervous systems are just a little bit more prone to sending those angry signals. There is a correlation where if they've had a previous diagnosis, they may be at higher risk for developing another neurologically driven pain type diagnosis.
• Arthroscopic hip surgery.  Pudendal neuralgia is actually a known complication of arthroscopic hip surgery. It is not a very high risk, about a 2% prevalence, but a two in 100 chance of a somewhat adverse outcome is worth noting. The good news is if this does develop as part of the outcome of having had arthroscopic hip surgery, it's typically transient and often resolves on its own.
• Shoulder dystocia or prolonged deep lithotomy during childbirth. Deep lithotomy means pushing a baby out with your knees all the way up to your chest. We think that that is probably due to positioning and that prolonged tractioning, and also more likely in those who were in those positions for significant periods of time. 
• Excessive masturbation. There is a correlation between a history of excessive masturbation and developing pudendal neuralgia, but we don't really understand what this relationship is.

Common comorbidities include the following: 

• Constipation. 
• Sexual dysfunction. 
• Pain. 
• Ejaculatory or erectile dysfunction. 
• Difficulty achieving orgasm. 
• Persistent genital arousal disorder (PGAD). 
• Urinary incontinence. 
• Low back pain.

We're not really sure if constipation generally comes first and then the pudendal neuralgia develops or the other way around, but it's a very common comorbidity. Sexual dysfunction, pain, and also ejaculatory or erectile dysfunction in those who have penises are also common. Those are the main functions of this nerve and so it makes sense that that would be potential outcomes and something that we might need to work with people on as we're treating them. Difficulty achieving orgasm during sexual intercourse is another one. There is a specific type of pudendal neuralgia that is called persistent genital arousal disorder. It's often abbreviated PGAD. A person with PGAD feels like they're in this state of constant arousal, which when you say that, sometimes people will say, "Oh, that sounds nice," but it's actually really not. It causes irritability and is not a pleasurable thing. Those people with PGAD can be triggered by something as simple as sitting down while wearing a pair of pants.  People can also experience urinary incontinence and then they often have a history of low back pain. Often chronic low back pain existed long before they ever developed the pudendal neuralgia symptoms.  

This Ask the Expert is an edited excerpt from the course, Pudendal Neuralgia Evaluation and Treatment presented by Jennifer Stone, PT, DPT, OCS, PHC