Pudendal Nerve Neuralgia - an Anatomic-Surgical Approach

Anatomy: The pudendal nerves supply the principle innervation of the perineum. The pathway of this nerve runs deeply through the perineum and is subjected to compression in various zones: between the infraspinous and the sacro-coccygeal ligaments, between the sacro-tuberal and the scro-spinous ligaments, and in Alcocks's canal, at the level of the obturator internus. This compression can lead to a syndrome of perineal pain. Symptoms: The signs and symptoms of this syndrome are typical of a classical nerve compression syndrome. However, due to its atypical location and presentation, perinea' pain due to pudendal nerve compression presents a diagnostic challenge. The pain of pudendal nerve compression is often described as burning in the perineum, occurring consistently in the same region, unilaterally, and increasing in sitting position. These symptoms should evoke the thought of pudendal nerve compression. Diagnosis: The diagnosis relies heavily on a good history and clinical examination. Electrophysiological tests and diagnostic imaging are useful to exclude other pathology. Diagnostic infiltration of Alcock's canal may be therapeutic in 30-40% of cases. Surgical decompression is efficacious in 65-70%. The effect is not immediate and the patients should be informed of this prior to the procedure. A multidisciplinary approach to treatment is mandatory.