Pudendal Neuralgia and Vulvodynia

Links:

• “Pudendal Neuralgia”
• “Health Organization for Pudendal Education”
• “National Vulvodynia Association”

Pudendal Neuralgia:

“Pudendal neuralgia is described as a neuropathic pain in the distribution of the pudendal nerve” (Hibner, Desai, Robertson, & Nour, 2010).

• Symptoms
  • Pudendal Neuralgia Symptoms. https://www.pudendalhope.info/pudendal-neuralgia-symptoms/

“The main symptom of pudendal neuralgia (PN) and pudendal nerve entrapment (PNE) is pain in one or more of the areas innervated by the pudendal nerve or one of its branches. These areas include the rectum, anus, urethra, perineum, and genital area. In women this includes the clitoris, mons pubis, vulva, lower 1/3 of the vagina, and labia. In men this includes the penis and scrotum. But often pain is referred to nearby areas in the pelvis. The symptoms can start suddenly or develop slowly over time. Typically pain gets worse as the day progresses and is worse with sitting. The pain can be on one or both sides and in any of the areas innervated by the pudendal nerve, depending on which nerve fibers and which nerve branches are affected. The skin in these areas may be hypersensitive to touch or pressure (hyperesthesia or allodynia).

“Possible symptoms include burning, numbness, increased sensitivity, electric shock or stabbing pain, knife-like or aching pain, feeling of a lump or foreign body in the vagina or rectum, twisting or pinching, abnormal temperature sensations, hot poker sensation, constipation, pain and straining with bowel movements, straining or burning when urinating, painful intercourse, and sexual dysfunction – persistent genital arousal disorder (genital arousal without desire) or the opposite problem – loss of sensation.

“It is not uncommon for PN to be accompanied by musculoskeletal pain in other parts of the pelvis such as the sacroiliac joint, piriformis muscle, or coccyx. It is usually very difficult to distinguish between PN and pelvic floor dysfunction because they are frequently seen together. Some people refer to this condition as pelvic myoneuropathy which suggests both a neural and muscular component involving tense muscles in the pelvic floor.

“Other Possible Symptoms

• The chief symptom is pain in the area innervated by the pudendal nerves such that sitting becomes intolerable.
• The pain may be lessened when sitting on a toilet seat or a doughnut pillow as this lessens the pressure on the pudendal nerve. Most people simply have to avoid sitting because it is impossible to find a cushion that relieves pain in all areas.
• The pain is often not immediate but delayed and continuous and stays long after one has discontinued the activity that caused the pain (stop sitting, cycling, sex…).
• Often the pain is lower in the morning upon awakening and increases throughout the day.
• There may be extreme pain or tenderness along the course of the nerve when the nerve is pressed on via the vagina or rectum.
• Pain in perineum.
• Pain after orgasm.
• Loss of sensation with difficulty achieving orgasm.
• Strange feeling of uncomfortable arousal without sexual desire.
• Intolerance to tight pants or elastic bands around the legs.
• Friction and feeling of inflammation along the course of the nerve when walking for too long or running.
• Constant pain even with standing or lying down.
• Problem with urinary retention after urination. Need to push to empty bladder. Harder to detect the feeling of urine when passing through the urethra.
• Urethral burning with or after urination
• Feeling like the bladder is never empty or feeling the need to urinate even when the bladder is empty.
• Urinary frequency.
• Pain after bowel movement. Sometimes sufferers also report pain prior to and during the bowel movement.
• Painful muscles spasms of the pelvic floor after bowel movement.
• Constipation.
• Sexual problems. Men complain of a diminution of sensations. Pain after ejaculation is common. For women pain during and after intercourse is often reported.
• Scrotum/Testicular pain is possible. The testicle itself is innervated by another nerve however the difference in pain from scrotum/testicle can be hard to detect.
• Buttock sciatica and everything that goes with it: numbness, coldness, sizzling sensation in legs, feet, or buttock. This is more often due to a reaction of the surrounding muscles to the pain in the pelvic region. It could also be from “cross talk” of the nerves.
• Low back pain resulting from radiation of the pain.
• The symptoms can be unilateral or bilateral. If the entrapment is only on one side, the pain can also be reflected to the other side.
• Some people develop conditions such as complex regional pain syndrome and even post-traumatic stress disorder after prolonged or severe pain.” 

Vulvodynia:

• National Vulvodynia Association. (n.d.). What is vulvodynia?. Retrieved from https://www.nva.org/what-is-vulvodynia/ 

“Vulvodynia, simply put, is chronic vulvar pain without an identifiable cause. The location, constancy and severity of the pain vary among sufferers. Some women experience pain in only one area of the vulva, while others experience pain in multiple areas. The most commonly reported symptom is burning, but women’s descriptions of the pain vary. One woman reported her pain felt like “acid being poured on my skin,” while another described it as “constant knife-like pain.”… For women with generalized vulvodynia (GV), pain occurs spontaneously and is relatively constant, but there can be some periods of symptom relief. Activities that apply pressure to the vulva, such as prolonged sitting or simply wearing pants, typically exacerbate symptoms. Some women experience pain in a specific area, e.g., only in the left labia or near the clitoris, while others experience pain in multiple areas, e.g., in the labia, vestibule, and clitoris. In the latter group, pain may also occur in the perineum and inner thighs, as demonstrated in the diagram on the right.”

• Symptoms:
  • Medical News Today. (2017).Vulvodynia: What you need to know. Retrieved from http://www.medicalnewstoday.com/articles/189076.php

“Pain is the most notable symptom of vulvodynia, and can be characterized as a burning, stinging, irritation or sharp pain that occurs in the vulva, including the labia and entrance to the vagina. It may be constant, intermittent or happening only when the vulva is touched, but vulvodynia is usually defined as lasting for at least three months. The pain is usually found around the urethra and at the top of the legs and inner thighs, and it can be either intermittent or constant. Symptoms may occur in one place or the entire vulvar area.

“The pain is usually described as a burning, stinging, itching, irritating or a raw feeling. Sexual intercourse, walking, sitting or exercising can make the pain worse. It can be present in the labia majora and/or labia minora. Sometimes it affects the clitoris, perineum, mons pubis and/or inner thighs. The pain may be constant or intermittent, and it is not necessarily initiated by touch or pressure to the vulva. The vulvar tissue may appear inflamed, but in most cases there are no visible findings. Vulvodynia usually starts suddenly and may last for months to years. Although it isn’t life-threatening, the pain may make one cut back on some normal activities. It can also make one upset or depressed. It might even cause problems in one’s relationship with spouse or partner, because it can make sexual intercourse painful.” 

• Diagnosis:
  • Fox, S. (2012). Vulvodynia and Interstitial Cystitis: Causes of Pelvic Pain; An Expert Interview With Susan Hoffstetter, PhD, WHNP-BC. Retrieved from https://www.medscape.com/viewarticle/773575#vp_2 

“The best tool for making a diagnosis of vulvodynia is your ears — listen to what your patient is telling you! As part of the patient’s medical history, make sure you note any association between the onset or exacerbation of symptoms and life changes/stressors, changes in medical status, surgeries, and hormonal changes, including childbirth, lactation, and menopause. Physical examination should include evaluation for infection, inflammatory process, and vulvar dystrophies. Vulvodynia may present as generalized on the vulva or localized within the vestibule. Q-tip testing is very important in making the appropriate diagnosis of vulvodynia. Note if sensitivity is present on the vulva or within the vestibule at the Skene’s and Bartholin glands. Use a 0- to 10-point rating scale, with 0 being no pain/symptoms and 10 being the worst level of pain/symptoms. If a diagnosis of vulvodynia is made, Q-tip testing is helpful as an objective measure of level of discomfort (and hopefully improvement) over time. Vulvodynia is ultimately a diagnosis of exclusion after all other potential causes have been ruled out and symptoms have persisted for at least 6 month

• Treatment:
  • Fox, S. (2012). Vulvodynia and interstitial cystitis: Causes of pelvic pain: An expert interview with Susan Hoffstetter, PhD, WHNP-BC. Retrieved from http://www.medscape.com/viewarticle/773575#2

“The initial treatment for any woman presenting with vulvar symptoms is to institute vulvar skin-care guidelines. These are designed to remove any contact irritants to the vulva, such as scented soaps, detergents, hot water, shaving, and washcloths. Neuropathic pain medications are the mainstay of treatment for vulvodynia. These alter the perception of pain by blocking reuptake transmitters, norepinephrine, and serotonin.
My first-line therapy is normally the tricyclic antidepressants, including amitriptyline, nortriptyline, and desipramine. I use amitriptyline primarily, which has a 60% response rate. It is generic and readily available at minimal cost. Fatigue is the primary side effect at the low doses used for treatment. Most patients develop a tolerance for this over time.
My next line of treatment is the anticonvulsants. Gabapentin can be used individually or in combination with amitriptyline. More than 60% of patients have shown significant improvement when prescribed gabapentin. I have also used pregabalin, which has been associated with results similar to gabapentin.

“Infrequently, I use amitriptyline 2% with baclofen 2% as a topical treatment, but that preparation must be compounded and has greater costs. If the patient has concurrent depression, I will also use a selective serotonin–norepinephrine reuptake inhibitor, such as duloxetine. I avoid most topical medications because they serve as a contact irritant over time and offer little symptom resolution. I have commonly seen women being prescribed topical lidocaine. This can become a contact irritant with routine use, but it can provide emergency relief to break the pain cycle. 

“Many women with vulvodynia have increased resting tone, poor strength, and/or irritability of muscles. In those patients, biofeedback therapy can be very helpful. Biofeedback has a success rate of 60% to 80%. Physical therapy with a therapist trained in the pelvic-floor musculature can be very helpful, either alone or in conjunction with biofeedback. It is important not to start physical therapy or biofeedback until the vestibular Q-tip testing has improved (i.e., the gland scores have decreased). Starting these therapies too soon will likely inhibit results and give woman a sense of failure.         

“Since stress plays a role in vulvodynia, any stress-reduction technique, such as meditation and yoga, can be used. Some have found acupuncture helpful. Psychotherapy can be useful because this is a chronic-pain state and women often suffer with depression or relationship problems. It is especially important to let patients know that you understand their problem is a real and debilitating condition, not just “in their heads.”

“The last option for women suffering from localized vulvodynia is vestibulectomy. This should be considered only after all other options have failed. 

“It is thought that there can be overlap between vulvodynia and IC. Studies suggest that the prevalence of concurrent IC and vulvodynia ranges from 12% to 68%. Both IC and vulvodynia are syndromes of the urogenital sinus, including pelvic-floor muscle dysfunction, inflammatory changes with activation of mast cells, increased angiogenesis, and neural hyperplasia.”

Reference

Hibner, M., Desai, N., Robertson, L. J., & Nour, M. (2010). Pudendal neuralgia. Journal of minimally invasive gynecology, 17(2), 148-153. Retrieved from https://doi.org/10.1016/j.jmig.2009.11.003