Pudendal neuralgia

A muscular man with a serious expression walks into the office. His urologist referred him to me, although the patient had hoped it would all be resolved with a short course of antibiotics:

— “I just got back from Latin America, was literally trekking through the jungle. We lived in tents, bathed in natural ponds, almost alongside crocodiles. I thought I’d picked up an infection, but the tests came back clean. No discharge either.”

— “Please describe your symptoms again.”

— “It’s an intense pain in the most intimate area and nearby. It’s like a sharp shooting pain. Sometimes it turns dull, but it never really goes away. It can intensify within a split second if I move suddenly.”

— “Pelvic pain syndrome can occur with many conditions. When did you first feel it?”

— “After a barbell workout. I do weightlifting. Never had anything like this before — it came on suddenly, if you can say that.”

— “That suggests a higher risk of pudendal neuralgia. Do you experience itching? Where exactly is the pain located? How would you describe it?”

— “It feels like — sorry for being blunt — like something’s been inserted into my penis, and it’s hot. The pain is in the perineum, sometimes radiates to the buttocks. Touching the area makes it worse… But, to be honest,” — the patient hesitates, “my sensations might be a little off right now. I tried to ease the pain by putting an ice pack on my scrotum and think I may have given myself a cold burn.”

This kind of thing happens occasionally. A patient overwhelmed by constant pain and unable to see a doctor right away will try to relieve the discomfort with whatever means are at hand. Sometimes they overdo it.

— “Doctor, is there a surgery for this?”

— “Technically, yes. But it’s too early to talk about that. First, we need to pinpoint exactly what's causing your pain. Second, surgery is only done when there are clear indications. It's a complex procedure, and we need to be certain that it can actually help.”

— “So, it might not be pudendal nerve entrapment after all? Could it be something easier to treat?” — there's a flicker of hope in the man’s eyes.

— “I can’t say for sure yet, but none of your symptoms rule out that possibility. We need more accurate diagnostics. I’ll refer you for an ultrasound and electroneuromyography. These aren’t 100% definitive, but they’ll give us a general picture. A third method is a nerve block. We'll inject an anesthetic into the painful area, and if that brings relief, we can confidently say the pudendal nerve is indeed affected.”

— “But what do I do right now? I’m going home after this, I’ve got work tomorrow — I have to live with this somehow.”

— “For now, let’s consider starting medication and possibly combining it with local anesthesia methods. You won’t need that ice pack anymore, of course. There are lidocaine patches that work well for many patients, and there are also medications that have proven effective.”

— “But every movement hurts! I’ve taken so many pills — anti-inflammatories, painkillers — nothing works.”

— “The treatment should bring some relief once we begin. But you’ll also need to make a few lifestyle adjustments. For example, get a cushion with a hole in the middle so sitting doesn’t put pressure on the nerve. That will ease your condition and help you work at a computer more comfortably. In the meantime, we’ll tailor your medication, run the tests, and analyze the results. Sound good? Then we’ll reassess your condition and decide on next steps.”