The causes of pudendal neuralgia: herpes and compression
Neuropathy of the pudendal nerve is a condition
for which there is no single identified cause. Research on this topic continues
worldwide to this day. The pudendal nerve can theoretically be damaged by
anyone—for example, during horseback riding or heavy athletics. There is also a
version that in many cases, the condition is hereditary. According to this
theory, the highest risk of developing it is among those who are genetically
predisposed (due to anatomical features or other reasons) and lead a lifestyle
conducive to nerve damage.
The most common causes of nerve compression
Almost
any trauma, even if it initially seemed insignificant, can serve as a
"trigger" for nerve compression and the onset of neuropathic pain in
the genital area. As the nerve stretches, causing even more damage, the pain
intensifies and quickly brings the patient to the doctor's office.
The
symptoms are quite common: pain in the area of the anal opening, labia, and
clitoris, radiating to the buttocks. The patient finds it difficult to have
intimate relationships, and she is also very limited in physical activity. And
she just came to the doctor for cystitis.
— I've had all the tests done, been prescribed treatment, but the pain won't go away. I used to have flare-ups before, but the medicine would help quickly. Now the doctor says there should be no inflammation in the bladder and urethra area. And there shouldn't be any pain either. So they referred me to you.
— Tell me, has the nature of the pain changed since you started treatment?
— Yes. Firstly, it has become stronger. And now it occurs not only when going to the toilet but even if I just sit in a chair. But it's hard for me to compare now, honestly. It just hurts, and they said it's no longer cystitis.
— Have you had any tests done? Or maybe invasive procedures were performed?
The patient thinks.
— I had an endoscopy. After that, I was in pain for several days, but the doctor said it happens, and it will pass on its own. And now, a month later, I'm here with you. If I sit for more than 15 minutes, my buttocks start to hurt a lot, it feels like I've been stabbed with a knife.
— Does the pain change during the day?
— Yes. There are sharp attacks. It's hard to sit. And it noticeably intensifies by the evening, but it's easier again in the morning.
— But it doesn't disturb your sleep? Or do you wake up at night from the pain?
— Strangely enough, no... Doctor, tell me, could the doctor who performed the cystoscopy have damaged something there?
Our mind always wants to find the root cause, but often it's simply not possible to pinpoint it precisely. In medicine, the concept of "after" doesn't always mean "because of," and cystoscopy cannot be the cause of pudendal neuropathy.
— You know, I think it's not so important anymore. Let's focus on treatment and getting rid of the pain so that you can lead a full life again. We will need to conduct several tests, and then we can find out for sure what's going on with you.
Contemporary medicine identifies several common causes of pudendal neuralgia:
Compression
The
pudendal nerve is most often compressed in Alcock's canal (this variant of the
disease is called "Alcock's syndrome") or between the sacrospinous
and sacrotuberous ligaments. In both of these areas, the nerve is narrowed—an
anatomical norm necessary for its natural sliding. When inflamed, it enlarges,
leading to increased pressure, as well as swelling and, consequently, intense
pain.
Statistically, neuralgia of the pudendal nerve is more common in women than in men (the ratio is approximately 1:3). Women are also exposed to a risk factor that men may not be aware of: the disease is often provoked by injuries sustained during childbirth. The risk of compression is particularly high if the labor contractions were prolonged or if the delivery process was complicated.
Other common predispositions to compression injury include:
-
Sedentary work
- Heavy weightlifting (deadlifting, etc.), especially intense and irregular workouts
- Some active sports such as horseback riding, cycling, and motor sports
- Fractures of the pelvic bones resulting from accidents and other mishaps
- Malignant or benign tumors in the pelvic area pressing on the innervated region
- Past surgical interventions on pelvic organs
- Prolonged sitting positions (work that doesn't involve physical activity, frequent train and plane travel)
- Chronic constipation
Patients often, but not always, manage to recall the moment that served as the starting point of the disease, as it immediately precedes the onset of the pain syndrome. However, the nature of pudendal nerve compression does not significantly influence the choice of treatment methodology.
Postherpetic neuralgia of the pudendal nerve
The
assumption that the herpes virus increases the risk of genital neuropathy is
based on the fact that in some cases, antiviral drugs alleviate the condition
when used as part of neuralgia therapy.
Postherpetic neuralgia is caused by the reactivation of the varicella-zoster virus, commonly known as chickenpox, which the patient has had in the past. It spreads along the nerve fibers, causing rashes and painful sensations. The disease it causes, herpes zoster, usually resolves, but sometimes the virus can damage the nerves, leading to the manifestation of neuropathy symptoms.
Risk factors increasing the likelihood of developing pudendal nerve neuropathy after herpes include:
- Advanced age (the problem is detected in 30% of herpes zoster patients in the older age group, compared to only 10% in the younger age group)
- Concurrent pathologies negatively affecting the immune system (AIDS, other types of immunodeficiency)
- Suppressed immune state due to the intake of immunosuppressants, after chemotherapy for cancer
The action of medications varies among different patients, as each has their own anatomical features and the specific course of the disease.
Regardless of the etiology of the disease, the physician prescribes comprehensive therapy. Within the framework of conservative treatment, medications of several categories are used, ranging from nonsteroidal anti-inflammatory drugs and antidepressants to opioid analgesics.
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