Neuralgia Pudenda is a problem that every time I see most often in the consultation and that most patients usually go after seeing different specialists (urologist, gynecologist, surgeon, neurologist) without having a clear diagnosis or treatment orientation .
The pudendal nerve
The pudendal nerve arises from the anterior branches of spinal segments S2, S3 and S4. This plexus is based on coccygeus and leaves the pelvis below the piriformis muscle. Then surrounding the ischial spine and reenters the pelvis by the lateral wall of pit ischiorectal. Continue on the inner side of the ischial tuberosity, where it meets the pudendal vessels in the canal or pudendal canal Alcock Alcock's canal, and runs through the channel in the direction of the sacro-tuberous ligament.
Later, the pudendal nerve is divided into three branches:
1. Peroneal nerve (lower leg), born in the output channel Alcock and runs along the inner edge of the deep transverse perineal muscle. On his way, it issues a lateral perineal branch to the superficial transverse muscle resulting in branches to the scrotum (in the case of men) or labia (in women), where also comes the superficial branch perineal. Subsequently, the deep peroneal nerve issues another branch or Bulbourethral. The deep branch pierces the middle aponeurosis of the perineum and leads to branches to the superficial and deep transverse muscles of the perineum. This deep branch dies into two: the branch bulbar (which penetrates the bulbospongiosus muscle) and urethral branch (which runs along the underside of the body and ends spongy glans / vestibular bulb). In women ischio- and bulbospongiosus supplies the muscles, ending in the vestibular bulb. Thus, their sensory branches innervate the lower third of the vagina and urethra, in addition to the lips of the vagina. Furthermore, motor nerve branches perineal pass through the perineal membrane and die in striated urethral sphincter.
2. inferior rectal nerve. Generally, also it born in the channel Alcock. Its branches innervate the anal canal, the third volume of the rectum, skin vulvar fork back and peri-anal skin inconsistent with perineal endings in the dorsal. His motor branches ending in the levator ani and external anal sphincter.
3. dorsal nerve of clitoris / penis. Like the rest, also born in the channel Alcock. Runs along with internal inside the fascia pundenda pudendal vessels, crosses the anterior aspect of the transverse ligament of the perineum and passes under the symphysis pubis to reach the dorsal aspect of the penis or clitoris through the suspensory ligament. The dorsal nerve of clitoris generates two branches. Clitoral branch runs along the pubic ramus and has terminations from the pubic arch to the inguinal canal. These inconsistent endings could explain some painful symptoms in the groin area and occasionally in the lower iliac cavity.
Symptoms of Neuralgia Pudenda
The main symptom of Pudenda Neuralgia is often perianal or genital pain, which may be accompanied by burning, stinging, constipation, sexual dysfunction (eg, pain during sexual intercourse), burning or pain when urinating or defecating. Symptoms can appear on both sides or be unilateral. They are usually worse when sitting and when standing improvement.
Causes of Neuralgia Pudenda
The causes of pain can not be so clear. Most often due to a nerve entrapment or compression on its way and this may be due to surgery (episiotomy delivery), trauma or accidents, sports such as cycling or weight lifting, infection (prostatitis); It can often be due to spend much time sitting and in other cases the specialists in Pain Unit we can not find the cause.
It is important to know the anatomy of the pudendal nerve to explain the pain and accompanying symptoms.
So in summary the pudendal innervation is:
- Sensitive: skin of the perineum and genitals
- Motorboat (mainly perineal nerve) levator ani, deep and superficial transverse perineal, bulboesponjoso, ischio-, striated urethral sphincter and anterior portion of the external anal sphincter.
- Autonomous: erection and feeling of wanting to urinate.