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Neuropathy of the genital organ: what can be understood from the symptoms?

Neuropathy of the genital organ: what can be understood from the symptoms?

Diagnosis of pudendal neuralgia is a complex task that requires careful examination of symptoms and additional testing. It is necessary to distinguish it from damage to other nerves located approximately in the same area of the body. Symptoms of inflammation localized in adjacent areas may be similar and partially overlap with signs of pudendal nerve entrapment, but these conditions are treated differently.

Diagnostic criteria based on symptoms

To establish a diagnosis, both symptom analysis and instrumental techniques are used. Since there are no signs that definitively distinguish pelvic pain caused by damage to the pudendal nerve from any other, Nantes criteria developed in 2006 are applied. According to them, pain in pudendal neuralgia:

- is localized from the anal opening to the external genital organs, including the penis in men and the clitoris in women;

- worsens when the patient assumes a sitting position, as this increases pressure on the affected area;

- does not cause awakenings at night;

- does not cause serious sensory disturbances;

- is successfully relieved by diagnostic nerve blocks.

There are many more possible symptoms characteristic of genital neuropathy, but they may not manifest themselves or may not be strongly pronounced. These include genital arousal without genuine sexual desire, pain during or after sexual intercourse or ejaculation, decreased sensitivity, or the inability to achieve orgasm.

Assistive devices

Orthopedic seat cushion

One characteristic symptom is pain relief when using a doughnut cushion or other devices that relieve pressure on the genitals. However, finding a cushion that helps reduce pain and discomfort throughout the affected area is rather fortunate; most patients have to avoid sitting positions as much as possible or use local anesthetics (suppositories, ointments, cold or hot compresses) when doing so.

Patient's regular history during appointment:

Chronic pelvic pain syndrome often affects athletes or fitness enthusiasts, and this middle-aged man is no exception. He came to the urologist complaining of painful urination, burning, discomfort, and a constant sensation of bladder fullness—even minutes after visiting the restroom. The doctor suspected prostatitis, but the diagnosis was not confirmed.

— Tell me, are there any other difficulties? For example, with your sex life.

— You know, doctor, yes... I feel like there might be issues with potency. Although, when you're almost constantly in pain and discomfort, it's not surprising.

— Did this start suddenly?

— Quite quickly. Initially during workouts, I felt numbness in my genital organs, and then the pain appeared.

— What kind of workouts?

— I participate in cycling, cross-country races. I've won first place several times at regional events, and even participated in international ones a few times.

— And are you still cycling?

— Unfortunately, no. It's very painful. And, to be honest, I'm hoping you can help me because I haven't been separated from my bike for long since I started riding it. It's been about forty years.

Here we have one of the main risk factors. Impingement of the pudendal nerve in Alcock's canal is even termed "cyclist's syndrome" among specialists. The position of the body while cycling and pedaling, prolonged close contact with the saddle often lead to constant pressure on the nerve, which subsequently results in pudendal neuropathy.

— Does it get easier in other positions?

— If I don't sit and lean over the handlebars? In general, yes. Standing is not as painful compared to cycling. But the discomfort is constant. Ordinary painkillers, I think, don't help.

— And if you imagine yourself sitting on a toilet and relax, do you feel relief?

— I've even tried that a few times, not intentionally, just noticed that it becomes easier. Doctor, can you tell me what's wrong with me already?

— For now, there's a possibility that you've developed what's called Alcock's canal syndrome, and the cause of the pain and other symptoms lies in the impingement of the pudendal nerve. But before making a final diagnosis, we'll conduct several tests. I'm afraid if my assumption is correct, you'll need to work on changing your lifestyle.

Fear reflects in the patient's eyes.

— I won't be able to cycle? Is it not treatable?

— It's hard to say. It depends on many factors: the nature of your condition, your body's response to therapy. Some patients find relief with the first prescribed treatment. Moreover, if the diagnosis is confirmed, then you could say you're "lucky": genital neuropathy with compression specifically in Alcock's canal is typical for professional cyclists. Many models of special seats have been created that relieve pressure from the nerve and reduce pain.

— So, it's not possible to cure it completely?

— I can't answer that yet. In some cases, surgery—pudendal decompression—is recommended. It has a fairly high success rate. Conservative treatment is palliative, but with the current level of medical advancement, patients can receive comprehensive treatment and, with some limitations, continue to engage in the same activities as before the illness. But right now, we need to focus on determining the diagnosis as quickly as possible...

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Nerve segments susceptible to compression

Nerve injuries can occur at various locations as the nerve passes through several narrow areas. The most common sites of compression are:

- The area between the sacrospinous and sacrotuberous ligaments (intraligamentary pudendal neuropathy).

- Alcock’s canal (before branching).

Different studies show different results, but on average, intraligamentary (intraligamentous) compression occurs in approximately 65–80% of cases. 12–20% are attributed to pudendal canal syndrome, and the rest to other locations (particularly combined ones).

The Nantes criteriademonstrate the overall clinical picture of pudendal entrapment, but they do not determine which specific segment of the nerve is damaged. This can only be identified through instrumental diagnostics, although some specific signs are still present, and they are sufficient to suggest the site of entrapment.

Intraligamentary Pudendal Neuropathy

Disorders of normal rectal sphincter function may occur, but this is rather rare.

The intraligamentary form of the disease is characterized by:

- Aching pain in the buttocks, anal area, and genitals.

- Mild sphincter pathologies—slight urinary retention or urinary incontinence (a rarer case).

- Erectile dysfunction.

- Intensification of pain not only when sitting but also when walking, during sexual intercourse, and during urination.

- Pain around the ischial tuberosity.

Pudendal Nerve Entrapment in Alcock's Canal

Compression of Alcock's canal

Alcock's syndrome manifests with:

- Chronic anal and perineal pain affecting the area of the external genital organs.

- Fecal and urinary incontinence—rarely.

- Hyper- or hypoesthesia of the perineum: increased and decreased pain sensitivity.

- Pain of the nerve during rectal examination.

- Sharp pain occurring when certain manipulations are performed by the doctor in specific areas of the perineum.

Common signs of all entrapments, regardless of localization, thus include pain, possible minor disturbances in sensation, defecation, urination, and sexual dysfunction.

Exclusion of inappropriate diagnoses

Differential diagnosis is necessary to avoid treating the patient incorrectly for an entirely different disease. The physician must be attentive to distinguish pudendal nerve compression neuralgia from syndromes:

- Femoral-genital nerve.

- Iliohypogastric nerve.

- Posterior cutaneous nerve of the thigh.

- Coccygeal nerve.

- "Coccygeal Christmas tree."

It is also necessary to distinguish perineoanal syndrome, which occurs with damage to the lower parts of the horse's tail—a group of nerve nodes located below the lumbar region. It is characterized by leg paresis, as the horse's tail is responsible for transmitting nerve impulses to the lower extremities. This symptom is not observed in pudendal neuropathy.

Due to the difficulty in accessing the nerve and the insufficient accuracy of individual studies, diagnosis of pudendal neuralgia requires examination of each of the likely compression sites before making a diagnosis.

Sergey B. Izvozchikov
Neurologist, Ph.D. of Medical Sciences
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