Pudendal Neuralgia is a painful condition caused by irritation of the pudendal nerve, usually via compression by muscles or ligaments along its pathway in the pelvis.  This irritation causes pain and dysfunction (urinary/bowel and sexual) in both males and females. It is well established that most men wait years before seeking help with pelvic floor issues therefore, this blog will focus on men.

The diagnosis of Pudendal Neuralgia is primarily based on signs and symptoms. Diagnostic tests alone are not typically valid for an accurate diagnosis but MRI and EMGs have been used as well as nerve blocks.

Symptoms will depend on which of the 3 branches of the pudendal nerve have been compromised:

  1. Inferior rectal nerve: controls the anal sphincter and provides sensory information of the anal sphincter and anal canal.
  2. Perineal branch: controls pelvic floor muscles and urethral sphincter, provides sensory information of the perineum and scrotum (the sack that hold the testicles).
  3. Dorsal Branch: provides sensory information of the skin of the penis.

Typical symptoms include:

  • Penile pain, scrotum pain, rectal pain (many times worse with sitting)
  • Urgency to urinate, painful urination.
  • Painful or difficult bowel movements
  • Pain during or after sex
  • Erectile dysfunction
  • General pelvic pain or perineal pain.
  • Sensation of fullness or foreign object in the rectum
  • Seen with pain in other areas such as buttocks or low back.
  • Other symptoms are seen when pain spikes: are sweating, increased heart rate and blood pressure, goosebumps, and anxiety.

Causes of pudendal neuralgia:

  • Hypertonic (tight) pelvic floor or tension of pelvic ligaments causing compression of the nerve.
  • Direct trauma from falls
  • Complications from surgery in the pelvis
  • Sustained compression from sitting: biking, horseback riding.
  • Sports activities with excessive bearing down: squatting, weightlifting, excessive core exercises
  • Constipation with associated straining
  • Joint dysfunction: hip joints, sacroiliac, sacrococcygeal


A thorough review of your history and a comprehensive physical examination is critical. The examination would include an evaluation of your spine, pelvic girdle, hips, and legs regarding joint mobility, muscle function, alignment, and general presentation (tight, loose, or weak). The exam would also include an internal examination to assess tone, function, and symptom reproduction. Diagnostic ultrasound imaging is also used to assess pelvic floor function and to provide biofeedback to the patient.

Based on examination findings is how treatment would be determined, and obviously, each case would be dealt with individually. Treatments vary but would include joint mobilization, myofascial and trigger point release via dry needling or manual technique, neuromuscular re-education to establish normal functional mechanics and resting tone, laser, extensive education on your current condition and established patterns, stress management and breathing assessment, and a home program to address mobility/tone issues and to help normalize function.

In many cases, these symptoms have become “chronic,”; meaning you’ve had them for quite a while. This, in turn, results in central sensitization, where your central nervous system has become very efficient in maintaining this pain pattern; it has become hypersensitive. Therefore, expectations must be managed to set realistic goals. A treatment plan is established based on objective findings and will change based on your response to treatment and feedback.

This condition can be managed in the right setting and with the right clinician. Savas Koutsantonis PT, DPT, CMTPT is a male physical therapist with an extensive history in treating persistent chronic pain conditions, especially concerning male pelvic health.


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About The Author

Savas Koutsantonis PT, DPT, CMTPTDr. Savas Koutsantonis, PT, DPT, CMTPT

Male pelvic floor physical therapist with over 35 years of clinical experience specializing in chronic pain conditions, male pelvic health, headache, and jaw issues.