A patient suffering from pudendal neuropathy or neuralgia, orperineodynia, with high pain scores reacting positive on our in housedeveloped 5% amitrptyline cream, pain severity decreased more than 50%after starting this cream. The pudendal nerve carries senations fromthe external genitals, the lower rectum, and the perineum (between thegenitals and the anus).

Neuropathy is in general  disease of the peripheral nerves, so pudendalneuropathy can cause symptoms in any of these areas. Some people havemostly rectal pain, sometimes with defecation problems. Others havemostly pain in the perineum or genitals. The symptoms may includestabbing, twisting or burning pain, pins and needles, numbness orhypersensitivity, all classical neuropathic symptoms. Usually thesymptoms are made worse by sitting, as in this patient.

Literature discussing the diagnosis and treatment of pudendal neuralgia or neuropathy without organic causes is scant. But the syndrome might not be rare. The International Pudendal Neuropathy Association (tipna.org) estimates the incidence of pudendal neuropathy in general to be 1/100,000. It is also suggested that most practitioners treating patients with this condition feel the incidence may be significantly higher. ^[1] Pudendal neuralgia is in general defined as a burning neuropathic pain in the distribution of the pudendal nerve, and the pain ican be lokalized in the glans penis, scrotum excluding testicles, perineum, and rectum in males. Sometimes, as also in our case, patients may also have pain adjacent to the area of innervation of the pudendal nerve such as in the thighs.  The phenomenology of this pain is comparable to other neuropathic painsyndromes: burning, cold, shooting, tingling, pins and needles.  Symptoms are especially present when patients are sitting down; in lying down or standing symptoms may vanish. 

The causes of pudendal neuropathy are many, entrapment and compression or stretching of the pudendal nerve in the Alcock's canal can induce the so called "pudendal canal syndrome" (PCS) "pudendal nerve entrapment" (PNE) or "pudendal neuropathy" ^[2][3] The most frequent causes are trauma, surgical injury and childbirth. In man pelvic trauma cause numer 1. Diagnosis is based on the anamnesis and physical examination, asthere are no imaging methods that diagnose pudendal neuralgia. Since 2008 most of us follow the Nantes Criteria for Diagnosis Pudendal Neuralgia ^[4]: 

1. Pain in the area innervated by the pudendal nerve—extending from anus to clitoris (or penis) 
2. Pain more severe when sitting 
3. Pain does not awaken patients from sleep 
4. Pain with no objective sensory impairment 
5. Pain relieved by diagnostic pudendal block

Description of the case of perineal pain

A 55 year old male patient visited our clinic with comlaints of chronic pain, numbness and tingling since 3 years. It started with cold sensations in the medial thighs and this sensation after some time also affected the perineum. Pain was more severe when sitting, but sleep was undisturbed. The neurological consultant did not find any objective sensory impairement. MRI from lumbar spine and pelvis were clean. There was a slight Peronie. The urologist did also not find any objective cause. The diagnose: pudendal neuropathy.  When we saw this patients, his painscores were 8 over 10 on an 11-points Likert scale. The patient however declined pharmacotherapy with pregabeline and pudendal blocks.

We treated this patient topically, administrating a 5% amitrptyline cream, and pain severity decreased more than 50% after starting this cream, to a score of 3-4 over 10.   

Jan M. Keppel Hesselink, MD, PhD, april 2010 

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