Pain in the pelvic floor region, including around the anus at the back or genitals at the front, may develop due to a problem along the pathway of one or more of the small nerves that supply skin sensation to this ‘saddle region’. When we refer to the ‘saddle region’, we mean the area between the hips that would contact a saddle when riding a horse or bicycle. Pain related to a nerve is called “Neuralgia”. You can read more about “neuralgia” in our previous blog . One of the more frequently experienced neuralgias is pudendal neuralgia.
Nerves Related to Pain in the Pelvic Floor and Pudendal Neuralgia
Nerves that supply the saddle region (see diagrams below) include:
- the genitofemoral nerve
- the pudendal nerve and its branches
- the inferior cluneal nerve
- the coccygeal plexus – small nerves that supply the area around the coccyx (the bone at the very bottom of your tailbone). The anococcygeal nerve serves the skin in this area.
* Please note: Nerve supply can overlap and be quite variable between individuals. The diagrams provided here only provide an approximate guide of skin supply of each nerve.
Pudendal Neuralgia – a frequent cause of pelvic floor pain
Pudendal neuralgia is the most common type of neuralgia reported in the saddle region. This small nerve may be compressed or irritated on its pathway through the buttock, where it travels from inside the pelvis to outside the pelvis and then turns around and travels into the perineal (pelvic floor) area. It runs between the strong pelvic ligaments (sacrospinous and sacrotuberous) and through a fibrous tunnel (Alcocks canal) and may be compressed or irritated on this journey.
Unfortunately, pudendal neuralgia is often misdiagnosed.
Symptoms of Pudendal Neuralgia
Symptoms of pudendal neuralgia include:
- pain over the external genitalia and the skin around the anus and perineum (see diagrams above)
- aggravated by sitting – sitting can put pressure on the nerve as it passes through the deep buttock area. In contrast, sitting on the toilet seat is not painful.
- pain that builds during the day but is usually better at night or when lying down, when the gravitational pressure on the pelvic floor, and thus the nerve, is reduced
- symptoms related to the nerve’s motor supply (the ability to make the muscles work/contract) to some of the pelvic muscles. Examples of this include:
- symptoms such as bladder frequency (needing to urinate frequently or urgently)
- the sensation of an urgent need to open the bowels and sexual dysfunction
- altered sensation/feeling or numbness in the perineal region (area between the pubic bone at the front, and the coccyx or tailbone at the back) served by the nerve (See pictures above)
Why might Pudendal Neuralgia occur
This condition may occur:
- following childbirth or pelvic trauma or surgery
- in association with sacroiliac joint problems
- due to hypertrophy (large size) of the piriformis muscle, where the muscle presses the nerve against the overlying sacrospinous ligament
- due to direct pressure in the area – e.g. long durations cycling or during hip arthroscopy surgery where a stabilising ‘post’ may press against the perineum
How can a Hip Pain Professional Help
Your Hip Pain Professional can:
- perform specific tests in the clinic to see if nerve involvement is likely
- provide treatments and give you exercises that may improve the health or movement of the nerve
- help improve health of the muscles and tendons beside the nerve (this may be the source of nerve irritation)
- review the positions you spend time in and activities you perform daily and provide strategies when performing these tasks that might help protect the nerve, thus reducing your symptoms. This may include changing your sitting or lying posture, or changing stretches or strength exercises that you have been performing that may be contributing to the irritation the nerve
- provide nerve gliding or mobility exercises that can be useful in some situations
- refer you for further tests or to a neurologist, orthopaedic specialist or other pain specialist if required.
- in some cases, your hip pain professional may refer you to a pelvic floor physio for further assessment should they consider the pelvic floor muscles are involved.
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We have aimed to bring you a thought provoking blog full of information on pelvic floor pain relating specifically to nerves. It will be no means provide all the answers for every individual. If you have ongoing pelvic floor pain, we strongly suggest you get in touch with a Hip Pain Professional with a special interest in pelvic pain. The Professionals on our Hip Pain Help Directory know hip and pelvic pain – get in touch now – click here. And remember – video consultation is an excellent alternative if the professional you think would be best for you is located too far away for a face-to-face visit. Make sure to give it a try.
We hope this blog has helped you to understand more about the ways nerves may be involved with pelvic floor pain, and in the case of pudendal neuralgia, what this condition is, why it may occur and the symptoms.
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Check Out More You Can Read on Self Help Ideas at HipPainHelp:
- Pregnancy Related Pelvic Girdle Pain Pregnancy related pelvic girdle pain is pain around the pelvic ring. This may develop during pregnancy but can persist into the time well after birth. Learn more about what this is, why and what you can do about it
- Is My Hip Pain Nerve Pain (Neuralgia or Radicular Pain)? Nerve pain can occur around the hip and pelvis. Nerve pain can be caused by many things. Radicular pain relates to the back, neuralgia to local nerves
- The Pelvic Floor and Pelvic Floor Pain (Vaginismus, Hypertonic pelvic Floor, Coccydynia)
- Pelvic Floor Pain, includes Vaginismus, Hypertonic pelvic Floor, and Coccydynia. Learn about the pelvic floor, pain and ways to help
- Coccydynia Pain and The Sacrococcygeal Joint – Tailbone Pain The sacrococcygeal joint is the joint in the tailbone formed between the sacrum and the coccyx. Pain here is known as coccydynia. Learn more
- Top Tips for Hip Pain Relief Sitting, when Socialising or Travelling Learn ideas for how you might reduce your pain when sitting, a position you need for doing so much in life.
- Top Tips on Hip Pain Relief Sleeping – Learn How Sleep is essential for wellbeing. Yet hip and pelvic pain can leave you struggling to find a comfortable position – we will help you with a few simple ideas.
Self Help Strategies For Hip Pain. Learn many tips, ideas and strategies on how you can reduce hip and pelvic pain
Many people with Pain in the pelvic floor also struggle with Buttock Pain – if you are struggling with buttock pain you may want to consider if you have Deep Gluteal syndrome. YOU CAN LEARN MORE ABOUT DEEP GLUTEAL SYNDROME AND HOW TO MANAGE IT IN THIS GREAT COURSE “”Recovering from Piriformis Syndrome, Deep Gluteal Syndrome or Hip Related Sciatica” – CLICK HERE or THE GRAPHIC BELOW TO LEARN MORE
This blog was written by Dr Alison Grimaldi and Kirsty McNab, physiotherapists who have over 50 years of combined professional clinical experience, dealing with patients suffering from a wide range of hip and pelvic conditions.
Dr. Alison Grimaldi BPhty, MPhty(Sports), PhD is Practice Principal of Physiotec Physiotherapy, an Australian Sports Physiotherapist and Adjunct Senior Research Fellow at the University of Queensland, author and global educator.
Kirsty McNab BSc Hons, MPhty(Sports), is Practice Principal of Physiologix and a highly experienced Sports and Exercise Physiotherapist having worked extensively with elite athletes, the Olympic Winter Institute of Australia, and Tennis Australia.
Nerve entrapment in the hip region: current concepts reveiw. Martin et al, 2017. Int J Sports Phys Ther. 2017 Dec; 12(7): 1163–1173.
Differentiating Hip Pathology From Lumbar Spine Pathology. Aaron et al, Journal of the American Academy of Orthopaedic Surgeons, 2017; 25 (2): e23
Coccydynia: An Overview of the Anatomy, Etiology, and Treatment of Coccyx Pain. Lirette et al Ochsner J. 2014 Spring; 14(1): 84–87.
Pelvic Girdle Pain – Pregnancy Care Guidelines. Australian Government, Department of Health.
Recognition and Management of Nonrelaxing Pelvic Floor Dysfunction. Faubion et al. Mayo Clin Proc. 2012 Feb; 87(2): 187–193.
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