What is Pudendal Neuralgia?
Pudendal neuralgia is debilitating chronic nerve-related pelvic pain condition. Symptoms are characterized by pelvic pain, usually in the genitals or ano-rectal area that are typically made worse by sitting, and can occur on one or both sides. Pudendal neuralgia pain often feels like a stabbing, aching, burning, pinching, numbing, or bruised feeling in the genitals and anus.

Other symptoms include:
Pain during sex, having to pee more often, pain with peeing or with bowel movements, labial/vaginal pain, penis pain, difficulty reaching orgasm, and erectile problems/dysfunction. The pain can also spread into the thighs and back.

The images below show the pudendal nerve branches at the pelvic floor and the nerve as it is formed inside the pelvis.

What causes Pudendal Neuralgia?
The kinds of things that cause pudendal pelvic pain / pudendal neuralgia are usually the following:
– Regular prolonged sitting
– Activities that put chronic pressure on the sitting bones and tailbone areas such as long-distance cycling, and rowing,
– Tension or compression of the nerve from straining with constipation and prolonged or traumatic childbirth (eg. forceps, suction), and from other forms of exercise such as squats and weight-lifting
– Pelvic surgery due to stretching or compression of the nerve because of the surgery itself or from positioning for it.

There are four places where the pudendal nerve can be compressed or irritated:

1. As it leaves the pelvis right beside the tailbone and passes by the piriformis muscle,
2. As it passes the coccyx and is pressed between the sacrospinous and sacrotuberous ligaments,
3. As it passes through the pudendal (Alcock’s) canal, a fascial tunnel formed by the obturatus internus fascia,
4. At or after the nerve splits into its terminal branches to the genitals (perineal nerve, inferior rectal nerve, dorsal nerve of the clitoris or penis).

Getting diagnosed is key, so be sure to talk to your doctor to get properly diagnosed. There are effective treatments available including pelvic health physiotherapy.

How can Pelvic Floor Physiotherapy help me?
Pudendal nerve blocks, and surgical interventions are often prescribed for pudendal neuralgia.
But emerging research shows that pelvic health physiotherapy, with a focus on pelvic floor relaxation, is an effective, non-invasive approach to treating the condition.
Internal myofascial releases, relaxation and breath training, and specific exercises and to get the nerve gliding with movement are key to pelvic physiotherapy treatment.

How can Osteopathy help me?
Osteopathy is key for addressing the spinal and pelvic joints that are in relation to the pudendal nerve and need mobilizing. Visceral manipulation of the fascias around the pelvic organs can be very helpful in releasing tension along the nerve pathway. But osteopathy does not just assess and treat locally. There is a deep understanding of the fascial, circulatory, neural and functional relationships between the pelvis and the rest of the body. So areas that seem far away from the pelvis and the pudendal nerve may be affecting it. Osteopathy assesses the whole body, and then addresses those areas also.

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Pain at the tip of the penis (glans penis) can be burning, itching, sharp, shooting, dull, achy, or a feeling of heaviness along the glans penis. It may happen with repeated sexual activity, prolonged sitting or standing or walking, specific positions or movements, stress, or a combination of any of these factors. Compression of the dorsal nerve to the penis (there is a right and left dorsal nerve) can be a part or the main issue, resulting from gripping or tightness of the pelvic floor, or there might be scar tissue affecting one or both of these nerves from sports injuries. Spinal problems can be the culprit, causing pressure on branches of the sacral nerves that fuse to form the dorsal nerves. Occasionally, muscle spasms of the pelvic floor muscles (aka levator ani muscles) can refer pain to the glans penis.

Pain at the base of the penis is a very common part of chronic pelvic pain in men and, just like tip of penis pain, can be aggravated by the same activities and stress. The pain can be achy or dull, and is usually associated with gripping of the pelvic floor muscles. Sometimes this happens after having one or more prostate infections where the muscle reaction to the pain of the infection does not subside even though the infection has cleared.

Hard Flaccid Syndrome is a condition of having a semi-rigid penis during the flaccid state when there is no arousal or desire, plus a cluster of other symptoms: altered sensation of the penis, difficulty maintaining an erection, and pain with ejaculation and/or urination. Initial causes are unclear but men often report an initiating trauma to the base of the penis, and typically present with pelvic floor and hip tightness affecting the nerves and blood flow to the penis.

In all three types of penis pain there may be spinal involvement, or scar tissue from prior injuries
as mentioned above with pain at the tip of the penis.

Pelvic floor physiotherapy and osteopathy assesses both locally and globally. Treatment has to address the layering of factors, including stress and anxiety. The result is a program of treatment including myofascial release, visceral manipulation, nerve glides, trunk mobility and core strengthening, cranial osteopathy, breath work, and stress reduction.

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The Vagus Nerve contains 75% of our parasympathetic system’s nerve fibers and is involved in many key functions:

1. Relaxation and stress response: the parasympathetic nervous system, and particularly the Vagus Nerve, is responsible for our rest and digest state which counteracts the fight/flight response of the sympathetic nervous system. Vagus Nerve activity acts to slow down the heart rate and lower blood pressure, promotubg feelings of calm and relaxation.
2. Breathing: The Vagus Nerve helps modulate the depth and rate of breathing by relaying messages between the lungs and the brainstem. It slows down the breathing rate, promoting deeper and more relaxed breathing.
3. Digestion: the Vagus Nerve stimulates the release of digestive juices and enzymes which helps with nutrient absorption, and it regulates gut motility which helps with bowel and bladder emptying.
4. Inflammation: The Vagus Nerve plays an important role in counteracting and reducing the body’s inflammatory response via what is known as the neural inflammatory reflex. When the brain receives information that there is inflammation in an area of the body, the Vagus Nerve output in turn suppresses it. Techniques to strengthen the Vagus Nerve’s ability to response include meditation and breathing techniques. And Neurostimulation of the Vagus Nerve is a relatively new approach to treating inflammation-mediated diseases (Neuroimmune Circuits Activated by Vagus Nerve Stimulation, Kuwabara, S., Goggins, E., Tanaka, S. doi: 10.1159/000518176. Epub 2021 Aug 17).
5. The Gut and Brain: there are extensive connections between the brain and the gut (our so-called “second brain”), and the Vagus Nerve fibers play a huge role in messaging back and forth about the state of digestion, the microbiome, motility, level of stress, etc.

What is the pelvic floor?
The pelvic floor is a group of muscles and connective tissues that stretch from the pubic bone to the tailbone, supporting the pelvic organs including the bladder and urethra, reproductive organs, bowel, rectum and anus. The pelvic floor has a crucial function in maintaining urinary and bowel continence, as well as facilitating sexual function. A healthy pelvic floor can contract, squeeze, lift and relax.
Common disorders of a weak pelvic floor include stress urinary incontinence, anal incontinence, and pelvic organ prolapse. Disorders of an overactive pelvic floor include overactive bladder, chronic pelvic pain, painful vaginal penetration, and erectile and/or ejaculatory dysfunction.

What connects the Pelvic Floor and the Vagus Nerve?
The winding extensive branches of the Vagus Nerve extend all the way to the pelvic floor. In many pelvic pain conditions there is muscle guarding of the pelvic floor. This muscle guarding can occur as a result of: visceral pain such as endometriosis pain, low back dysfunction, persistent sitting postures including prolonged cycling, and chronic anxiety.

Let’s look at chronic anxiety to show how a cycle of pain creates chronic pelvic pain:
-high anxiety elicits a stress response throughout the body
-certain muscles in your body including the pelvic floor muscles get tense and stay tense
-chronically tight pelvic floor muscles can cause pain or increase existing pain
-because anxiety lowers pain tolerance, painful sensations get stronger
-these painful episodes reinforce the idea that you need to be on high alert, fueling the cycle.

How can we access the Vagus Nerve to help the Pelvic Floor be as healthy as possible?
Techniques such as deep breathing exercises, meditation, and vagal maneuvers, have been proven to help activate the parasympathetic response and promote relaxation throughout the body.
Pelvic floor exercises, such as kegels, can be beneficial in strengthening the pelvic floor muscles and improve muscle tone.

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Pelvic floor muscle retraining (PFMT) is the primary non-surgical (or so-called “conservative”) treatment for pelvic organ prolapse

References:

1. Basnet R. Impact of pelvic floor muscle training in pelvic organ prolapse. Int Urogynecol J. 2021 Jun;32(6):1351-1360. doi: 10.1007/s00192-020-04613-w. Epub 2021 Jan 8. PMID: 33416965.
2. Mattox TF, Lucente V, McIntyre P, Miklos JR, Tomezsko J. Abnormal spinal curvature and its relationship to pelvic organ prolapse. Am J Obstet Gynecol. 2000 Dec;183(6):1381-4; discussion 1384. doi: 10.1067/mob.2000.111489. PMID: 11120500.
3. Resende APM, Bernardes BT, Stüpp L, Oliveira E, Castro RA, Girão MJBC, Sartori MGF. Pelvic floor muscle training is better than hypopressive exercises in pelvic organ prolapse treatment: An assessor-blinded randomized controlled trial. Neurourol Urodyn. 2019 Jan;38(1):171-179. doi: 10.1002/nau.23819. Epub 2018 Oct 12. PMID: 30311680.
4. Kari Bø,^1,2 Sònia Anglès-Acedo,³ Achla Batra,⁴ Ingeborg H. Brækken,^5,6 Yi Ling Chan,⁷ Cristine Homsi Jorge,⁸ Jennifer Kruger,⁹ Manisha Yadav,¹⁰ and Chantale Dumoulin^11. Are hypopressive and other exercise programs effective for the treatment of pelvic organ prolapse? Int Urogynecol J. 2023; 34(1): 43–52. Published online 2022 Nov 23. doi: 10.1007/s00192-022-05407-y
5. Ting Wang ¹, Zhengfang Wen ², Meng Li ^. The effect of pelvic floor muscle training for women with pelvic organ prolapse: a meta-analysis. Int Urogynecol J 2022 Jul;33(7):1789-1801.doi: 10.1007/s00192-022-05139-z. 

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Assessing and treating the local tissues of the pelvis is a key component of addressing this issue. And doing so in the context of the entirety of the whole body–the pelvic floor dose not live in isolation–is particularly important. There can be fascial and neuromuscular connections to other areas of the body such at the diaphragm and low back. There are visceral fascial connections to the bladder, uterus, colon, kidneys. Fluidic connections involve lymphatic and vascular vessels and their pathways through and around tissues plus dural fluidic links up to the cranium. This is where osteopathy, combined with physiotherapy, makes such a difference in making changes that are truly healing.

If you have any questions about this topic or the points discussed, please contact me!

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What is the Philosophy?

The philosophy of Osteopathy is based on four basic principles:

• Each structure in the body supports the body’s functions.
• The natural flow of the body’s fluids – lymphatic, vascular and neurological – must be preserved and maintained.
• The human body is the sum of its parts. Its physical, emotional, social, spiritual, and cognitive systems don’t work independently – they work in harmony.
• When the body has no restrictions, it has the inherent ability to heal itself.

Osteopathic Manual Practitioners recognize a person as an integrated whole. When all of the body’s components are in balance, a person is complete and in total health. Osteopathic Manual Practitioners work to maintain, improve and restore the normal physiological function of interrelated body structures and systems, enhancing the body’s natural ability to heal itself.

Using various manual assessment and techniques and modalities, Osteopathic Manual Practitioners work to identify and ease restrictions, constrictions and pain; reduce swelling; improve tissue mobility; and promote proper function and healing in people of all ages.

What types of techniques are used in osteopathy?

A combination of functional techniques, strain-counterstrain methods and facilitated positional release techniques.

• Direct techniques
  A combination of functional techniques, strain-counterstrain methods and facilitated positional release techniques.
• Indirect techniques
  A combination of functional techniques, strain-counterstrain methods and facilitated positional release techniques
• Balancing techniques
  Works on ligamentous tension and ligamentous articulatory strain
• Combined techniques
  Comprised of myofascial release, fascial unwinding, myotensive techniques, still techniques, exaggeration techniques, cranial techniques, and visceral and neural mobilization
• Reflex-based techniques
  Such as Chapman’s reflexes, trigger points and neuromuscular techniques
• Fluid techniques
  Including lymphatic and visceral pump techniques.

SOFT TISSUE MANIPULATION

Soft tissue manipulation can be used in many different ways. This method is used to evaluate the condition of tissues, ease restrictions, help the body’s fluids (blood, lymph, etc.) flow smoothly and restore function. Optimal neuro-vascular flow helps to reduce harmful fluid retention and allows the body’s immune system to work more effectively. Throughout the care, Osteopathic Manual Practitioners will continuously check on the state of the body’s tissues. The goal is to gently guide the tissue back to health without over-treating.

OSTEOPATHIC ARTICULAR TECHNIQUE

The osteopathic articular technique, involving gently moving two joint surfaces, is used to reduce muscle spasms, ease neurological irritations, assist in joint mobility and help reduce pain and discomfort. It is a less forceful technique than joint manipulation. Osteopathic Manual Practitioners will carefully prepare the soft tissues around the treatment area, positioning the patient so that there is minimal (if any) force needed to perform the maneuver.

CRANIAL OSTEOPATHY

As the gentlest osteopathic technique, Cranial Osteopathy is also one of the most significant. It is used to assess and treat the mobility of the skull and its contents. It may also be used to assess and treat the spine, sacrum and other parts of the body. The goal of this technique is to adjust the body’s physiology by restoring balance and optimal neuro-vascular flow surrounding the Central Nervous System and all of its autonomic centers. Osteopathic Manual Practitioners achieve this by treating the body’s inherent biorhythm. Osteopathic Manual Practitioners trained in this technique can feel this rhythm in the patient’s head, spinal cord, and in the sacrum and the rest of the body.

VISCERAL MANIPULATION

Visceral Manipulation is used to effectively treat fascial restrictions of the organs and viscera of the body, including the lungs, heart, liver, spleen, kidneys, stomach, pancreas, intestines, the bladder and the uterus. Osteopathic Manual Practitioners will gently move the fascia and ligaments that surrounds them to restore full movement. Applied with gentle pressure, visceral manipulation corrections can improve the mobility of an organ, improve neuro-vascular flow surrounding the organ and ultimately promote maximal organ function.

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It creates areas of thin white patchy skin that can become frail, resulting in tearing.

Some people do not have any symptoms, whereas others have intense itching and discomfort that occurs episodically, i.e. flares and then eases. Over time erosions can form which will heal by forming scar tissue. This scar tissue can lead to narrowing of the urethral, vaginal or anal openings, and in men, phimosis (scars preventing retraction of the foreskin).

Medical treatment is key, and involves potent corticosteroid creams.

The itchiness/pain/discomfort of lichens sclerosis typically results in muscular guarding of the area–a natural protective response to pain. Often the pelvic floor muscles tense and guard, resulting in painful intercourse, and sometimes difficult urination or bowel movements. Pelvic physiotherapy and osteopathy treatment is key for these issues by helping prevent scarring over of the clitoris, urethra, vagina and anus.

Contact me if you are interested further information about or treatment for this condition.

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Uterine pain or pain from endometriosis lesions and adhesions can cause the surrounding muscles–abdominals, hips, back, pelvic floor– to protectively tense and guard the area of pain. This muscular response is a typical protective response that occurs anywhere we experience intense pain.

Over time this muscular guarding of the pelvic area can result in chronic pelvic and vaginal pain, painful intercourse–from tissue shortening and chronic tension– and can contribute to poor fluid drainage of the pelvis and abdomen i.e. bloat and congestion. As a side note, this type of muscle holding in the pelvic area also contributes to jaw tension.

The way that pelvic physiotherapy and osteopathy treatment helps with these effects is by helping the tense and short muscles stretch and lengthen and then strengthen, and also by decongesting the abdomen and pelvis with lymphatic drainage. Visceral manipulation is an osteopathic technique that is also very helpful in normalizing, as much as possible, the mobility of the uterus, fallopian tubes and ovaries, colon and intestines.

Contact me if you are interested further information about or treatment for this condition.

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