Pelvic pain is very common in men, with estimates of about 1 in 9 men suffering from pain across the underside somewhere between the pubic bone and tailbone. We call this the “perineal region”. The main nerve that provides sensation and muscle control in the perineal region is the pudendal nerve.
The pudendal nerve is drawn in orange in the picture below. It arises from the sacrum (tailbone), and takes a relatively complicated path along the bottom of the pelvis to cover the whole pelvic floor from front to back. This path will be discussed in more detail later in this article.
Adapted from image by Mikael Häggström, used with permission.
The pudendal nerve provides sensation to the skin in the perineal region, including the penis, scrotum, and anus. It powers the muscles in this area, including the outer sphincters that control the bowel and bladder. It also plays a key role in control of bowel, bladder and sexual functions without having to think about them. To do this, it ties into the “autonomic” nervous system (often called the “fight or flight” system) which makes this area sensitive to emotional stress.
There are a few places along the pudendal nerve’s path where it can be compressed by other structures, causing it to become irritated. When this happens, there can be pain, tingling or unusual sensations anywhere in the territory of the nerve, from the top of the tailbone to the tip of the penis. This pain is known as “pudendal neuralgia”, which literally means “pudendal nerve pain”.
The pain here is usually described as burning, stabbing or shooting. There can also be tingling sensations or numbness. Symptoms are often worsened by activities that involve bending at the hip, for example sitting or squatting. Standing or lying down often relieves the symptoms. Sometimes sitting on a toilet relieves symptoms. Because of this nerve’s many functions, pressure on this nerve can also contribute to other troubling symptoms in the neighborhood such as erectile dysfunction, pain during ejaculation or urination, urinary urgency or frequency, bladder or bowel incontinence, and the like. Sometimes there can be pain in other areas as well. For example, many men with pudendal nerve pain also have a sore back or pain in the buttocks.
It’s a good idea to talk to your doctor about any new erectile, urinary or bowel symptoms, or any significant worsening in old symptoms. Sometimes there’s a medical cause for these symptoms that your doctor needs to look for. However, if no medical cause can be found, there’s a really good chance that it’s muscles or other tissues putting pressure on the nerve in the pelvic floor. In this kind of situation, pelvic floor physiotherapy can be very helpful.
In 2012, there was a study conducted in Australia in which 25 men with pudendal neuralgia without medical cause were treated with physical therapy, exercise and postural education.  Average duration of symptoms for all men was 4 years. Over a 3-month period, each man attended an average of 4 or 5 visits (although some attended as many as 16 visits). By the end of that time, 20 men reported that their symptoms had completely resolved. The remaining five men reported their pain had dropped to 1 out of 10 on average, compared to levels averaging 5 out of 10 before they started treatment.
When the men were contacted 3 months after the end of treatment, their results had not changed significantly. During that period, nine of the 25 men had experienced at least one flare up, but reported that their home exercises had been effective in bringing the symptoms back under control.
Aside from pain, there was improvement in some of the other problems that the men had been suffering with (sexual, bladder, and bowel difficulties). The level of change in these other problems was variable, but the improvements were still present when the men were asked about them 3 months later.
This study shows that in some cases, physiotherapy interventions can dramatically help pudendal neuralgia and other pudendal nerve symptoms, sometimes fairly rapidly.
There are a couple of main places that the pudendal nerve can become compressed.
In the illustration above, if you follow the nerve (drawn as orange) from left to right, it arises from spinal nerves as they leave the tailbone, then passes between a couple of strap-like ligaments (drawn as brown). These ligaments overlap more extensively than shown in the diagram, and the nerve can get sandwiched as it goes between them, particularly if the ligaments are pulled tight. Nerves need to be able to slide around between tissues, and pressure creates friction that can cause the nerves to get irritated. These ligaments get pulled tight in certain postural positions: slouched sitting is probably the worst offender (and usual culprit!).
After passing between the ligaments, the nerve passes through a tunnel in the tissues called the “pudendal canal” (drawn in yellow). This tunnel is actually a space between tissue layers along the edge of a muscle that is used to control hip position. If this muscle is tight or irritated, the tunnel can narrow, creating pressure and friction on the nerve, restricting its movement and causing it to become irritated.
Once the nerve leaves the tunnel, it divides into several branches. One of these branches (labelled as the “dorsal nerve of the penis”) continues forward, along the edge of the bone, to supply sensation to the penis. This branch is sometimes injured by using a hard or poorly fitting bicycle seat, and can cause tingling along the top or sides of the penis that many cyclists are familiar with.
There are several ways that physical therapy can help with these problems.
Ensuring that the tailbone is properly aligned and moving on the other bones of the pelvis can help reduce tension in the ligaments that the pudendal nerve passes between. There are a variety of hands-on techniques and home exercises that can help with this. Reducing tension in these ligaments can result in less compression on the nerve, and less resulting pain and other symptoms.
Soft tissue techniques are used to reduce muscle irritability and tightness along the pudendal canal. There are some easy stretches and other home techniques that can help keep these muscles loose, and reduce pressure on the pudendal nerve.
Because the pelvis is connected to the rest of the body, there can be problems in other areas that are contributing to the symptoms. Sometimes a fair bit of detective work is required to uncover and treat problems in the back, abdomen, legs or other areas that can be feeding the pelvic symptoms.
Your therapist can also help uncover and address particular postures, habits and activities that may be causing or aggravating the symptoms. As mentioned previously, poor or prolonged sitting posture is often the biggest culprit, but there can be many other contributors. Some men, for example, have a habit of clenching muscles near this nerve when they get under stress or perform various activities, which can increase pressure on the nerve and cause increased symptoms.
The symptoms described above occur when the nerve is irritated or compressed. They do not imply the nerve is trapped. Even if the nerve is stuck, this is likely to be a temporary situation caused by soft tissues putting pressure on it, and the types of techniques described above stand an excellent chance of getting it moving again.
If you have pelvic pain or other symptoms, physical therapy may be able to help! Call (403)249-5253 to book an appointment.
 P. R. Dornan and M. W. Coppieters, "A musculoskeletal approach for patients with pudendal neuralgia: a cohort study," BJU International, 18 10 2012. [Online]. Available: http://www.bjuinternational.com/case-studies/a-musculoskeletal-approach-for-patients-with-pudendal-neuralgia-a-cohort-study/. [Accessed 02 10 2018].