Understanding Pudendal Nerve Neuralgia: A Chiropractic & Pelvic Floor Practitioner's Perspective
- Marnie Hansen
- Aug 10
- 7 min read
Article written by Dr. Marnie Hansen, DC for Salt Lake Spine & Pelvis
"Everything looks normal..."
If you've been experiencing pain with sitting, burning pelvic pain, groin pain, discomfort during intimacy, incontinence, or unexplained numbness, you've probably heard those frustrating words or even been passed off from practitioner to practitioner without answers.
Just so you know... what you're experiencing is not so uncommon or mysterious. And it's very real.
One possible cause of these symptoms is a condition referred to as 'pudendal nerve neuralgia.' It's described as an irritation, compression, or entrapment of one of the pelvic floor's key nerves. It can be incredibly uncomfortable. But the good news is that, in many cases, it's an issue that can respond well to the right combination of movement therapies, treatment, and patience.
Let's break it down!
Meet the Pudendal Nerve
The pudendal nerve could be described as being like the communication highway in your pelvic floor. It branches off from Sacral Nerves S2-S4 (the lower spine or tailbone area), winds around the pelvic floor bones and ligaments, passes through or nearby many important layers of pelvic floor and hip muscles, and eventually branches through the lower pelvis. Its main job is to provide sensation throughout the pelvic region, including the genitalia, help you use the bathroom, and carry messages
between your brain and many of the structures that help you sit and use the bathroom.
It has to take quite the winding journey through the pelvis... which also means there are many areas where it can become compressed or entrapped along the way.
So...What Is Pudendal Nerve Neuralgia?
In short, "Pudendal neuralgia" simply means pain or discomfort caused by an irritated pudendal nerve.
It doesn't mean there is permanent damage to the nerve. In most cases, it's irritated and angry, and just looking for a little breathing room.
Just like hitting your funny bone, and how that twangs on the ulnar nerve in your elbow, the pudendal nerve can also become irritated or compressed by surrounding tissue inflammation, entrapped by scar tissue, stretched, or entrapped by muscles and pelvic floor structures over time. The nerve can even start sending pain signals to different areas of the pelvis and pelvic floor, even long after injury or insult.
What Does It Feel Like?
This can vary from person to person, but here are some common denominators in pudendal nerve neuralgia presentation:
Burning or electric-feeling pain in the groin or pelvis
Pain while sitting that improves when standing
Vaginal, vulvar, rectal, or perineal pain
Pain during or after intercourse
Tingling, numbness, or hypersensitivity
A feeling like you're "sitting on a golf ball"
Difficulty tolerating bike seats or prolonged driving
There's a reason I call it the sitting syndrome in my office: many of my patients have told me that they feel better when they are standing or walking, and worse after long periods of sitting. This is an important clue in putting the puzzle pieces of this frustrating condition together.
Why Does It Happen?
Here's where I put on my detective hat and have fun being a diagnostician. In my clinic, I usually find that there are many overlapping causes here, and the pudendal nerve itself isn't usually the original problem.
I usually find that it's the connective tissues, muscles, joints, and fascia surrounding or running nearby the nerve becoming dysfunctional first, leading to its irritation. Some key contributors for this can include:
Tight Pelvic Floor Muscles
When the pelvic floor muscles are chronically guarding or tense, they can place pressure around the nerve. It can be like wearing compression socks... only they are really, really tight. Eventually the nerve will complain to take them off, and reduce that choking pressure!
Obturator Internus Dysfunction
I see this a lot with my pelvic floor work. The obturator internus muscle is a deep hip muscle that sits right next door to the pudendal nerve and shares some of the same connective tissue with the pelvic floor. It helps your hips rotate (and you have two of them, by the way... one on each side).
If one or both of these muscles are tight, under-firing (weak), overworked, or have developed trigger points (uncomfortable bundles of muscle tissue that affect how the muscle moves and feels), this can contribute to pudendal nerve irritation, and pain can be referred into the pelvis or hip.
Many of my patients are surprised when they learn that what they thought was pelvic pain is coming from a hip muscle!
Scar Tissue
This is where previous surgeries or injuries play a big role. Hernia repairs, hysterectomies, C-sections, pelvic mesh procedures, significant tears during childbirth, or other pelvic surgeries can all create scarring to the surrounding tissues. This can change how all the tissues in the pelvic floor glide around and next to one another.
Scar tissue can be very gummy, fibrous tissue that can web around the nerves and be very painful and restrictive to the overall motion of the tissues around it. It's a great built-in tissue repair mechanism to have: as it does a good job repairing damaged tissues. However, if it doesn't heal properly, or the surrounding tissues are not addressed or mobilized appropriately, it can put the pudendal nerve in quite the sticky situation!
Sitting... Like A Lot
You have probably heard the term "sitting is the new smoking," as it can do serious damage to the posture and body as a whole. If done a lot over time, that is.
And we modern humans sure do our fair share of sitting. We spend hours at our desks, commuting, scrolling...
While our bodies are amazingly intelligent and adaptable, sitting for long hours can increase pressure throughout the pelvic floor and affect tissue movement around the pudendal nerve... not always for the better.
Welcome: pudendal nerve neuralgia. That poor little nerve being compressed all day with our jobs and duties can get a little grumpy under pressure. And rightfully so.
Low Back and SI Joint Problems
This is one of the biggest connections I see clinically, as the pudendal nerve branches off the sacral nerve roots. If your lower back or sacroiliac (SI) joints are not moving the way they should, the musculature in and around the pelvis will compensate. These adaptive patterns can affect pelvic floor muscle tone, increase tension, affect hip mechanics, and create the perfect storm for nerve irritation.
Most times, working with the spine can really help the pelvis!
How Do We Treat It?
First, we have to improve the environment around the nerve so it has a little "wiggle room."
Imagine being entrapped or encased in tight or restrictive tissue bundles or muscles; you'd probably start speaking up, too!
Phew.
So that's where we listen to what the nerve needs. Depending on the patient, treatments can include:
Chiropractic care to improve spinal and pelvic mechanics and mobility
Pelvic floor therapy to reduce excessive muscle guarding and balance muscle tone
Soft tissue work around the obturator internus, piriformis, adductors, glutes, and surrounding fascia. I sometimes even work with the psoas for a nice pelvic release.
Scar tissue mobilization after surgery when indicated
Breathing retraining to calm the nervous system and reduce pelvic floor tension
Postural correction and movement retraining
Home exercises to restore normal mobility and strength
Lifestyle modifications like standing or walking around every 30 minutes when sitting, core stability work, or strengthening
The awesome thing about nerves is that they usually respond really well to soft tissue mobility work and spinal mobilization therapies. They like taking the load off!
Three Gentle Exercises to Start
Remember: none of these should increase your pain. Think "gentle reset," not aggressive stretching. Make sure to listen to your body; if it's too much, stop. If you can safely push through without injuring yourself, give these a try:
1. Diaphragmatic Breathing
Lie comfortably on your back with your knees bent, hands on your belly or ribs.
Take a slow, deep breath into your lower ribs, back, and abdomen, feeling them expand.
As you inhale, imagine your pelvic floor gently softening downward and relaxing. It's ok; you can let it go :)
As you exhale, simply relax; feel how the pelvic floor naturally rises back up again.
Practice this for five or ten minutes.
No squeezing necessary; the goal here is releasing, relaxing, and letting go.
1. Child's Pose Rock Backs
Begin on your hands and knees.
Sit your hips gently back toward your heels, then slowly return to the starting position, while using diaphragmatic breathing, if possible. You might feel a nice pelvic floor stretch here if you let go!
Remember to move only within your comfortable range. Knee pads can be helpful here for sore knees, or even a cushion on the ground. Feel free to widen your knees for a deeper stretch (wide-leg child's pose).
Repeat 10-15 times while breathing slowly and intentionally.
This helps restore gentle movement through the hips, pelvis, and lower back, keeps the tissues mobile, and provides tissue circulation.
3. Happy Baby (Modified)
Lie on your back and gently hold your feet, or behind your thighs or knees.
Allow your hips to open and relax outward without forcing the stretch. Rocking back and forth like a happy baby is highly encouraged and can be quite relaxing!
Stay for 30-60 seconds while breathing deeply.
If this position increases symptoms, skip it for now, and return to breathing exercises instead.
A Final Thought
One of the most confusing parts of pelvic pain or pudendal nerve neuralgia is that it often feels like a mystery to decode.
The frustration is very common and very real, and you're not alone in it. There are many things you can do.
Getting a diagnosis of pudendal nerve neuralgia doesn't mean that you have permanent nerve damage. More often than not, it just means that the nerve is compressed or irritated because the surrounding tissues aren't optimally moving.
When we improve posture, calm overactive muscles and nervous systems, and restore healthy movement to the pelvic, spine, and pelvic floor, many individuals will find that the symptoms decrease and they can get back to doing the things they love.
If you have been experiencing persistent pelvic pain, know you don't have to just live with it. Get checked! A thorough evaluation of your spine, pelvis, and hips and their movement patterns could uncover pieces of the puzzle you may have never known were there. Your body and nervous system are amazingly adaptable, and with the right approach, have enormous capacity to heal.
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