The Diagnosis and Management of Pudendal Neuralgia

Abstract

Introduction

Pudendal neuralgia (PN) is a chronic neuropathic pain syndrome affecting the pudendal nerve, often presenting with perineal or pelvic pain exacerbated by sitting. The aim of this systematic review was to summarize the existing knowledge on the diagnosis and management of PN.

Methods

A PubMed database search identified 475 articles, of which 35 met the inclusion criteria. Nine studies focused on diagnostic strategies, and 26 on management.

Results

Diagnosis of PN is largely clinical, with the Nantes criteria providing a widely adopted framework. Imaging modalities such as MRI and MR neurography, along with neurophysiological tests including quantitative sensory testing, have been explored as adjuncts, though their roles remain limited. Pudendal nerve blocks are both diagnostic and therapeutic, with response rates up to 94%. Management follows a stepwise approach, beginning with conservative therapies and progressing to nerve blocks, and extending to neuromodulation or surgery when necessary. Pulsed radiofrequency and nerve stimulation techniques demonstrate promising results, with reported pain reduction in up to 95% of refractory cases, though long-term durability remains uncertain. Surgical decompression remains the most common operative option, with several techniques described.

Conclusions

Despite the established recognition of PN, there is a paucity of high-quality comparative studies and randomized controlled trials assessing diagnostic accuracy and treatment efficacy. Current evidence suggests conservative measures and nerve blocks are sufficient for most patients, with stimulation techniques and decompression surgery reserved for refractory cases. Emerging modalities may offer future therapeutic options, but require validation in larger cohorts.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40122-025-00803-w.

Key Summary Points

Diagnosis of pudendal neuralgia (PN) is primarily clinical, with the Nantes criteria serving as the gold standard; imaging (MRI/MRN) and neurophysiological testing can provide supportive, but not definitive, evidence.

Ultrasound and electrophysiological tests show limited diagnostic accuracy, whereas MR neurography may help identify structural abnormalities supporting a PN diagnosis.

Pudendal nerve blocks remain both a diagnostic and therapeutic cornerstone, showing success rates of 68–94% in pain reduction.

Nerve stimulation techniques—including pulsed radiofrequency, transcutaneous electrical nerve stimulation (TENS), and implantable neurostimulators—are effective in refractory cases, providing significant short-term relief, though long-term outcomes remain uncertain.

Surgical decompression is the main operative intervention for patients unresponsive to conservative and interventional therapies, with transgluteal, laparoscopic, and robotic approaches all demonstrating positive outcomes.

Emerging therapies such as cryoablation, lipofilling, and topical treatments show early promise as minimally invasive alternatives, but evidence remains limited to small cohorts.

The current evidence base is heterogeneous and limited by the lack of randomized controlled trials; future studies should focus on standardized diagnostic validation and comparative evaluation of management strategies.

Introduction

Pudendal neuralgia (PN) is a condition causing chronic pelvic and perineal pain in the distribution of the pudendal nerve. Generally, this onset of pain is subtle, being less severe in the morning and progressing through the day; and is often described as a burning, tingling, aching, stabbing, or electric shock-like pain. The pudendal nerve derives from the anterior divisions of the S2 to S4 roots of the sacral plexus. After its merging, the nerve travels between the piriformis and ischiococcygeus muscle, leaving the pelvis via the greater sciatic foramen, crossing the sacrospinous ligament and re-entering via the lesser sciatic foramen. Once in the Alcock canal, the nerve divides into branches; first giving off the inferior rectal nerve, then the perineal nerve, before continuing as the dorsal nerve of the penis in males or the clitoris in females. The nerve carries sensory innervation to the external genitalia—specifically the penile shaft and glans in males and the clitoris and glans in females—as well as to the skin around the anus, the anal canal, and the perineum. It also provides motor innervation to various pelvic muscles, including the external urethral sphincter and the external anal sphincter [1–3].

The condition is noted to affect both genders, though it is notably more prevalent in women, at a ratio of 2:1 [4]. The estimated incidence of PN is estimated to be 1 in 100,000 by the International Pudendal Neuropathy Association, though this is almost certainly an underestimate due to the complexity of diagnosing the condition [5, 6]. Pudendal neuralgia is most commonly caused by entrapment, which can be subdivided into four categories based on pathology; 1. Entrapment below the piriformis muscle, 2. Entrapment between the sacrospinous and sacrotuberous ligaments, 3. Entrapment in the Alcock canal, 4. Entrapment of the terminal branches. Other notable causes of pathology include cancer, obesity, and childbirth-associated trauma to the pelvis [6, 7].

Pudendal neuralgia is frequently overlooked or misdiagnosed because its symptoms can be vague and easily mistaken for other conditions. Common signs include perineal pain that worsens when sitting and improves when standing, affecting both men and women. Women may experience urinary urgency or frequency, difficulty reaching orgasm, or discomfort in the vaginal or vulvar area. Men may report painful ejaculation, testicular pain, or sensations of a foreign object in the urethra. Both genders can experience a feeling of a foreign object in the rectum or anus, or issues related to external anal sphincter control [8]. As symptoms often appear separately—such as isolated chronic anal pain or vulvodynia—the diagnosis of pudendal neuralgia is frequently missed.

This review aims to compile the currently recognized diagnostic and management options available in PN described in the literature and evaluate their effectiveness in PN diagnosis or management.

Methods

Literature Search Strategy

An online literature search was conducted using PubMed on December 3, 2024, using two medical subject heading (MeSH) terms. Term A was “pudendal” OR “Alcock canal” in the Title or Abstract; term B was “pain OR neuralgia OR chronic pelvic” in the Title or Abstract. Three filters were applied; these ensured that the results were available in English, involved only human participants, and provided access to the full text.

We also reviewed the reference lists of the identified papers to find additional eligible studies that may not have appeared in our initial literature search.

Inclusion and Exclusion Criteria

Articles deemed eligible to be included in this review had the following characteristics:

• The study discussed the diagnosis or management of pudendal neuralgia.

• The study subjects were human.

• The study language was English.

• The studies were available in full text.

Articles were excluded for the following reasons:

• Studies discussed pudendal neuralgia, but did not provide helpful information on diagnosis or management

• Studies discussed the pudendal nerve in irrelevant pathologies (i.e., prostatitis)

• Article was a review, single case report, or case series with five or fewer patients

Two researchers were responsible for screening the search results. The abstracts were examined in a primary screening to produce a list of papers suitable for secondary screening of full text, to be analyzed for eligibility for inclusion in the review.

The screening process was carried out in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines [9]. The PRISMA item checklist is available as Supplementary material. The quality of papers was assessed through recognized scoring scales such as the Jadad score for randomized control trials [10] and the Newcastle–Ottawa scale for case–control and cohort studies [11], and is available as Supplementary Material.

Ethical Approval

This paper was registered in the PROSPERO database for meta-analysis and systematic reviews (Registration number CRD420251027007). This article is based on previously conducted studies and does not contain any new studies with human participants or animals performed by any of the authors.

Results

A total of 475 papers were identified following the search string. After screening, 34 papers met the inclusion criteria. One more paper was found following reference searching, leading to 35 total eligible papers. Figure 1 illustrates the study selection process.

Fig. 1.

PRISMA chart

Of the 35 papers reviewed, nine focused on diagnostic strategies and 26 on management strategies. In terms of study design, 27 were cohort studies, three were case series, three were RCTs, one was an open-label study, and one was a case–control study.

Diagnosis

Nantes Diagnostic Criteria

The clinical diagnostic criteria for PN were universally ratified in the Nantes criteria [12]. Following a multidisciplinary meeting in Nantes, France, in 2006, a defined clinical criterion for PN was established. Following the recognition by SIFUP-PP (Société Interdisciplinaire Francophone d'UroDynamique et de Pelvi-Périnéologie) the criteria gained international recognition and have become the staple criteria for diagnosing PN. The development of this algorithm was pivotal to the diagnosis and recognition of pudendal neuralgia. Prior to this framework, pudendal neuralgia was often diagnosed as only its symptomology, such as isolated vulvodynia or isolated chronic anal pain. Diagnosis relied on vague bedside testing or clinical presumption.

Five absolute inclusion criteria have been included: pain in the territory of the pudendal nerve (from the anus to the penis or clitoris); pain predominantly experienced while sitting; pain that does not wake the patient at night; pain with no objective sensory impairment, and pain relieved by diagnostic pudendal nerve block. Similarly, absolute exclusion criteria have been described: pain that is exclusively coccygeal, gluteal, pubic, or hypogastric in nature; presence of pruritus, exclusively paroxysmal pain, and imaging abnormalities able to account for the pain. To be diagnosed with pudendal neuralgia, a patient must exhibit all five inclusion criteria and demonstrate the absence of all exclusion criteria. There is some leniency to this in that the first four absolute inclusion criteria may be enough to diagnose PN, given that nerve blocks can be both diagnostic and treatment options, a clinical may choose to diagnose PN based on the presence of the other four absolute criteria in conjunction with the absolute exclusion criteria and positive supplementary criteria. Supplementary clinical signs for diagnostic aid are also described in the criteria. The full criteria are presented in Table 1.

Table 1.

Nantes diagnostic criteria [12]

Essential criteria	1. Pain in the territory of the pudendal nerve 2. Pain is predominantly experienced while sitting 3. Pain does not wake at night 4. Pain with no objective sensory impairment 5. Pain relieved with diagnostic nerve blocka
Exclusion criteria	Exclusive pain in the region of the coccygeus, pubis, gluteus, or hypogastrium Pruritic sensation Exclusive paroxysmal pain Pain can be accounted for by imaging abnormality
Supplementary diagnostic criteria	Allodynia or hyperpathia Pain triggered by defecation Foreign body sensation in the rectum or vagina Worsening pain throughout the day Burning, shooting, or stabbing pain Numbness Predominately unilateral pain Presence of exquisite tenderness over the ischial spine
Associated signs	Buttock pain on sitting Urinary incontinence or frequency Erectile dysfunction Dyspareunia or pain after sexual intercourse Suprapubic or sciatic pain Normal clinical electrophysiology

All five essential criteria must be met for a definite diagnosis of pudendal neuralgia

^aAs diagnostic nerve block is both a diagnostic and a management strategy, pudendal neuralgia can be preliminarily diagnosed if the first four essential criteria are met with certainty, alongside further supplementary criteria

Figures 2, 3, 4, and 5 illustrate the anatomical course of the pudendal nerve, the sites of entrapment and the distribution of the PN in males and females.

Fig. 2.

Three-quarter view of the pudendal nerve course in a female in the sitting position. The pudendal nerve derives from the anterior divisions of S2-S4 roots of the sacral plexus. It exits the pelvis through the greater sciatic foramen, crossing the sacrospinous ligament and re-entering via the lesser sciatic foramen. It then travels through Alcock canal, dividing into three branches: inferior rectal nerve, perineal nerve, and dorsal nerve of the clitoris (respectively, dorsal nerve of the penis in males). The pain distribution area observed in pudendal neuralgia is marked with diagonal lines

Fig. 3.

Three-quarter view of the pudendal nerve course in a male in the sitting position. The image has been divided to showcase the four categories of pudendal nerve entrapment: 1. Entrapment below the piriformis muscle, 2. Entrapment between the sacrospinous and sacrotuberous ligaments, 3. Entrapment in the Alcock canal, 4. Entrapment of the terminal branches. The pain distribution area observed in pudendal neuralgia is marked in diagonal lines

Fig. 4.

Bilateral pudendal neuralgia pain distribution area in a male in the lithotomy position

Fig. 5.

Left pudendal neuralgia pain distribution area in a female in the lithotomy position

Imaging

Ultrasound (US) as a diagnostic tool was assessed in a study by Tagliafico et al. [13]. Ten patients with clinically diagnosed PN according to the Nantes criteria were assessed. The pudendal nerve was considered pathological if it displayed abnormal findings in accordance with defined criteria in the literature of US-supported diagnosis of peripheral nerves (increased cross-sectional area (CSA) in the compression site or related extrinsic compression, focal or diffuse increased CSA, shape, and echogenicity). Of these ten patients, US showed at least one of the above-described findings in eight patients (sensitivity 80%).

Color duplex US was assessed in a study by Mollo et al. [14]. This study looked at assessing PN specifically caused by pudendal nerve entrapment in 83 patients with suspected PN (166 nerves). All 166 nerves were evaluated using the Nantes criteria and 67 nerves were deemed to be pathological based on the Nantes criteria and thus eligible for inclusion. The technique involved cutaneous scanning of the abdominal and pelvic vessels with a Nemio Color Duplex ultrasound machine (Toshiba Medical Systems Corporation, Japan), using a convex array transducer (3.75 MHz) and an endocavitary array transducer (6.0 MHz) imaging probe and pulsed Doppler. Of the 67 nerves, color duplex ultrasound identified 60 nerves showing pudendal vascular entrapment in keeping with a PN diagnosis. This conferred 90% sensitivity and 67% specificity. Magnetic resonance imaging (MRI) and magnetic resonance neurography (MRN) as diagnostic tools were examined in two studies [15, 16].

Ly et al. performed MRN using of a 3-T machine in diagnosing PN in 139 nerves meeting the diagnosis of PN based on the Nantes criteria [15]. They reported that MRN identified positive findings suggestive of PN in 90 out of 139 nerves assessed, corresponding to a sensitivity of 65%. Notable pathology was scarring around the pudendal nerve or thickening of ligaments such as the sacrospinous or sacrotuberous.

Piloni et al. [16] assessed MRI as a diagnostic tool in 580 patients with chronic pelvic pain in keeping with Nantes criteria PN. They note that 454 patients displayed radiological findings (hyperintensity or distortion of the nerve pathway) supporting a diagnosis of PN and suggesting a sensitivity of 78%. They note three MRI findings consistent with PN; (i) damage of the pudendal nerve along the Alcock canal affecting the labial and clitoral branches (female) and scrotal or dorsal penis nerve (male); (ii) involvement of the gluteal or sciatic nerves at their encroachment with the greater or lesser sciatic foramen and (iii) increased signal intensity in close proximity of the ischial spine.

Neurophysiological Testing

Beco et al. [17] evaluated the usefulness of thermal quantitative sensory testing (QST) comparing 90 females with suspected PN based on the Nantes criteria with 41 considered healthy women. The technique involved placing the patient in a gynecological position, assessing the pudendal nerve through three branches (inferior rectal nerve, perineal nerve, and dorsal nerve of the clitoris). A baseline temperature of the patient and the room was taken. A contact thermode of Peltier elements (sized 18 × 18 mm) was then applied to the skin set at a baseline temperature equivalent to the skin temperature. For each threshold (warm and cold), five stimuli were applied, at a thermal rate of change of 1 °C/s, with an interstimulus interval randomly distributed within 4–6 s. For each stimulus, the patients were instructed to press a button at the first sensation of cold or warm (detection threshold) at which point the temperature was recorded and returned to the baseline temperature. An average of the five stimulations was taken to record an overall cold detection threshold (CDT) and warm detection threshold (WDT). Detection thresholds were compared between healthy individuals and suspected PN patients at six levels: left thenar eminence (TNR), left para-anal (LPA), right para-anal (RPA), left labia (LLB), right labia (RLB), and clitoris (CLT). On average, CDT values were lower in the 90 patients than in healthy controls: respectively, with a 45% reduction at the LPA (p = 0.044), a 12% reduction at the RPA (p = 0.17), a 41% reduction at the LLB (p = 0.0004), a 39% reduction at the RLB (p = 0.0024), and a 30% reduction at the CLT (p = 0.030). WDT were not significantly different at any level between pathological patients and healthy controls.

Antolak and Antolak [18] looked at the WDT in 25 male patients with chronic pelvic pain caused by PN. The technique involved the use of an NTE-2C Thermoprobe and Controller (Physitemp Instruments Inc., Clifton, NJ, USA). The thermode (surface measuring 0.44 cm²) was placed on the skin and set at a baseline of 31.5 °C, which was then increased in a three-stage stepping algorithm with temperature increments of 4°, 2°, and 1 °C. Quantitative and qualitative subject responses were recorded, in which quantitative responses were direct measures of WDT and qualitative responses were patient-reported symptoms such as dysesthesia or allodynia. They noted that of the 25 patients, 22 showed abnormal quantitative WDT (sensitivity 88%), and all 25 showed a qualitative abnormal WDT.

Notably, in clinical practice and other electrodiagnostic strategies can be used to supplement the diagnosis of PN. Such methods include somatosensory-evoked potentials (SSEP), pelvic floor electromyography (EMG), bulbocavernosus reflex, and pudendal nerve terminal motor latency (PTMNL); however, we did not identify relevant publications meeting our inclusion criteria. These tests are recommended as supplementary tools to allow for clinical suspicion of pudendal neuropathy to which further testing may be warranted [1, 6].

Diagnostic Nerve Blocks

As noted by Labat et al. [12], a pudendal nerve block (PNB) is both a diagnostic and management strategy. Two papers were found that looked at using PNBs as a diagnostic tool for PN, Dickson et al., and Vancaillie et al.

Dickson et al. [19] performed transrectal guided nerve blocks in 76 patients (61 females and 15 males) to aid in the diagnosis of pudendal neuralgia. Patients were delivered an injection containing 20 ml of 0.25% bupivacaine hydrochloride and 40 mg methylprednisolone acetate via a transrectal approach. Of these patients, 62% reported a positive response and thus fulfilled the fifth Nantes criteria. When asked to quantify their pain post block, 63% reported some positive effect 72 h post block; 4% reported an excellent effect, 49% experienced a good effect, 6% reported some effect and 4% reported a delayed effect. Three patients reported a side effect of unilateral numbness, but this was not long-lasting.

Vancaillie et al. [20] performed transvaginal finger-guided nerve blocks in 82 women. Patients received a single 5-ml injection of levobupivacaine 0.5%. The 82 women were assessed at 64 h post PNB to assess for positive response conforming to a diagnosis of PN; of which 66/82 (81%) fulfilled the fifth Nantes criterion. Seven patients reported minor side effects such as incontinence or headache, but none of these lasted beyond 24 h. These 66 women were assessed again at 1 month for therapeutic of which 57/66 (87%) had a reduction in one or more pain symptoms such as vulvodynia or anal pain, while 29/66 (44%) reported that more than one of their pain symptoms had not returned.

Management

Nerve Block

Pudendal nerve blocks were discussed as a management strategy in six papers: Basol et al. [21], Mamlouk et al. [22], Ly et al. [15], Labat et al. [23], Kastler et al. [24], and Benson and Griffis [25]. Generally, a pudendal nerve block will consist of an anesthetic agent and a steroid. Three methods of delivery were described in the literature: a transvaginal approach, a transrectal approach, and a transcutaneous approach (often with the aid of CT-guided imaging). Table 2 summarizes these studies.

Table 2.

Summary of PNB-focused papers

Authors (year)	Population (male: female)	Approach	Regimen	Findings
Ly et al. [15] (2019)	91 patients, 139 injections (29:62)	CT-guided transcutaneous	2 ml of 2% lidocaine + 2 ml of 0.5% bupivacaine + 1 ml of 4 mg dexamethasone	93/139 injections reported positive results (41 were absolutely positive and 52 were possibly positive 46/139 injections reported no effect No side effects were reported
Basol et al. [21] (2022)	56 women	Transvaginal	8 ml of 0.5% bupivacaine + 2 ml of 8 g dexamethasone	Mean VAS pain scores decreased from 9.05 to 3.31 at final follow-up of 24 months (p < 0.001) 56/56 women reported some improvement in pain symptoms at final follow-up with 29 (52%) reported a > 50% reduction in pain, 8 (14%) reported a 30–50% reduction in pain and 19 (34%) reporting a < 30% reduction
Mamlouk et al. [22] (2014)	31 patients, 52 injections (3:28)	CT-guided transcutaneous	5 ml of 1% bupivacaine + 2 ml of 80 mg triamcinolone acetonide	Mean VAS pain scores decreased from 6.13 to 2.14 at final follow-up of 6 weeks (p < 0.001) 2/31 patients reported no improvement 14/31 patients opted to have further surgical decompression
Labat et al. [23] (2016)	3-arm RCT, 201 patients (78:123)	CT-guided transcutaneous	Arm 1: 4 ml of 1% lidocaine only (67 patients) Arm 2: 4 ml of 1% lidocaine + 0.5 ml of 40 mg methylprednisolone Arm 3: 4 ml of 1% lidocaine + 0.5 ml of 40 mg methylprednisolone + 30 ml NaCl	8/67 patients reported improvement in arm 1 while 10/68 reported improvement in arm 2 (p = 0.62) There was no significant improvement in any other metric in all three arms Corticosteroid provided no additional pain relief
Kastler et al. [24] (2018)	95 patients, 155 injections (34:61)	CT-guided transcutaneous	1 ml of 1% lidocaine + 2 ml ropivacaine hydrochlorate + 1.5 ml cortivazol	Mean VAS pre-procedure was 8.06 ± 1.38, at 1 month 2.07 ± 1.24, at 3 months 2.90 ± 0.85 and at 6 months 3.29 ± 0.6. SRI scores were 71%, 62.3%, and 60.4%, respectively. Mean VAS scores were significantly different at 1 and 3 months, p < 0.05, however were not significantly reduced at 6 months, p > 0.05
Benson and Griffis [25] (2005)	64 patients (18:46)	Transrectal	9cc of 1% lidocaine + 1cc triamcinolone	All 64 patients started on conservative treatment, of which all 64 reported some relief but not complete relief 38/64 patients opted for a nerve block of which 12/38 reported improvement

CT computed tomography, VAS Visual Analog Scale

Transvaginal Nerve Block

Basol et al. [21] assessed transvaginal nerve blocks in 56 women. Mean VAS scores decreased significantly from 9.1 to 3.3 (p < 0.001); 56/ 56 (100%) reported some improvement. Mamlouk et al. [22] performed 52 CT-guided transcutaneous nerve blocks in 31 patients (three males, 28 females). Pain scores significantly reduced from pre to post procedure, 6.1–2.1, p < 0.001. 29/31 (93.5%) reported a positive response at final follow-up while 2/31 (6.5%) reported no effect.

Kastler et al. [24] performed 155 transcutaneous CT-guided nerve blocks in 95 patients (34 males, 61 females) with Nantes criteria positive PN. Mean VAS significantly decreased from 8.06 ± 1.38 pre-op to 2.90 ± 0.85 at 3 months (p < 0.05) SRI scores were 71% at 1 month, 62.3% at 3 months and 60.4% at 6 months. Ly et al. [15] performed 139 transcutaneous CT-guided nerve blocks in 91 patients (29 males, 62 females 93/139 were reported as positive.

Benson and Griffis [25] compared conservative management versus transcutaneous CT-guided nerve injection in 64 patients (18 males, 46 females); 100% of patients reported some degree of pain relief after conservative management, though no patient reported complete relief. Thirty-eight patients opted for a PNB of which 12/38 (31.5%) reported improved pain relief and 26/38 (68.4%) reported no positive additional effect.

Labat et al. [23] performed a three-armed, 201-patient (78 males, 123 females), RCT comparing CT-guided nerve block alone (n = 67) vs. CT-guided nerve block and a corticosteroid (n = 68) vs. CT-guided nerve block, a corticosteroid, and normal saline (n = 66). There was no significant difference in any pain metric or quality of life metric between any of the three arms.

Nervous System Stimulation

Nervous system stimulation was discussed in nine papers [26–34]. Several techniques for nervous system stimulation have been described, including pulsed radiofrequency (PRF), locally implanted devices that directly interact with the pudendal nerve, and centrally implanted devices that interact with the central nervous system either at the level of the spinal cord or at the brain. Table 3 summarizes the papers found discussing nervous system management strategies.

Table 3.

Summary of nervous system stimulation interventions

Author (year)	Population (male: female)	Technique	Main findings
Wang and Song [26] (2022)	Seventy naïve patients (26:44)	Superficial PRF performed at 42 °C, 2 Hz and 20 ms for 900 s Voltage started at 40 V and was gradually increased until the patient was unable to tolerate the abnormal sensation; the maximum voltage was 70–90 V	Mean VAS scores were taken at baseline, and at 1, 4, and 12 weeks post-procedure. Mean VAS pre-op: 5.97 ± 1.01; 2.40 ± 1.03 at 1 week; 2.74 ± 0.95 at 4 weeks, and 3.37 ± 0.97 at 12 weeks; p < 0.001 at all three intervals Quality of life using the SF-36 and depression scores using the PHQ-9 were also significantly improved post-treatment at all three time-points
Krijnen et al. [27] (2021)	Twenty female patients who failed conservative therapy and PNB’s	Superficial PRF delivered using a 45 V current in pulses of 20 ms with a frequency of 2 Hz for a duration of 240 s	Patient assessment was performed using a Patient Global Impression of Improvement (PGI‐I) scoring tool at two follow-up periods of 3 months and 2 years After 3 months, 1 patient was lost to follow-up but 15/19 (79%) reported their condition as improved and 1 reported their condition as worsened All 19 patients received a further regimen of PRF and were assessed at 2 years; at which 15/19 reported continued improvement, 2/19 reported new improvement, one reported no change and one reported worsening
Ji et al. [28] (2021)	Twenty patients who failed drug therapy (6: 14)	US-guided superficial PRF performed at a temperature of 42 °C, stimulation frequency 2 Hz, pulse width 20 ms, and duration 900 s	Mean VAS scored were measured at baseline and then 7 days. Change in VAS score was assessed from 7 days to 6 months VAS significantly decreased from baseline 7.0 ± 0.9 to 3.2 ± 1.7 on day 7 (p < 0.05) and remained steady till 6 months 18/20 remained in remission at 6 months, 2/20 reported no obvious pain relief
Masala et al. [29] (2014)	Twenty-six patients who failed conservative therapy (10: 16)	CT-guided superficial PRF delivered at parameters of 1200 pulses at 45 V with 20-ms duration followed by 480-ms silent phases	Mean pre-procedure VAS was 9 ± 0.7 (range 8.3–9.7). The mean VAS was 3.8 ± 1.7 (range 2.2–5.5) at 1-week post-procedure, 2.2 ± 1.2 (range 1.0–3.4) at 2 months, 1.8 ± 1.4 (range 0.4–3.2) at 3 months, 1.5 ± 1.1 (range 0.4–2.6) at 6 months and 1.9 ± 0.7 (range 1.2–2.6) at 1 year. These reductions were significant at all checkpoints, p < 0.05
Eid et al. [32] (2021)	52 male patients double-blinded RCT Arm 1 (n = 26): TENS therapy + physical therapy exercise program + analgesic medication Arm 2 (n = 26): physical therapy exercise program + analgesic medication + sham TENS	Transcutaneous electrical nerve stimulation (TENS) delivered at the rectus abdominus, hip adductors, gluteus medius, gluteus maximus, piriformis, and quadratus lumborum muscles	The NRS pain scale decrease in the control group went from 9.51 ± 0.51 to 6.22 ± 2.22 while the NRS scale in the intervention group fell from 9.44 ± 0.5 to 4.25 ± 1.9. The average NRS decrease between both groups, post-intervention, was significant (p < 0.001) Overall NRS decrease was more significant in the intervention group than the control group, p < 0.05
Peters et al. [30] (2014)	Nineteen patients who failed pain relief via PNB or sacral stimulation (7:12)	In a two-stage process, a quadripolar lead connected to an external battery was placed at the pudendal nerve using the ischial-rectal approach in stage 1. Patients progressed to stage 2 if urinary and/or pain symptoms improved by at least 50% after initial lead placement; the lead was connected to an implanted pulse generator (IPG) during a second procedure	All 19 patients reported some improvement in pain and urinary symptoms after 2 weeks (three reported complete pain relief, three reported almost complete relief, ten reported significant relief, and three reported small relief) At final follow-up, 10/19 patients responded to the survey (five had their device explanted, three reported loss of efficacy, and one was no longer using the device) Of these ten patients, 8/10 reported complete satisfaction and 2/10 reported neutral feeling towards the management. All ten were happy to continue using the device long term
Roberts et al. [31] (2021)	Thirteen naïve PN patients (1:12)	Stimwave: the device consists of two parts: a 45-cm long-tined quadripolar lead, which houses the circuit board, receiver, and electrodes, and an external wireless wearable antenna assembly (WAA), which contains the radio frequency generator and transmitting antenna. Pulsed radiofrequency signals are sent wirelessly from the WAA to the receiver stimulating the electrodes, which are then activated to produce an electric field to nearby nerves, thus blocking pain signals The average setting was a pulse rate of 924 Hz (779.5–1332.67 Hz), pulse width of 105.7 ms (53.3–126.7 ms), and power of 0.67 mA (0.5–1.25 mA) Patients were trialed in a two-stage process. All patients were trialed for 6–11 days and those who reported > 50% pain reduction were offered long-term Stimwave therapy	After the initial phase 10/13 (76.9%) reported a > 50% reduction in pain with 6/13 (46.1%) reporting complete pain relief; 9/10 chose to have long-term Stimwave therapy At last post-operative visit, 5/9 (55.6%) reported continued benefit with long-term Stimwave. Two patients chose to have their device explanted at this stage Seven patients responded to phone call at 1 year, of which 100% reported continued benefit, with two reporting markedly improved pain, four reporting moderately improved pain, and one reporting mildly improved pain
Hodaj et al. [33] (2020)	Eighteen patients who failed PNB or surgical decompression (5:13)	repetitive transcranial magnetic stimulation (rTMS) of the motor cortex The device uses an angled B70 figure-of-eight coil delivering a 10 Hz stimulus at 80% of the resting motor threshold at the vertex of the motor cortex. The rTMS protocol consisted of an induction phase of one session per day for five days during two consecutive weeks, then 2 sessions in the next week for a total of 12 sessions. Then, in patients with analgesic response, a maintenance therapy was undertaken, consisting of one rTMS session in week 4 and then bi-monthly sessions for the next five months, for a total of 11 sessions	At the end of induction phase, 12/18 patients reported some positive response with 4/12 reporting very good response and 8/12 reporting moderate response Average VNS pain scores went from 5.4 ± 1.9 to 3.7 ± 3.0, p = 0.013. NPSI for burning and spontaneous pain and SF36 scores also significantly decreased At final follow-up, 6/12 patients reported continued pain relief, five reported relapse, and one was lost to follow-up
Buffenoir et al. [34] (2015)	Twenty-seven patients who failed decompressive surgery (5:22)	Implanted device directly stimulating the conus medularis. One of three types of stimulation electrodes (Lamitrode™ S8 electrode, St Jude Medical, Inc.; Lamitrode™ 44C two-column electrode, St Jude Medical, Inc.; Specify™ three-column electrode, Medtronic, Inc.) was implanted under fluoroscopic guidance. A trial induction phase was used in all 27 patients, after which a maintenance phase was induced if a < 50% reduction in pain was reported Stimulation intensity ranged between 1.4 and 8.7 mA, stimulation pulse width ranged between 60 and 325 μs and stimulation frequency ranged between 50 and 200 Hz	At the end of the induction phase, 20/27 patients reported a < 50% reduction in pain. The mean reduction of the maximum pain score was 54% [range 35–83%] and the mean reduction of the average pain score was 57% [range 25–87%] at the end of the induction phase Of the 20 patients, 19 reported for final follow-up (one was lost due to death by suicide). All 19 patients reported continued positive effect after the test phase. Mean VAS pain scores significantly decreased from 55.0 ± 13.1 to 26.2 ± 10.1, p < 0.001. Mean reduction of 53.5% (VASmax), and 51.4% (VASaverage)

CT computed tomography, VAS Visual Analog Scale, NRS Numerical Rating Scale

Peripheral Stimulation

Pulsed Radiofrequency

Wang and Song [26] assessed superficial pulsed radiofrequency (PRF) treatment in 70 patients (26 males, 44 females) with naïve PN. Mean VAS scores significantly decreased from 5.97 ± 1.01 at baseline to 3.37 ± 0.97 at 12 weeks (p < 0.001). Quality of life using the SF-36 and depression scores using the PHQ-9 were also significantly improved post-treatment, p < 0.001.

Krijnen et al. [27] assessed superficial PRF in a case series of 20 female patients with PN, who had failed to achieve relief after conservative measures and pudendal nerve blocks; 17/19 (89%) reported improvement after receiving PRF at the end of a 2-year period.

Ji et al. [28] assessed US-guided superficial PRF in 20 patients (six males, 14 females) who failed drug therapy. Mean VAS score significantly decreased from baseline, 7.0 ± 0.9 to 3.2 ± 1.7 at day 7 (p < 0.05); 18/20 reported remission at 6 months.

Masala et al. [29] assessed computed tomography (CT)-guided superficial PRF in 26 patients (ten males, 16 females) unresponsive to conservative management. Mean VAS significantly decreased from 9 ± 0.7 (range 8.3–9.7) at baseline to 1.9 ± 0.7 (range 1.2–2.6) at 1 year, p < 0.05.

Transcutaneous Electrical Nerve Stimulation (TENS)

Eid et al. [32] performed a 52-patient, two-arm RCT. The NRS pain scale decrease in the control group went from 9.51 ± 0.51 to 6.22 ± 2.22 (p < 0.001) while the NRS scale in the intervention group fell from 9.44 ± 0.5 to 4.25 ± 1.9 (p < 0.001). Mean NRS fell more significantly in the intervention group than the control group, p < 0.05.

Local Implants

Peters et al. [30] assessed PRF using a locally implanted pudendal nerve stimulation device in 19 patients (seven males, 12 females) who had failed previous treatment in a two-stage process. At stage 1, 100% of patients reported some relief. At stage 2, only ten patients were eligible, of which all ten reported positive feelings towards long-term management using the method.

Central Stimulation

Hodaj et al. [33] assessed rTMS of the motor cortex in 18 patients (five males, 13 females) with PN. At the end of the induction phase, 12/18 were responders with a significant reduction in average VNS pain scores from 5.4 ± 1.9 to 3.7 ± 3.0, p = 0.013. At the end of the maintenance phase, 6/12 maintained positive outcomes, five relapsed and one was lost to follow-up.

Roberts et al. [31] assessed the use of an implanted epidural neurostimulator in 13 patients (one male, 12 females) with PN. At the initial phase, ten of the 13 patients reported a > 50% reduction in pain. Nine of these ten patients elected to have a permanent stimulator inserted post-initial phase of which seven of nine patients reported a maintained > 50% reduction in pain at the final follow-up.

Buffenoir et al. [34] assessed the use of an implanted spinal cord stimulating device directly targeting the conus medullaris in 27 patients (five males, 22 females) who had failed relief following decompressive surgery. Patients were reviewed at two stages, once in a test phase at 13 days post-implantation and secondly at an assessment stage at 15 months post-implantation. At the test stage, 20/27 (74.1%) reported positive results. Ten were eligible for final follow-up, of which all 19 patients reported continued positive effects. Mean VAS pain scores significantly decreased from 55.0 ± 13.1 to 26.2 ± 10.1, p < 0.001.

Nerve Release

Nerve release is a surgical approach to the management of PN. While several techniques for nerve release are described in the literature, the goal of the procedure is to create space within the Alcock canal, thereby alleviating the effects of inflammation or reducing the pressure effects within the canal. Table 4 describes the different techniques for nerve decompression described in the literature, while Table 5 describes the findings of papers that looked at nerve release.

Table 4.

Nerve release techniques

Approach	Authors	Procedure descriptiona
Endoscopic transgluteal minimal-invasive (ENTRAMI)	Jottard et al. [35, 36]	The patient is placed in the ventral decubitus position. A horizontal line between the anterior and the posterior superior iliac spines is traced and a first trocar placed at the middle of this line, entering the trocar into the deep gluteal space. The piriformis muscle and the sciatic nerve are identified, and a second trocar is introduced caudal to the first one and situated on a horizontal line level of the coccyx. A third 5-mm trocar is then inserted, medial to the first one, releasing the Alcock canal
ISTANBUL	Erodgru et al. [37]	The technique involves using blunt dissection to create a peritoneal window medial to the obturator nerve. The inner border of the peritoneal layer is then retracted medially to allow visualization of the internal iliac artery, vein, and arcus tendineus fasciae pelvis. Following appropriate creation of this window 5-mm scissors are used to divide the SSL with retraction and protection of the pudendal nerve with an endo-dissector
Transperitoneal	Bollens et al. [38] Giulioni et al. [39]	Patients are placed in the Trendelenburg or gynecological position, following which a peritoneal window is created by identifying the internal obturator muscle (OM), levator ani (LA), coccygeus muscle (CM), and the fascial tendinous arch (AT) of the pelvis and division of the fibers of the coccygeus muscle. Finally, the pudendal nerve is identified and released from the surrounding tissues and transposed medially away from the sciatic spine
Transgluteal/transperineal	Robert et al. [40] Mauillon et al. [41] Beco et al. [42, 43]	Patients are placed in the prone position, following which the gluteus maximus fibers are sectioned to have access to the sacrotuberous ligament, following which the sacrospinous ligament is sectioned. Upon visualization of the pudendal neurovascular bundle, it is released from the dorsal surface of the sacrospinous ligament. Finally, a simple retractor opens the pudendal canal and a digitoclasic release of the nerve is performed

^aThe methods described in the table are not absolute and surgical variations may exist in the literature and in surgical centers

Table 5.

Summary of nerve decompression papers

Author (year)	Population (male: female)	Surgical approach	Findings
Jottard et al. [35] (2020)	10 patients (4: 6)	ENTRAMI	The average maximal NPRSat baseline was 9 (range 7–10). This significantly fell to 5 (range 0–10) at 12 months; p value < 0.05 At 1 year 73% of patients declared to have a “good treatment response” (PGIC > 30%) and optimal treatment response (PGIC ≥ 90%) was found in 40% (p value < .05), compared to 57% and 31% at 6 months, respectively No complications were recorded
Jottard et al. [36] (2021)	16 patients (2: 14)	ENTRAMI	The average maximum NPRS at baseline was 9.5 (range 7–10) and at 1 month it was 3.5 (range 0–10). This was a significant drop, p = 0.003. At 1 month, 12/16 (76%) reported a of > 50% impression of change of which 5/12 reported optimal treatment response (PGIC ≥ 90%) 4/16 (25%) reported no improvement (PGIC < 10%) Quality of life of energy, emotional well-being, and social functioning significantly improved in all 16 patients (p < 0.05)
Erdogru et al. [37] (2014)	27 patients (3: 24)	ISTANBUL	Outcomes of surgery were measured using a VAS pain score and a quality-of-life NIH-CPSI score at baseline, 1, 3, 6, and 12 months post op. Preoperative VAS scores were 5.6 ± 1.4. At 1 month, 1.5 ± 1.6, 3 months, 1.4 ± 1.8, 6 months, 1.6 ± 2.1, 12 months, 2.0 ± 1.5. These decreases were significant at all levels, p < 0.0001. Quality-of-life scores were 1.4 ± 0.4 pre-op and 2.8 ± 1.1 at 12 months. This was also significant, p < 0.05
Bollens et al. [38] (2020)	235 patients (93: 142)	Laparoscopic transperitoneal	The study looked at several makers of pathology, including pain using a VAS scale, erectile dysfunction using the International Index of Erectile Function (IIEF-5), constipation using the Patient Assessment of Constipation Symptoms (PAC-SYM), and incontinence using the Urinary Symptom Profile (USP). The study found that perineodynia VAS dropped from 6.8 ± 0.9 to 2.2 ± 1.8, p < 0.001; mean IIEF-5 scores significantly improved one month post-surgery, 15.2 vs. 19.3, p = 0.036; mean USP scores significantly improved for dysuria, 4.2 vs. 1.6, p = 0.021, but not for stress urinary incontinence, 3.9 vs. 4.1, p = 0.082, or overactive bladder, 14.1 vs. 13.8, p = 0.079 and mean PAC-SYM scores significantly improved, 1.8 vs. 1.1, p < 0.001
Giulioni et al. [39] (2023)	32 patients (13: 19)	Robot-assisted transperitoneal	Pain was measured using a numeric pain rating score (NPRS). Median NPRS at baseline was 8, IQR 8–9. There was a statistically significant reduction at 3- and 6 months post op, with NPRS at 5, IQR 4–5 at 3 months and 4, IQR 3–4 at 6 months. The p value was less than 0.001 at both stages. No major complications were reported
Robert et al. [40] (2005)	2-arm, 32-patient RCT Arm 1 (16 patients, 4: 12): transgluteal nerve decompression Arm 2 (16 patients, 5: 11): anticonvulsant and antidepressant neuropathic pain medication	Transgluteal	At 3 months post-op, the surgical group showed significantly better outcomes than the control group with eight patients of the surgery group significantly improved versus 1 patient of the control group, p = 0.0155 At 12 months, 10 patients in the surgery group and 2 control group patients had a successful outcome, p = 0.0025. Nine of the 16 patients in the control group expressed a desire to receive surgical decompression
Mauillon et al. [41] (1999)	12 patients who failed 3 rounds of CT-guided PNB (4: 8)	Transgluteal	Patients were followed at various stages in a case series At 3 months 7/12 (58.3%) reported some positive pain reduction with 4/7 reporting complete relief and 3/7 reporting partial pain relief At 21 months post-op 4/12 (33.3%) reported pain relief, with 3 reporting complete pain relief and 1 reporting partial pain relief. Of the 3 who reported partial pain relief at 3 months all 3 relapsed
Beco et al. [42] (2018)	113 patients (23:90)	Endoscopic transperineal	Four scores were assessed: International Consultation on Incontinence-Short Form (ICIQ-SF) for urinary incontinence, St Mark’s score for anal incontinence, Wexner score for constipation and National Institutes of Health Chronic Prostatitis Symptom Index (NHI-CPSI) for pain, lower urinary tract symptoms, and quality of life Perineodynia was measured using a visual analogue scale (VAS) from 0 (no pain) to 10 (extreme pain) 82/113 (72.6%) reported improvement in pain with 47/82 reporting a > 50% reduction. 12/113 (10.6%) reported worsening of pain Mean VAS decreased from 7.2 ± 1.4 to 4.5 ± 2.9 after 2 years (p < 0.0001) Mean ICIQ-SF decreased from 4.0 ± 5.2 to 2.7 ± 4.3, p = 0.0011; mean St Mark score decreased from 4.9 ± 4.7 to 3.1 ± 4.2, p < 0.0001, mean Wexner score decreased from 8.9 ± 5.5 to 7.0 ± 5.5, p < 0.0001 and mean NHI-CPSI decreased from 31.6 ± 5.3 to 21.3 ± 10.8, p < 0.0001
Beco et al. [43] (2004)	74 women	Transperineal	Three metrics were assessed: perineodynia in 18 patients, anal incontinence in 36 patients, and urinary incontinence in 5 patients 14/18 reported improvement in perineodynia, with 11/18 (61.1%) being completely resolved and 3/18 being partially resolved 30/36 (83.3%) reported improved anal incontinence with 23/30 reporting complete cure and7/30 reporting partial improvement; 2/36 (5.6%) reported worsening anal incontinence and 4/36 (11.1%) reported no change 4/5 (80%) women reported improved urinary incontinence

Jottard et al. performed two studies assessing the ENTRAMI technique, a 10-patient (4 males, 6 females) cohort study in 2020 [35] and a 16-patient (two males, 14 females) pilot study in 2020 [36]. In the ten-patient cohort study, the average NPRS significantly decreased from nine at baseline (range 7–10) to five (range 0–10) post-procedure; p value < 0.05. In the 16-patient pilot study, the average NPRS significantly decreased from 9.5 (range 7–10) to 3.5 (range 0–10) at 1 month, p = 0.003.

Erodgru et al. [37] introduced the ISTANBUL technique for nerve release in 27 patients (three males, 24 females). Outcomes of surgery were measured using a VAS pain score and a quality-of-life NIH-CPSI. Mean VAS decreased from 5.6 ± 1.4 to 2.0 ± 1.5 at 12 months, p < 0.0001. NIH-CPSI significantly decreased from 1.4 ± 0 to 2.8 ± 1.1 at 12 months, p < 0.05.

Bollens et al. [38] performed laparoscopic transperitoneal nerve release in 235 patients (93 males, 142 females). Perineodynia VAS significantly dropped from 6.8 ± 0.9 to 2.2 ± 1.8, p < 0.001; mean IIEF-5 scores significantly improved, 15.2 vs. 19.3, p = 0.036 and mean PAC-SYM scores significantly improved, 1.8 vs. 1.1, p < 0.001.

Giulioni et al. [39] performed the first robot-assisted transperitoneal nerve release in 32 patients (13 males, 19 females). Median NPRS significantly dropped from 8, IQR 8–9 at baseline to 4, IQR 3–4 at 6 months, p < 0.001.

Robert et al. [40] performed a two-arm 32-patient RCT comparing transgluteal nerve decompression to standard care with anticonvulsant and antidepressant neuropathic pain medication. The surgical group showed significantly better outcomes than the control group at 12 months, p = 0.0025. Nine of the 16 patients in the control group expressed a desire to receive surgical decompression.

Mauillon et al. [41] produced a 12-patient (four males, eight females) case series assessing transgluteal nerve release with transposition; 3/12 reported complete pain relief at final follow-up at 21 months and one reported partial pain relief.

Beco et al. assessed endoscopic transperineal nerve decompression in two papers. A 113-patient (23 males, 90 females) cohort study [42] and a 74-woman case series [43]. In the cohort study, 82/113 reported pain improvement with mean pain VAS scores significantly decreased from 7.2 ± 1.4 to 4.5 ± 2.9, p < 0.0001.

In the 74-woman transperineal case series, three metrics were assessed: perineodynia, anal incontinence, and urinary incontinence; 14/18 (77.7%) reported improvement in perineodynia, 30/36 (83.3%) reported improved anal incontinence, and 4/5 (80%) reported improved urinary incontinence.

Cryoablation

Prologo et al. [44] assessed CT-guided cryoablation in 11 patients. The technique involved the insertion of a 17-gauge cryoablation probe (Ice Sphere; Galil Medical, Arden Hills, MN) into the distal portion of the pudendal canal via a CT-guided transgluteal approach. Two 8-min to 5-min freeze–thaw intervals were then performed. Patients reported their pain on a ten-point Likert scale. The average pain score pre-procedure was 7.6; at 24 h, 45 days, and 6 months post-treatment, pain intensity dropped to 2.6, 3.5, and 3.1, p < 0.005. No complications were reported.

Lipofilling

Venturi et al. [45] assessed a lipofilling technique in 15 patients with PN. The technique involved the injection of adipose along the Alcock canal following the Coleman technique. In unilateral neuralgia, each patient received four injections of 2 ml of adipose tissue and in patients with bilateral neuralgia, eight 1.5-ml lipoaspirate injections were used: four in each Alcock canal. The first injection was near the ischiatic spine and the other three were at distances of 5 mm along the Alcock's canal. The mean VAS pain score significantly reduced from 8.1 ± 0.9 to 3.2 ± 0.6 (p < 0.001). The quality of life, measured using the SF36 health survey, also significantly improved from 75.5 ± 4.1 to 85 ± 4.5 (p < 0.01). At 12 months, 10 patients remained pain-free, two patients still required topical treatment and three were lost to follow-up.

Topical Therapy

Ruoss et al. [46] used a topical treatment of 0.5% amitriptyline with 0.03% estradiol in 376 women. Women self‐reported AOO to be beneficial across all age groups; with 21/41 (51.2%, 95% CI 35.4–66.8%) of the < 30 age group; 78/117 (66.7%, 95% CI 57.3–74.9%) of 30 to 50‐year‐old group, and 109/187 (58.3%, 95% CI 50.9–65.4%) of the > 50 age group reporting significant improvement. 90 patients reported one or more side effects, of which stinging at the site of application was the most common problem (64/90).

Figure 6 shows the available management options and a suggested clinical algorithm.

Fig. 6.

Proposed management algorithm integrating available therapeutic options to support clinical practice. Evidence for spinal cord implant is still weak (dashed arrow). NSAID nonsteroidal anti-inflammatory drug, SSRI selective serotonin reuptake inhibitor, SNRI serotonin–norepinephrine reuptake inhibitor, TCA tricyclic antidepressant, GABA gamma-aminobutyric acid, PRF pulsed radiofrequency, TENS transcutaneous electrical nerve stimulation, rTMS repetitive transcranial magnetic stimulation

Discussion

In this systematic review, it is notable that the papers identified shared a broad heterogeneity. Indeed, this is likely of most reviews of subspecialized conditions such as peripheral neuropathies and given the undefined management ladder for this condition, it is not unsurprising. This heterogeneity does cause an element of confusion in the diagnosis and management of PN as while there is a rough framework that can be designed, it is difficult to justify leaps between diagnosis and management steps given the non-robust nature of the research. This finding in our review is not dissimilar to other similar reviews such as by Conic et al. [8] and Andiman et al. [47] who identified similar branches of diagnosis and management option in PN however also concluded that there was no clear pathway to follow and due to the variation in quality of the research available, it is primarily clinician individual experience of personal preference that may guide diagnosis or management.

It is apparent in the literature that the diagnosis of pudendal neuralgia is predominately made clinically. The advent of the Nantes criteria has provided a robust clinical aid to diagnosticians to accurately diagnose PN. However, it should be noted that the Nantes criteria have notably lacked challenge in the literature and there has been a lack of assessment of psychometric evaluation of this framework or assessment of sensitivity and specificity to various populations though the universal belief remains that this framework remains the primary tool for diagnosing PN. In our literature search and indeed other reviews that have looked at diagnostic tools in PN, there is a notable lack of articles that look at imaging or electrophysiology testing. One could tentatively suggest that ultrasound has no role in the diagnosis of PN, as the literature is particularly scarce on this imaging modality and that which is available is limited in population and credibility. MRN has been recognized to have a role in diagnosing PN such as in the scoping review from Wadhwa et al. [48], but due to the robust nature of the Nantes criteria, it seems researchers are less inclined to evaluate with MRI machines, an understandable position. In similar stead to most of the diagnostic-focused papers in PN, there is little work looking at the sensitivity and specificity of imaging modalities; an area that we hope future academics will look to fulfil in greater populations. While electrophysiology has been assessed for the pudendal nerve, it is suggestable that the size and anatomy of the nerve make it inefficient for this diagnostic strategy and thus it is better suggested that electrophysiology testing has no real scope for PN in its current form. As noted by Kaur et al. [1] and Soon-Sutton et al. [6], the role of other diagnostic strategies such as SSEP or EMG are not diagnostic of pudendal neuralgia but rather should be used to aid suspicion in pudendal neuropathy, prompting consideration of PN. Clearly, there is some role of warm and cold detection thresholds in diagnosis, but the hassle and current procedure make it inefficient in most patients. It is apparent that in modern literature, the Nantes criteria are the single best tool for diagnosing PN, though there is a notable gap in the literature regarding its overall effectiveness rate.

As with most management strategies in medicine, the goal of treatment is to produce the greatest outcomes with the least invasive treatment option. Conservative management and injection therapy will prove to be adequate management for most patients with MP. Pudendal nerve blocks have a 68–94% success rate in producing satisfactory pain reduction in PN based on which paper you look at in the literature. It is hard to dispute that for most patients, nerve blocks will be the best management strategy. There has been some work looking at the supplementation of nerve blocks with steroids, such as by Labat et al. However, this has thus far been shown to be ineffective. Notably, there is discussion in the literature regarding multiple-use nerve blocks; however, this regimen would still be considered less invasive than advanced surgical management options.

An intermediate step between nerve block and further invasive surgery is becoming more apparent in the literature. The use of nerve stimulation, either centrally or peripherally, guided has been shown to be an effective strategy. Pulsed radiofrequency has been extensively assessed in the literature, and it is suggestable that this treatment modality has an 80–95% success rate in producing pain reduction. Notably, of the studies found in our review looking at pulsed radiofrequency, 4/5 papers looked at patients suffering from pain not relieved by other management strategies in these populations, pain was significantly improved. Furthermore, there is growing discussion that this strategy may be preferable to nerve blocks and the next steps would be to produce RCTs comparing the two strategies. An interesting discussion point regarding peripheral nerve modulation refers to the short-term effects of this treatment Krijnen et al. [27] and Ji et al. [28] have shown that pain reduction occurs after 6 months to a year. While the pain is still better than at baseline, there is a trend for the effects of this pulsed radiofrequency to diminish. An interesting piece for future work may be to look at a long-term regimen of multiple courses of pulsed radiofrequency and look at patients' responses over an extended period of time. Central stimulation, either of the lumbar spine or motor cortex, is a growing field of interest for this condition. While in its infancy, there are promising results about this management strategy for PN; however, furthermore, robust work is required on this strategy before it can be considered as a definitive management strategy.

When surgery may be advised, it will often be reserved for the 8–15% for whom conservative measures or nerve blocks have failed. The only majorly discussed surgical strategy in the literature was a nerve release. There were no papers found that discussed strategies such as neurolysis or complete dissections, likely due to the miniature nature of the pudendal nerve and the physiological importance of this nerve. Several methods of nerve release such as the ENTRAMI, Istanbul, or robot-assisted have been described in the literature. There appears to be no significant difference in patient outcomes with these strategies and so this is largely operator preference.

There is a growing scope of literature looking at alternative management strategies to PN. Methods such as cold cryoablation, transcutaneous electromagnetic nerve stimulation and lipofilling were all identified, though in preliminary discussions. The role of these management strategies remains in their infancy, though preliminary results appear positive, and these strategies may further be used to bridge the gap between conservative options and nerve blocks or minimally invasive management strategies and surgery. This review aligns alongside similar work in this field, which suggests a stagnation in the development of diagnostic or management options. In a similar line to other PM-review papers, we found limited work on diagnostic options on PN. This is likely due to the establishment of the Nantes criteria and clinicians using this aid as absolute; however, given the lack of robust analysis of the framework, it is a shame that more research has not been done into looking at other diagnostic strategies such as electrophysiology or imaging modalities. Ultimately, further research in larger cohorts is required for all these proposed strategies and RCTs are the next logical progression to adoption. This sentiment can be shared for most management strategies proposed in PN; there is a definitive lack of comparative studies or RCT’s and we hope that future researchers will recognize this gap and produce academia to fill this.

This review is limited by the use of a single database (PubMed) for the literature search. Although PubMed is one of the largest and most comprehensive biomedical databases, relying solely on it may have led to the omission of relevant studies indexed elsewhere. Despite this, PubMed’s extensive coverage of peer-reviewed biomedical research ensures that the majority of high-quality and relevant studies are captured.

Conclusions

Despite the long-standing history of pudendal neuralgia, there is limited comprehensive research discussing its diagnosis and management. It is clear that the Nantes criteria are universally recognized to be sufficient alone to diagnose PN. This overreliance has led to a gap in research for alternative or supportive strategies in diagnosing PN. As in most facets of medicine, it is the job of the clinician to use all available diagnostic aids available to make the diagnosis. Once that diagnosis is made, the management strategy is typical of any condition, wherein a patient will move up the intervention ladder. It is apparent that conservative management and nerve blocks are both adequate management strategies in the majority of patients. Nerve stimulation, either peripherally or centrally is a growing field of intervention and may become the preferred treatment modality in the future. Nerve decompression remains the only proposed surgical option in PN, though this does not discredit its effectiveness as a strategy. Other management strategies such as lipofilling, TENS and cryoablation may have some value, but limited research exists on these strategies, and further research into these is required.

Supplementary Information

Below is the link to the electronic supplementary material.

Author Contributions

Mohammed S. Ahmed screened the papers, collected the data, and drafted the manuscript. Perikles Zavridis critically revised the manuscript. Despina Hadjiconstanti designed the figures and critically revised the manuscript. Panagiotis Zis designed the study, screened the papers, analyzed the data, and drafted the manuscript.

Funding

No funding or sponsorship was received for this study or publication of this article.

Data Availability

The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.

Declarations

Conflict of Interest

Mohammed S, Ahmed, Perikles Zavridis, and Despina Hadjiconstanti have nothing to disclose. Panagiotis Zis is an Editorial Board member of Pain and Therapy. Panagiotis Zis was not involved in the selection of peer reviewers for the manuscript nor any of the subsequent editorial decisions.

Ethical Approval

This paper was registered in the PROSPERO database for meta-analysis and systematic reviews (Registration number CRD420251027007). This article is based on previously conducted studies and does not contain any new studies with human participants or animals performed by any of the authors.