Saturday, March 14, 2009

Chronic pelvic pain syndromes:

The purpose of this article is to introduce the reader to pudendal neuropathy & physical therapy treatment options.
Chronic pelvic pain can present in various pain syndromes (1). PPOD (pelvic pain and organic dysfunction) is not an uncommon finding in the low back pain patient. Women appear to be more frequently involved than men (2).
3 types of pelvic pain syndromes (1):
1. Pudendal neuralgia,
2. Piriformis syndrome, and
3. "Border nerve" syndrome (ilioinguinal, iliohypogastric, and genitofemoral nerve neuropathy).

Piriformis syndrome is an uncommon cause of buttock and leg pain. Chronic neuropathic pain arise from the lesion or dysfunction of the ilioinguinal nerve, iliohypograstric nerve, and genitofemoral nerve (1).

Pudendal neuralgia commonly presents as chronic debilitating pain in the penis, scrotum, labia, perineum, or anorectal region. The pudendal nerve is located between the sacrospinous and sacrotuberous ligaments at the level of ischial spine (1). The results of recent electrophysiologic investigations indicate that many patients with urological, bowel or anorectal dysfunction demonstrate evidence of denervation neuropathy in muscles innervated by the branches of the pudendal nerve (2).

Diagnostic criteria for pudendal neuralgia by pudendal nerve entrapment (Nantes criteria) (4):

The 5 diagnostic criteria are:
(1) Pain in the anatomical territory of the pudendal nerve.
(2) Worsened by sitting.
(3) The patient is not woken at night by the pain.
(4) No objective sensory loss on clinical examination.
(5) Positive anesthetic pudendal nerve block.

Other clinical criteria can provide additional arguments in favor of the diagnosis of pudendal neuralgia. Exclusion criteria are also proposed: purely coccygeal, gluteal, or hypogastric pain, exclusively paroxysmal pain, exclusive pruritus, presence of imaging abnormalities able to explain the symptoms.

Role of ENMG in pudendal neuropathy (3):

Electroneuromyographic (ENMG) investigation is often performed in this context, based on needle electromyography and the study of sacral reflex and pudendal nerve motor latencies.
ENMG do not assess directly the pathophysiological mechanisms of pain but rather correlate to structural alterations of the pudendal nerve (demyelination or axonal loss). In addition, only direct or reflex motor innervation is investigated, whereas sensory nerve conduction studies should be more sensitive to detect nerve compression. Finally, ENMG cannot differentiate entrapment from other causes of pudendal nerve lesion (stretch induced by surgical procedures, obstetrical damage, chronic constipation…). Thus, perineal ENMG has a limited sensitivity and specificity in the diagnosis of pudendal nerve entrapment syndrome and does not give direct information about pain mechanisms. Pudendal neuralgia related to nerve entrapment is mainly suspected on specific clinical features and perineal ENMG examination provides additional, but no definitive clues, for the diagnosis or the localization of the site of compression. In fact, the main value of ENMG is to assess objectively pudendal motor innervation when a surgical decompression is considered.

Goals of Physical therapy management of pelvi/perineal and perianal pain syndromes (5).
A major feature of pelvi/perineal and perianal pain syndromes commonly encountered by multidisciplinary clinicians is pelvic floor imbalance and incoordination.

Pelvic floor physical therapy is considered to be effective in the management of functional urogenital and anorectal disorders.

A functioning pelvic floor is integral to
1. increases in intra-abdominal pressure,
2. provides rectal support during defecation,
3. has an inhibitory effect on bladder activity,
4. helps support pelvic organs, and
5. assists in lumbopelvic stability.

Coordinated release of the sphincters within a supporting extensible levator ani allows complete and effortless emptying. Precise pelvic floor and abdominal muscle coactivity, based on research, is used clinically. Motor and cognitive learning which can alter peripheral and central pain mechanisms and produce physical changes in the CNS, viscera, smooth and musculoskeletal tissues is the basis of physical therapy in pelvic floor and pelvic organ pain management.

1. Peng PW; Pain Physician. 2008 Mar-Apr;11(2):215-24.
2. Browning JE; J Manipulative Physiol Ther. 1989 Aug;12(4):265-74.
3. Neurophysiologie Clinique/Clinical Neurophysiology; Volume 37, Issue 4, August-September 2007, Pages 223-228
4. Jean-Jacques Labat et al; Diagnostic criteria for pudendal neuralgia by pudendal nerve entrapment (Nantes criteria); Neurourology and Urodynamics; Volume 27 Issue 4, Pages 306 – 310; Published Online: 7 Sep 2007
5. Markwell SJ; World J Urol. 2001 Jun;19(3):194-9.


  1. This is a great differential diagnostic viewpoint you present. The statement that jumped out at me was "Piriformis syndrome is an uncommon cause of buttock and leg pain."
    I believe there is an under diagnosing or under-reporting phenomenon going on with this syndrome as in my short career I have seen a fairly decent percentage of "radicular" patients that could qualify as "piriformis" syndrome patients or at the least have this as a comorbidity.

    Here is a recent article by Boyajian-O'Neill LA, McClain RL, Coleman MK, Thomas PP on this topic. Titled: Diagnosis and management of piriformis syndrome: an osteopathic approach. (Available for free:

    "Reported incidence rates for piriformis
    syndrome among patients with low back pain vary
    widely, from 5% to 36%.3,4,11 Piriformis syndrome is more
    common in women than men, possibly because of biomechanics
    associated with the wider quadriceps femoris muscle
    angle (ie, “Q angle”) in the os coxae (pelvis) of women.3
    Difficulties arise in accurately determining the true prevalence
    of piriformis syndrome because it is frequently confused
    with other conditions."

  2. hi Bo,

    i read your comment on my article on chr.pelvic pain. wonderful insight to the topic. i would like to add following to our discussion:

    1. not in all cases sciatic nerve pierce the pyriformis (i.e. pass between the 2 heads of the muscle). it is estimated that only in 15% cases sciatic nerve pierce the pyriformis.

    2. radicular pain with distal reference usually put this muscle in spasm is untreated this site becomes a independent site for pain production.

    3. pyriformis can become tight as other muscles become tight. one rule says tonic muscles become tight under dysfunctional conditions. for example if some body is sedentary and works in sitting position for hours then this muscle can become tight.For a comfortable sitting usually the hip roll into ER which can make this muscle tight.


    4. Pyriformis syndrome must be reserved to a condition where there is no other contribution to a radiculopathy except a pyriformis tightness.

    under this condition i have seen cases who are very very stubborn.


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