The Diagnosis and Management of Pudendal Neuralgia

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.