Pelvic Pain That Is Worse When You Sit

Pelvic pain that is reliably worse when sitting, and that does not wake you at night, fits a recognizable pattern. Pudendal neuralgia — pain in the distribution of the pudendal nerve — has a formal set of diagnostic criteria, agreed by a working party and known as the Nantes criteria, and knowing them is genuinely useful because this condition is diagnosed clinically rather than by scan.¹

The five essential criteria

The Nantes criteria set out five essential features:¹

1. Pain in the anatomical territory of the pudendal nerve
2. Pain worsened by sitting
3. The patient is not woken at night by the pain
4. No objective sensory loss on clinical examination
5. A positive response to an anesthetic pudendal nerve block

Two of those are counterintuitive and worth dwelling on. Not being woken by the pain is a positive criterion, not evidence against the diagnosis. And no objective sensory loss on examination is expected — so a normal neurological examination supports the diagnosis rather than undermining it.

What argues against the diagnosis

The same working party proposed exclusion criteria: pain that is purely coccygeal, gluteal or hypogastric; pain that is exclusively paroxysmal; exclusive itching; and the presence of imaging abnormalities capable of explaining the symptoms.¹

That last exclusion is the discipline of the framework. If a scan shows something that accounts for the pain, that finding takes precedence over a clinical pattern.

Why no test settles it

The diagnosis is essentially clinical. There are no pathognomonic criteria, and no specific clinical signs or complementary test results for this disease — but a combination of criteria can be suggestive.¹

This is why people with pudendal neuralgia so often accumulate normal investigations and, with them, the impression that nothing is wrong. Normal results are consistent with the diagnosis, not a refutation of it.

The block does double duty

The fifth criterion is a positive anesthetic pudendal nerve block, which makes the block part of establishing the diagnosis rather than only a treatment. A subsequent review notes that the Nantes criteria give structure to the diagnosis and recommends a step-ladder approach to therapy.²

Diagnostic and therapeutic blocks are described under nerve blocks. Where a neighboring nerve is the actual source, cluneal neuropathy and piriformis syndrome are relevant, and for refractory cases peripheral nerve stimulation is among the options. Because persistent pelvic pain carries a heavy psychological load, counseling for chronic pain is delivered in-house here.

Frequently asked questions

Does pudendal neuralgia only affect women?

No. The pudendal nerve is present in everyone and the diagnostic criteria are not sex-specific. Evaluation is the same regardless — see the range of pain treatments.

My pain does not wake me at night. Does that rule it out?

The opposite. Not being woken by the pain is one of the five essential Nantes criteria, so it supports the diagnosis rather than arguing against it. See nerve blocks.

All my scans are normal. What now?

Normal imaging is expected. The diagnosis is essentially clinical, with no specific test result confirming it, and imaging abnormalities that could explain the symptoms would in fact point elsewhere. See what imaging can and cannot show about pain.

Why would I have a nerve block if the diagnosis is not confirmed?

Because the block helps confirm it. A positive response to an anesthetic pudendal nerve block is the fifth essential criterion, so the block provides diagnostic information as well as potential relief. See nerve blocks.

Could this be something other than the pudendal nerve?

Yes. Pain that is purely coccygeal, gluteal or hypogastric falls outside the criteria, and neighboring nerves can produce overlapping symptoms — see cluneal neuropathy, or arrange an evaluation through the appointment request form.

To have persistent pelvic pain evaluated, request an appointment, call (314) 481-5000, or text (314) 886-5902.

Sources

1. Labat JJ, Riant T, Robert R, Amarenco G, Lefaucheur JP, Rigaud J. Diagnostic criteria for pudendal neuralgia by pudendal nerve entrapment syndrome (Nantes criteria). Neurourology and Urodynamics. 2008;27(4):306–310. doi:10.1002/nau.20505. Retrieved via PubMed. DOI
2. Khoder W, Hale D. Pudendal neuralgia. Obstetrics and Gynecology Clinics of North America. 2014;41(3):443–452. doi:10.1016/j.ogc.2014.04.002. Retrieved via PubMed. DOI

Dr. Gurpreet Singh Padda, MD, MBA, MHP