Pelvic pain that is reliably worse when sitting, and that does not wake you at night, fits a known pattern. Pudendal neuralgia is pain along the path of the pudendal nerve. It has a formal set of diagnostic criteria, agreed on by a working group and known as the Nantes criteria. Knowing them helps, because this condition is diagnosed by exam and history, not by scan.1
The five essential criteria
The Nantes criteria set out five essential features:1
- Pain in the anatomical territory of the pudendal nerve
- Pain worsened by sitting
- The patient is not woken at night by the pain
- No objective sensory loss on clinical examination
- A positive response to an anesthetic pudendal nerve block
Two of those go against what you might expect, so they are worth a closer look. Not being woken by the pain counts in favor of the diagnosis, not against it. And no measurable loss of feeling on exam is expected. So a normal nerve exam supports the diagnosis instead of undercutting it.
What argues against the diagnosis
The same working group set out exclusion criteria, findings that rule it out. These are pain only in the tailbone, buttock or lower belly; pain that comes only in sudden attacks; itching alone; and scan findings that could explain the symptoms.1
That last rule keeps the system honest. If a scan shows something that explains the pain, that finding wins over a clinical pattern.
Why no test settles it
The diagnosis is made mostly by exam and history. No single sign proves it, and no specific exam sign or test result is unique to this disease. But a mix of criteria can point to it.1
This is why people with pudendal neuralgia so often pile up normal test results. With them comes the sense that nothing is wrong. Normal results fit the diagnosis. They do not disprove it.
The block does double duty
The fifth criterion is a positive anesthetic pudendal nerve block, which makes the block part of the diagnosis, not just a treatment. A later review notes that the Nantes criteria give the diagnosis a clear structure. It also recommends a step-by-step ladder of treatment.2
Diagnostic and therapeutic blocks are described under nerve blocks. When a nearby nerve is the real source, cluneal neuropathy and piriformis syndrome matter. For stubborn, hard-to-treat cases peripheral nerve stimulation is one of the options. Long-lasting pelvic pain weighs on the mind, so counseling for chronic pain is delivered in-house here.
Frequently asked questions
Does pudendal neuralgia only affect women?
No. Everyone has a pudendal nerve, and the diagnostic criteria are the same for men and women. The workup is the same either way — 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 instead of arguing against it. See nerve blocks.
All my scans are normal. What now?
Normal imaging is expected. The diagnosis is made mostly by exam and history, and no specific test result confirms it. In fact, scan findings that could explain the symptoms would point somewhere else. 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 gives diagnostic information as well as possible relief. See nerve blocks.
Could this be something other than the pudendal nerve?
Yes. Pain only in the tailbone, buttock or lower belly falls outside the criteria. Nearby nerves can also cause similar symptoms — see cluneal neuropathy, or arrange an evaluation through the appointment request form.
To have long-lasting pelvic pain checked, request an appointment, call (314) 481-5000, or text (314) 886-5902.
Sources
- 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
- 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
