Pudendal Neuralgia in Cyclists: What You Need to Know

Understanding Pudendal Neuralgia aka Cyclist’s Syndrome

Pudendal neuralgia (PN), often known as cyclist’s syndrome, occurs when the pudendal nerve becomes compressed or irritated, leading to pain in the pelvic region.

Common symptoms include burning sensations, numbness, and discomfort when sitting, which can severely impact daily tasks and activities like cycling. The causes often relate to prolonged or intense pressure on the pelvis. Research suggests that up to 8% of long-distance cyclists experience pudendal neuralgia.

Our clinic is situated between Boulder and Denver in Colorado. These areas house a large cycling community, so we understand how cyclist’s syndrome affects your life and the activities you love. We have designed an effective treatment approach that allows cyclists to return to their passion pain-free, without the dependency on medications or need for surgery. Let’s dive deeper into how we can help improve your cycling experience.

Exploring Pudendal Nerve Anatomy

The pudendal nerve is an essential component of the pelvic region, providing sensory and motor functions. It is also the nerve responsible for causing cyclist’s syndrome when compressed or irritated.

The pudendal nerve is formed from three nerve roots: S2, S3, and S4. These roots exit from the sacrum, the triangular bone at the base of the spine. Together, they come together to form the pudendal nerve. Once formed, the nerve traverses several pelvic ligaments before heading anterior to the genital areas.

This nerve is responsible for:

Sensory functions: It provides sensation to the genital areas in both males and females, allowing you to feel touch and changes in temperature.
Motor functions: It controls several muscles in the perineum—the area between the genitals and the anus—crucial for functions like maintaining continence and coordinating movements. It also supports the muscles of the pelvic floor, which are key for bladder and bowel control.

There are two pudendal nerves, one on the right and the other on the left (1). Branches supply sensation to the anal canal and also innervate muscles of the perineum and the pelvic floor (2).

What Is Pudendal Neuralgia?

PN is a condition characterized by chronic pain in the pelvic region due to compression or irritation of the pudendal nerve. This nerve runs through the pelvic area, making it susceptible to injury or stress, particularly in activities that involve prolonged sitting or compression of the pelvic region, such as cycling.

PN can lead to sensations of burning, numbness, or discomfort in areas like the genitals, perineum, and anus, impacting daily activities and quality of life. It’s crucial to accurately diagnose this condition, as its symptoms can mimic other pelvic disorders, leading to potential misdiagnosis and delayed treatment.

Recognizing the Symptoms of Pudendal Neuralgia

Common symptoms of PN may include pain while sitting, discomfort in the pelvic region, or changes in sensation in the genitals. For male competitive cyclists, who are frequently affected by this condition, symptoms might include recurrent numbness of the penis and scrotum after prolonged cycling, altered sensation of ejaculation, with disturbance of micturition (urination) and reduced awareness of defecation. Recognizing these symptoms early allows for timely intervention, which is essential to prevent complications.

Positional Pain

The pain is typically caused by sitting, relieved by standing, and is absent when lying down or sitting on a toilet seat. If the perineal pain is positional (changes with the patient’s position, for example, sitting or standing), this suggests a tunnel syndrome. Anesthesiologist John S. McDonald of UCLA reports that sitting pain relieved by standing or sitting on a toilet seat is the most reliable diagnostic parameter of PN (3).

Disturbance of Micturition (Urination)

The pudendal nerve controls the bladder by transferring nerve signals to the muscles involved in the opening and closing of the urethral sphincter, which helps regulate the release of urine.

When this nerve is compressed or irritated, it can disrupt the signals between the brain and the bladder. This can result in symptoms such as difficulty starting urination, a frequent need to urinate, and a feeling of incomplete bladder emptying.

Erectile and Sexual Dysfunction

The pudendal nerve is responsible for sensation and function in the genital area. When it’s damaged or irritated, it can lead to a range of sexual dysfunctions. These might include reduced sensitivity, making it challenging to achieve or maintain an erection, or interfering with normal sexual responses.

Research shows that genital numbness and erectile dysfunction are two of the major symptoms of PN, and the prevalence has been reported to be 50–91% and 13–24%, respectively.

Fecal and Urinary Incontinence

Other than positional pain and numbness, the main symptoms are fecal incontinence and urinary incontinence, but these are less common compared to the pain and numbness.

The pudendal nerve helps control the anal and urethral sphincters, responsible for maintaining continence. When nerve function is compromised, it can lead to involuntary leakage of urine or stool.

Swelling in the Perineal Area

Irritation of the pudendal nerve can trigger the body’s inflammatory response. This leads to localized inflammation, which manifests with pain, changes in skin color, and swelling.

This swelling can worsen if the nerve compression is severe or persistent, intensifying pain and further impairing nerve function.

Painful Intercourse

Compression or irritation of the pudendal nerve can interfere with the transmission of nerve signals from the brain to the pelvis and vice versa. Since this nerve is responsible for providing sensation to the genitals, its compression can alter sensations, causing heightened sensitivity and discomfort during intercourse.

This can affect not only one’s physical health but also emotional and relational well-being, as it impacts intimacy with a partner.

Common Causes of PN

PN can result from various factors such as prolonged sitting, injury, or surgical complications. Identifying these causes helps tailor interventions and prevent future flare-ups, allowing you to return to sports and improve your quality of life.

Nerve Entrapment Due to Cycling Posture

Nerve entrapment syndromes, presenting as genital numbness, are among the most common bicycling-associated urogenital problems (4).

Sitting on a bike is typically the biggest trigger of symptoms, which is why it has been termed cyclist’s syndrome.

Repetitive Stress Injury to the Pudendal Nerve

Prolonged sitting on a bicycle seat can cause a compressive force through the soft tissue. Continued over a period of time, this creates a repetitive stress injury to the nerve and eventually causes symptoms.

Myelin Damage and Nerve Hypersensitivity

Repetitive stress to a peripheral nerve damages the outer coating of the nerve (myelin), and once the myelin has been damaged, the nerve starts becoming hypersensitive, resulting in the symptoms. This type of mechanism is similar to what happens in carpal tunnel syndrome and in the low back with sciatica.

Weak Pelvic Muscles

Weak pelvic muscles are unable to support the pelvic organs properly, compromising the stability of the pelvis. This can cause changes in how the weight of the organs is distributed, causing undue pressure on the pudendal nerve and, in some cases, nerve impingement.

This risk factor can develop gradually over time, especially with insufficient physical activity or aging.

Surgical Complications

Surgical procedures in the pelvic or lower abdominal area can sometimes lead to complications affecting the pudendal nerve. Scar tissue or inflammation following surgery can compress or irritate the nerve, leading to chronic pain and discomfort.

Infections or Illnesses

Conditions like persistent urinary tract infections or pelvic inflammatory disease can cause chronic inflammation and, in turn, pain and swelling. This can irritate or compress the pudendal nerve, leading to the development or worsening of PN symptoms.

Childbirth Trauma

Childbirth can sometimes result in trauma to the pelvic area, causing PN. The nerve may become irritated or compressed during delivery, particularly in cases of difficult or prolonged labor. This can lead to pain and numbness in the postpartum period.

When to Seek Medical Attention

If you are experiencing symptoms like pelvic pain, erectile dysfunction, or urinary incontinence, it is important to get an accurate diagnosis, which will guide a personalized treatment plan.

Consult a healthcare provider if you experience:

Persistent pelvic pain
Burning sensation
Numbness
Pain worsening when sitting
Bowel or bladder issues

How Pudendal Neuralgia Is Diagnosed

The symptoms of PN can mimic those of other conditions. That is why it is crucial to obtain an accurate diagnosis. A specialized healthcare provider will use multiple diagnostic tools to determine the root cause of your symptoms. These include:

Physical examination: A healthcare provider will assess pain levels, nerve sensitivity, and other symptoms in the pelvic area.
Medical history: Your physicians will evaluate past medical issues, current symptoms, and potential triggers, such as long-distance cycling, to identify patterns or causes.
Imaging tests: MRI or CT scans are used to visualize the pudendal nerve and surrounding tissues to identify signs of compression or inflammation.
Nerve blocks: This approach involves performing an injection to temporarily relieve pain, helping to confirm that issues with the pudendal nerve are the source of the symptoms.
Electrophysiological tests: These tests measure the nerve function and response. They help determine any abnormalities in nerve conduction and identify nerve damage.

Conventional Treatment Options

Conventional treatment options for cyclist syndrome focus on easing symptoms. Common options include:

Ergodynamic evaluation

An ergodynamic evaluation can help reduce the repetitive stress creating the damage. This can sometimes involve going to a specialty bike shop to get properly fitted for a seat that can better reduce the stress to the nerve.

Physical therapy

Physical therapy can also help strengthen the pelvic floor muscles as well as help relax tightened muscles.

Medications

Medications are merely pain reducers that can help decrease the severity of the symptoms. These can include non-steroidal anti-inflammatory medications (NSAIDS) or other drugs aimed at neuropathic pain, such as antiepileptics or antidepressants. These medications only mask the pain and, unfortunately, do nothing to help the condition long-term.

Corticosteroid injection

While this can give temporary reduction of symptoms, the likelihood of the pain returning is significant. In addition, the negative local and systemic effects of high dose corticosteroids can be quite damaging.

Radiofrequency ablation

Burning of the pudendal nerve, like a steroid injection, can only be temporary pain reduction. Side effects can be somewhat severe, with post-procedure pain, possible motor loss creating weakness in the pelvic floor, erectile dysfunction, or loss of bowel and bladder function.

Surgery

In cases where all other treatments have failed, surgical decompression may be considered as a last resort. This surgery involves relieving pressure on the pudendal nerve by freeing or decompressing it within the pudendal canal. While it can alleviate symptoms, this option comes with surgical risks—such as infection and nerve damage—and involves long recovery times.

NSAIDs

The other day I was evaluating a patient and reviewing the treatment options for their spine condition. After discussing prior treatments, we got to the topic of medications taken for pain relief. She explained that she mainly utilized anti-inflammatory (NSAID) medications and then she told me to hold much she takes and has been for many years…..she takes close to 2 grams (2000 milligrams) on a daily basis which equated to about 9-10 capsules of medication per day. I was shocked, considering she was pre-diabetic and with high blood pressure plus the kicker of it is that her PCP (primary care physician) is ok with this…

PRP Injections

PRP is short for platelet-rich plasma, and it is autologous blood with concentrations of platelets above baseline values. The potential benefit of platelet-rich plasma has received considerable interest due to the appeal of a simple, safe, and minimally invasive method of applying growth factors. PRP treatments are a form of regenerative medicine that utilizes the blood healing factors to help the body repair itself by means of injecting PRP into the damaged tissue. In regenerative orthopedics, it is typically used for the treatment of muscle strains, tears, ligament and tendon tears, minor arthritis, and joint instability. There have been more than 30 randomized controlled trials of PRP…

There Is a Safer Alternative for Pudendal Neuralgia Relief

At Centeno-Schultz Clinic, we are committed to offering you less invasive alternatives for PN that target the root cause of pain.

We prioritize non-surgical and non-radiation treatment options, aiming to alleviate your symptoms while minimizing risks. Our team leverages advanced regenerative orthopedic medicine techniques to tailor treatments that support your recovery and enhance your quality of life without the need for invasive procedures.

Being a leader in regenerative orthopedic medicine, we have successfully treated many cases of PN by utilizing our fourth-generation platelet lysate combined with precise ultrasound-guided PN hydro dissection.

As mentioned above, the repetitive stress injury that created the nerve problem results in the loss of the myelin covering of the nerve. The concentration of immediate release growth factors helps rebuild the myelin sheath, resulting in the healing of the nerve and the reduction of symptoms.

Here, Dr. Centeno explains what platelet lysate is:

Outside of physical therapy and ergodynamic adjustments, which are aimed at reducing the stress on the nerve, all other treatments are designed to treat the symptoms caused by the nerve injury. However, this new treatment option for PN is aimed at healing the nerve sheath and improving the electrophysiologic function of the nerve and thus reducing symptoms.

Do Not Let Pudendal Neuralgia Keep You From Being Active

At Centeno-Schultz Clinic, we are dedicated to providing you with innovative and safer alternatives to manage PN. These go beyond managing symptoms by targeting the root cause of pain. Our goal is to empower you with a personalized treatment plan that allows you to stay active and enjoy your favorite activities, including cycling.

If you have or anyone you know has been dealing with cyclist syndrome or pudendal neuralgia, please contact our office to set up an evaluation. One of my colleagues or I will discuss this advanced treatment option and your candidacy. If you have any questions, feel free to contact me via IG @ Dr. Markle or through our patient care center.

References:

Origo D, Tarantino AG. Osteopathic manipulative treatment in pudendal neuralgia: A case report. J Bodyw Mov Ther. 2019;23(2):247‐250. doi:10.1016/j.jbmt.2018.02.016

2. Khoder W, Hale D. Pudendal neuralgia. Obstet Gynecol Clin North Am. 2014;41(3):443‐452. doi:10.1016/j.ogc.2014.04.002

3. Pérez-López FR, Hita-Contreras F. Management of pudendal neuralgia. Climacteric. 2014;17(6):654‐656. doi:10.3109/13697137.2014.912263

4. Petrov-Kondratov V, Chhabra A, Jones S. Pulsed Radiofrequency Ablation of Pudendal Nerve for Treatment of a Case of Refractory Pelvic Pain. Pain Physician. 2017;20(3):E451‐E454.