In today’s episode of the PT on ICE Daily Show, Dry Needling lead faculty Ellison Melrose explores the role of dry needling in treating pudendal neuralgia, a condition often misdiagnosed and challenging to manage. Elli shares clinical insights, assessment strategies, and treatment techniques to help physical therapists effectively address this complex nerve issue.
Take a listen to the podcast episode or check out the full show notes on our blog at www.ptonice.com/blog
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EPISODE TRANSCRIPTION
ELLISON MELROSE
Good morning, PT on ICE Daily Show. My name is Dr. Ellison Melrose. I am lead faculty with the dry needling division of Ice Physio. Today we’re diving into a topic that doesn’t get talked enough in the physical therapy world, particularly in the orthopedic circles, and that is pudendal neuralgia. Specifically, what I want to talk about is how dry needling can play a role in treating pudendal neuralgia and what that
treatment might look like. This is one of those conditions that people often bounce around a lot between medical providers and it can often take years to truly diagnose. They might see urologists, they might see their gynecologist or even pain specialists. And sometimes we have to dive a little bit deeper and figure out the true cause of the symptoms.
and often an irritation to the pudendal nerve could be that driver. So let’s start a little bit with an overview of the pudendal nerve. So the pudendal nerve originates from the sacral plexus S2 through S4. It has both sensory and motor innervation to the pelvic floor muscles and sensory to the perineal region and genitals.
Clinically, what you might see is patients will often report symptoms of burning, sharp pain to the perineum, often pain with sitting. They can have either genital numbness or hypersensitivity, and they may have pain with prolonged activities, including things like cycling is a very common aggravator of their symptoms.
And it may also even progress towards impairing sexual function and bowel and bladder function. So all of those things are symptoms that I think sometimes people don’t necessarily correlate together as a patient, but as providers, we should know what to look for and screen in or out pudendal neuralgia. The number one key feature that you’ll see with pudendal neuralgia
Alan Fredendall (02:20.705)
is pain that is aggravated by sitting. So whether that be sitting at work or like I mentioned, sitting on something like a saddle for cycling, and this can be for really any duration, but sitting is going to be the pain driver. And while folks are either standing or lying down, their symptoms are often alleviated. So that is kind of a telltale sign that the pudendal nerve is irritated.
So once the nerve roots have exited the sacral plexus, they have a couple points where they can get irritated or even compressed often as well. And three main regions are going to be, it passes through the sacro-tubris and sacrospina ligaments. So if we have any hypertrophy of those ligaments for whatever reason, that can become an irritant there.
It then travels down into the alcox canal. The alcox canal runs with the par- or the pudendal nerve runs with the perineal artery in that alcox canal. And the alcox canal is positioned between two muscles. So the alcox canal runs in a fascial tube between the levator anii, which is a pelvic floor muscle that provides support to the pelvic floor or to the pelvis itself, excuse me.
and obturator internus. So when considering dry needling for pudendal neuralgia, we want to consider four main things. So first, we have to think about symptom behavior. So we have to utilize the symptom behavior model and make sure that we are testing and retesting their objective and subjective asterisk signs. So when we’re thinking about
all of those asterisk signs, need to make sure that we collect the data. Number two is respecting the irritability. Number three is retesting. So we’ve tested the symptoms and now we want to retest. And then we also always want to make sure that we’re combining dry needling with some form of either mobility training or exercise. So the four main points, test, respect irritability,
Alan Fredendall (04:44.172)
retest and then combine with a mobility or an exercise that can help reinforce the gains that you make. So as I mentioned, at Ice Physio, we treat based off of that symptom behavior model, which means we need data. And so we have some of those subjective asterisk signs that our patients might complain of, again, burning or sharp pain to the perineum.
genital numbness, pain with exercise or prolonged sitting, and then also potentially some changes in bowel and bladder function. From there, we wanna also gain some objective asterisk signs. So things that could be contributing to their symptoms. What we’re gonna look for is sitting tolerance. So this can be an objective measure. So we can obviously gain subjective information by saying,
doesn’t hurt when you sit, is it relieved when you stand or lie down? But you can also get a duration of sitting. And so we wanna make sure that again, we’re collecting as much data as possible. So this could be something oftentimes done outside of the clinic. So it will be kind of a subjective report, but they can document the duration of sitting, either whether that be again, sitting on a firm surface or tolerance to something like riding a bike.
Next up, we want to assess their hip range of motion. And that is because of that correlation with the tight muscles that can be contributing to some irritation to that pudendal nerve, particularly the deep hip rotators, and particularly obturator and ternus based off its proximity to the alcox canal. So we’re looking at internal and external rotations.
of the hip and they may have some limitations into internal rotation and then with that internal rotation deficit What they might feel is they may not feel the like pinching on the anterior side of the hip But they might feel tension or discomfort Medial to the ischial tuberosity. So when we have pain around the ischial tuberosity, we also want to consider pudendal neuralgia or sorry
Alan Fredendall (07:06.912)
Obtrurator internus hypertonicity or poor lengthening of that muscle as a contributing factor there. Next asterisk sign we want to assess is their pelvic floor tone. So pelvic floor muscle hypertonicity could also contribute to an irritation of that pudendal nerve in the alcox canal. With that, a gold standard for pelvic floor evaluation would be an intravaginal assessment.
But if that’s not something that you are trained in, you can assess via external palpation. And then lastly, we will also look at almost like a tonnella sign or palpation of the alkox canal area that can reproduce their symptoms. So again, the objective things we want to assess is their tolerance to sitting duration.
hip range of motion, particularly internal rotation, pelvic floor tone, and with that maybe some obturator internus tone, and then also external palpation to where the alkox now lives, which is going to follow the ischial pubic rami from the ischial tuberosity towards the pubic symphysis. So you can kind of palpate lateral to the external genitalia, which may reproduce some of their symptoms.
similar to that of like a tenel sign. Once we test for pudendal neuralgia and we have our data, we have some objective and subjective asterisk signs, we can treat. For pudendal neuralgia, we want to respect the irritability with any sort of neurogenic symptoms. We want to respect the irritability and we want to start with peripheral targets.
So typically with a high irritable pudendal neuralgia, we may even start up in the sacral nerve area. So we can treat the multifidus muscle that extends from the lumbar spine into the sacral spine, treating the muscle pump that’s close to those exiting nerve roots. We could also step slightly more lateral to where we would treat the multifidus and we could be
Alan Fredendall (09:27.308)
needling towards the exiting nerve root around the sacral foramen. So two places to attack the sacral exiting sacral nerve roots at the multifidus or a little bit more lateral towards the sacral foramen to target the exiting nerve roots S2, three and four. From there, the biggest bang for your buck when it comes to treating
for an irritation to the pudendal nerve, particularly if it’s in the alcox canal, which is the most common place that it gets irritated, is going to be dry needling obturator internus. So dry needling obturator internus, this is easiest to palpate on the medial aspect of the ischial tuberosity, where you’re going to sink your fingers anterior laterally towards the femurocitabular joint, and that’s where we can sink our fingertips into the
medial aspect of the obturator foramen. That is where the muscle belly lives. And so that is where we would try and aim a needle to needle obturator internals. When we have someone that is either towards the end of their plan of care or a lower irritability symptom, something that may take a couple hours to provoke their symptoms, that pudendal nerve is not as irritable. And so we can actually go after treating the peripheral nerve itself.
So we teach this in our, we teach peripheral nerve stim in our advanced course in our pelvic floor dry needling course, particularly for the pudendal nerve, we’re teaching this in the pelvic floor needling course. How you would access the pudendal nerve is you would target a muscle that lives right on the medial aspect of the ischial pubic graami, the ischial cavernosus muscle. And then from there, we can redirect that needle towards the alcox canal.
which is going to live slightly deeper than that ischial cavernosis. So again, we are treating, once we have the objective and subjective asterisk signs, we can treat the nerve based on irritability, starting more proximal, so sacral nerve roots, and then coming a little bit more peripheral towards that pudendal nerve as their symptom irritability reduces.
Alan Fredendall (11:54.762)
Once we treat with dry needling, think something that we often forget about is doing that test retest, right? So we’re going to want to retest their objective asterisk signs within session. If you found that they had a hypertonic pelvic floor, what this means is it’s retesting the tenacity of the pelvic floor.
Gold standard again would be with that interventional assessment if that is something that you are trained in. And so we want to make sure that if we are testing before, we are also retesting afterwards. If they had hip range of motion limitation, that is also something that we want to reassess and get true objective data with a measurement and not just eyeballing it.
From there, we wanna reinforce those gains with some form of mobility or exercise that can help with continuing to reduce symptoms following treatment. What’s really cool about dry needling is it’s, sometimes I feel like it’s voodoo magic, it does amazing things, but it’s not a long-term change. What we see is we create this amazing window of opportunity that we can then go,
regain some of that mobility that our deficits, where our deficits lie. And so from there, if we have hypertonicity of the pelvic floor, we would want to encourage that down training of the pelvic floor, elongating with eccentrics through the pelvic floor and really getting them to learn how to relax their muscles independent of having to stretch with your finger or stretch with a wand.
So teaching them how to gain that range of motion. In the pelvic space, we use an A-frame analogy. And when we are lengthening that pelvic floor, we want to let our pelvic floor come all the way down into that basement, lengthened out and down. For hip rotation limitations, we can do a couple different things. We can do a banded hip mobilization. So if they…
Alan Fredendall (14:12.408)
did have some actual joint restrictions associated with that hypertonicity or that decreased range of motion in the obturator internus, we can be doing some form of hip internal rotation. From there, we also want to make sure that we are loading with a weight into that range. And so what that might look like or a body weight into that range, that might look like a hip 90-90 internal rotation mobilization where we’re in a seated position.
with the knees in 90, 90 and the hips in 90, 90 and we’re rocking onto that back hip into some internal rotation there. With all of that, when we have nerve irritability and we’re treating with dry needling, we also wanna make sure that we’re following up with our patient within 24 to 48 hours to assess those subjective asterisk signs, right? So we don’t wanna just leave it at objective because really what our patients care about is are there symptoms
getting better subjectively, right? So that is the most effective way to treat for pudendal neuralgia when utilizing dry needling. So again, we reviewed what pudendal neuralgia might look like in the clinic. So it can be a differential diagnosis for hip dysfunction or any pain in the groin. We wanna make sure that we’re testing, retesting, respecting irritability, and then always ending with
Load is our love language at Ice Physio. So we want to make sure that all roads lead to load. Thank you so much for joining me this morning to discuss pudendal neuralgia. Feel free to catch us on the road. have a course coming up, a lower body course coming up in the end of the month at Raleigh, North Carolina. It’s almost sold out, so feel free to grab a seat there. We will
have an advanced course on road in April in Longmont, Colorado, and then we’ll be back in Longmont, Colorado for pelvic floor dry needling. So if you’re looking to treat pudendal neuralgia effectively in the clinic, hop into one of those pelvic floor dry needling courses. Thanks and have a good day.