It is important to determine the events that preceded the symptoms for pudendal neuralgia as well as its progression. Many patients will present after traumatic injury to the pelvis with either gradual onset or immediate pain. Their pain is located in the area of innervation supplied by the pudendal nerve. It is neuropathic in nature and is exacerbated by sitting [4]. The gradual progression in pain for patients usually is minimal in the morning and progressively worsens throughout the activities of daily living, becoming most severe in the evening. Classically, most patients will note they have less pain sensation when sitting on the toilet seat in comparison to a chair.

Almost all patients with pudendal neuralgia have pain with intercourse and postcoital dyspareunia. Patients often state that it is so severe they will refrain from having intercourse altogether, which negatively affects their partners as well. Along with dyspareunia, common complaints also include pain with bowel movements, urination, or sexual arousal, as discussed above.

  The physical examination is extremely important in order to rule out other possible causes of pain. Common findings among patients with pudendal neuralgia include pelvic floor muscle spasm and pain on pelvic examination; therefore, it can be difficult to determine any underlying nerve injury until the spasms are treated [5]. Among patients with pudendal neuralgia, the physical examination should always confirm pain within the dermatome supplied by the pudendal nerve. In patients with pudendal nerve entrapment, there will be tenderness over the sacrospinous ligament just medial to the ischial spine. Palpation of this area precipitates a tingling sensation commonly known as Tinel’s sign.

  As noted in Table 11.1, pudendal nerve motor terminal latency (PNMTL ) testing may help determine nerve conduction and the integrity of the nerve [6]. Electrical impulses are applied transvaginally or transrectally using a pudendal electrode (St. Mark’s) on the tip of the examiner’s finger. Increased conduction time signifies damage to the nerve. It is a nonspecific test, as it does not determine the cause or the level of the injury. Also, the results of the study have been shown to have wide range, as the length of this nerve can be variable [7]. The value of this testing therefore remains controversial.

Quantitative sensory threshold testing and mapping have been used for the diagnosis of other peripheral nerve disorders, but have not been validated for the pudendal nerve [8]. These tests gauge the ability to discern between hot and cold temperatures and also between two pressure points. Compressed nerves lose the ability of fine discrimination.

Magnetic resonance imaging (MRI ) of the pelvis is superior to other imaging modalities of the pelvis, as it can determine abnormalities of the muscles and soft tissue in great detail [9]. Higher resolution 3 T MRI can provide more detailed information along the pathway of the pudendal nerve, including scarring, inflammation, and entrapment. Magnetic resonance neurography (MRN) may also help identify the pudendal nerve along its pathway. Often the nerve is too small to be viewed accurately, unless it is grossly damaged and enlarged. In addition, MRN is typically performed in highly specialized centers, as it requires radiologists to be familiar with specific neuroanatomy to accurately interpret the images.

  The Nantes Criteria for diagnosing pudendal nerve entrapment was established by Professor Roger Robert in Nantes, France. He is one of the pioneers of surgical treatment of pudendal neuralgia. Table 11.2 lists these criteria, which have been validated [10]. Patients who meet these criteria are more likely to respond positively to surgical options than those who partially meet these criteria.

  This is a diffuse spasm of pelvic floor muscles. Symptoms are associated with pain during and after intercourse [11]. Patients also report hesitancy and sensation of incomplete voiding. On pelvic examination, there are pelvic floor muscle spasms. This may be confirmed by urodynamic testing. Of note, pelvic floor muscle spasms are nonspecific findings that often present among patients with other painful conditions, including pudendal nerve entrapment, endometriosis, and even inguinal hernia .