Diagnosis and treatment of pudendal and inferior cluneal nerve entrapment syndrome: a narrative review

Abstract

Aim

Pudendal and inferior cluneal nerve entrapment can cause a neuropathic pain syndrome in the sensitive areas innervated by these nerves. Diagnosis is challenging and patients often suffer several years before diagnosis is made. The purpose of the review was to inform healthcare workers about this disease and to provide a basis of anatomy and physiopathology, to inform about diagnostic tools and invasive or non-invasive treatment modalities and outcome.

Methods

A description of pudendal and inferior cluneal nerve anatomy is given. Physiopathology for entrapment is explained. Diagnostic criteria are described, and all non-invasive and invasive treatment options are discussed.

Results

The Nantes criteria offer a solid basis for diagnosing this rare condition. Treatment should be offered in a pluri-disciplinary setting and consists of avoidance of painful stimuli, physiotherapy, psychotherapy, pharmacological treatment led by tricyclic antidepressants and anticonvulsants. Nerve blocks are efficient at short term and serve mainly as a diagnostic tool. Pulsed radiofrequency (PRF) is described as a successful treatment option for pudendal neuralgia in patients non-responding to non-invasive treatment. If all other treatments fail, surgery can be offered. Different surgical procedures exist but only the open transgluteal approach has proven its efficacy compared to medical treatment. The minimal-invasive ENTRAMI technique offers the possibility to combine nerve release with pudendal neuromodulation.

Conclusions

Pudendal and inferior cluneal nerve entrapment syndrome are a challenge not only for diagnosis but also for treatment. Different non-invasive and invasive treatment options exist and should be offered in a pluri-disciplinary setting.

Keywords:

• Pudendal neuralgia
• pudendal entrapment
• cluneal entrapment
• chronic perineal pain

Disclosure statement

No potential conflict of interest was reported by the author(s).

Figure 1. Pudendal nerve anatomy, anterior-cranial point of view. 1: pudendal nerve, 2: sacral nerve roots, 3: piriformis muscle, 4: sacrospinous ligament, 5: sacrotuberous ligament, 6: inferior rectal nerve, 7 + 8: perineal nerves, 9: dorsal nerve of the penis/clitoris (© P.Bonnet).

Figure 2. Nerves of the right-sided gluteal region, dorsal point of view. 1 = Superior cluneal nerves. 2 = Sciatic nerve. 3 = Posterior femoral cutaneous nerve. 4 = Inferior cluneal nerves. 5 = Perineal branches of posterior femoral cutaneous nerve. 6 = Pudendal nerve. 7 = Medial cluneal nerves. (© P.Bonnet).

Table 1. Diagnostic criteria for pudendal neuralgia by pudendal nerve entrapment [12].

Table 2. Summary table surgical procedures pudendal nerve release.