OverviewOctober 1, 2024
Prof. Prof. DK Prof. Dr. med. Marc Possover, MD, PhD
Pudendal pain is common.
True pudendal nerve disease is rare.
Only a precise pain-based diagnosis can guide safe and effective treatment.
If you experience pain in the pudendal area such as pain while sitting, burning sensations in the genital region, perineal pain, perianal, you may quickly encounter the term “pudendal neuralgia.”While increased awareness of pelvic nerve pain is important, it has also led to a common and dangerous misunderstanding:
👉 Pudendal pain does not automatically mean disease of the pudendal nerve itself.
In other words: pain is a symptom - not a diagnosis.
Historically, pudendal neuralgia entered medical awareness largely through the work of neurosurgeons, particularly in France. Pioneers such as Roger Robert in Nantes described entrapment of the pudendal nerve in the so-called Alcock’s canal — a fibrous tunnel located below the pelvic floor, outside the pelvic cavity.
Because neurosurgical approaches are performed from the outside of the pelvis, the focus naturally concentrated on the extrapelvic segment of the nerve. Over time, pudendal neuralgia became almost synonymous with Alcock’s canal syndrome.
However, anatomically, the pudendal nerve originates from the sacral plexus above the pelvic floor, inside the pelvic cavity. The majority of its course is intrapelvic before it exits below the pelvic floor.
From a neuropelveological perspective, pathology of the pudendal nerve within the pelvis — what we describe as endopelvic pudendal neuropathy — is not only possible, but in clinical experience and published series, more frequent than classical Alcock’s canal syndrome.
In our previously published series of 128 consecutive patients, intrapelvic nerve pathology was significantly more common than isolated extrapelvic entrapment.
This distinction is crucial.
For the neuropelveologist, “pudendal neuralgia” does not automatically mean Alcock’s canal syndrome. It refers to pain in the pudendal distribution, which may originate:
Pudendal pain describes a symptom distribution. It does not define the anatomical level of pathology.
Many patients are told early on that their pain must come from the pudendal nerve, often even from a very specific location called Alcock’s canal. This assumption is frequently made without a detailed analysis of the pain itself. From a neuropelveological perspective, this approach is incorrect. The pelvis is one of the most complex nerve regions in the human body.
Several different nerves and nerve systems overlap, interact, and transmit pain signals to similar areas. As a result, pain felt in the pudendal region can originate from very different sources.
Many patients are told early on that their pain must come from the pudendal nerve, often even from a very specific location called Alcock’s canal. This assumption is frequently made without a detailed analysis of the pain itself. From a neuropelveological perspective, this approach is incorrect.
The pelvis is one of the most complex nerve regions in the human body. Several different nerves and nerve systems overlap, interact, and transmit pain signals to similar areas. As a result, pain felt in the pudendal region can originate from very different sources.
A fundamental principle in neurology is that when a nerve is irritated or injured, the pain is often not felt at the exact location of the lesion, but rather at the end of the nerve’s sensory distribution, in what we call the dermatome. In the genito-anal region, multiple nerves converge and share overlapping sensory territories. Whether these nerves are irritated at the level of the vulva, within the small pelvis, at the sacral roots, in the spinal cord, or even higher in the central nervous system, the patient may still perceive the pain in the vulvar region.
This is why the mere location of pain does not define its origin. The key lies in analyzing the combination of symptoms: the quality and radiation of pain, associated functional disturbances of the pelvic organs (bladder, bowel, sexual function), and possible symptoms in the lower limbs. Together, these elements help determine the most probable level and anatomical location of the nerve involvement.
A neuropelveologist will therefore never conclude: “You have pain in the vulva, so the problem must be the vulva or the pudendal nerve.” Instead, significant time is dedicated to collecting detailed information - often extending far beyond the boundaries of gynecology, urology, or gastroenterology. The objective is to identify which nerve is involved, at what level (intrapelvic versus central nervous system), and precisely where within the pelvis the pathology may be located.
Based on this comprehensive analysis, an individualized treatment strategy is developed. This approach is far removed from a reflexive “always operate” mentality. In fact, true pathology of the pudendal nerve below the pelvic floor — the so-called Alcock’s canal syndrome — is extremely rare, even though it has become a fashionable or “star” diagnosis in recent years. Moreover, most patients with pudendal-related pain can be successfully managed without surgery when the diagnosis is accurate and the therapy is appropriately tailored.
Pelvic pain perceived in the pudendal territory may originate from:
Importantly, in many patients the pudendal nerve itself is completely healthy.
Despite how frequently the diagnosis is made, true pathology of the pudendal nerve itself at the Alock’s canal is rare. This means:
The risk of oversimplification
When a symptom is mistaken for a diagnosis, patients may undergo treatments that are unnecessary, ineffective or potentially harmful. This is particularly important when surgery is considered. Every nerve surgery carries risks, including:
The fact that a nerve can be surgically accessed does not mean that it should be.
Neuropelveology does not begin with imaging alone. It does not begin with anatomy alone. It begins with listening to the patient. A detailed neuropelveological pain analysis focuses on:
Often, within a structured pain history, it becomes clear that the pudendal nerve is not the primary problem.
It is also essential to understand that the laparoscopic approach in neuropelveology is fundamentally different from the classical laparoscopic approach in gynecology.
In gynecology, laparoscopy is frequently performed for suspected endometriosis, adhesions, or other organ-based pathologies. In many cases, the approach can be described as “diagnostic and therapeutic at the same time”: one performs a laparoscopy to look inside the pelvis, identify visible organ pathology, and then treat what is found. This logic may work well for organ disease.
However, this concept does not apply to neurological disorders of the pelvic nerves.
In neuropelveology, surgery is never performed as an exploratory “let’s look and see what we find” procedure. A nerve is not an organ surface lesion that can simply be seen and removed. Pelvic nerve surgery requires a precise preoperative neurological diagnosis. The exact nerve involved must be identified beforehand, the level of the lesion must be determined (intrapelvic, radicular, or central), and the surgical strategy must already be clearly defined before entering the operating room.
The intervention must be targeted to a specific nerve and follow a predefined, anatomically and functionally reasoned procedure. Without a clear neurological hypothesis and a structured plan, surgery on pelvic nerves is not only ineffective but potentially harmful.
This is why neuropelveological surgery is never “exploratory” in the traditional gynecological sense - it is the execution of a previously established neurological diagnosis.
Only a thorough neuropelveological evaluation allows:
In pelvic nerve disorders, diagnosis must always come before intervention.
If you have been diagnosed with pudendal neuralgia — or if surgery has been proposed —
it is essential to first ask:
Has my pain been analyzed in detail from a neuropelveological perspective?
Because treating pelvic nerve pain correctly starts with understanding where the pain truly comes from - not simply where it is felt.
— Prof. Marc Possover
Founder of Neuropelveology
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