Can pudendal nerve impingement or injury cause numbness to the genitals and erectile dysfunction (ED)?

Pudendal Nerve Injury and Genital Symptoms

Yes, pudendal nerve impingement or injury can definitively cause both genital numbness and erectile dysfunction, and surgical decompression may restore function in appropriately selected patients. 1, 2, 3

Mechanism and Clinical Presentation

Pudendal nerve injury affects both sensory and erectile function through damage to its branches:

• The dorsal nerve of the penis (sensory branch) causes penile numbness, hypoesthesia, or paresthesia when injured 4
• Perineal and penile branches involvement leads to erectile dysfunction through disruption of neurogenic erectile pathways 2
• Patients typically present with penile, perineal, and scrotal sensory changes accompanied by erectile difficulties 2

The pudendal nerve can be injured through multiple mechanisms including trauma, compression (pudendal canal syndrome), chronic straining causing levator subluxation and nerve entrapment, or iatrogenic injury from procedures like brachytherapy 2, 5

Diagnostic Evaluation

Key clinical findings that suggest pudendal nerve injury:

• Loss of penile sensation or development of painful penis following trauma 3
• Erectile dysfunction with absent nocturnal penile tumescence 2
• Perineal/scrotal sensory abnormalities 2

Electrophysiological testing confirms the diagnosis:

• Increased bulbocavernosus reflex latency 2
• Prolonged pudendal nerve terminal motor latency (PNTML) 2
• Reduced sensory velocity of the dorsal nerve of the penis 4
• Diminished EMG activity of external urethral sphincter and levator ani 2

Rule out other causes of ED:

• Normal endocrine assays, Doppler examination, and cavernosometry help confirm neurogenic rather than vascular or hormonal etiology 2
• MR neurography can visualize nerve injury and guide treatment planning 5

Treatment Outcomes

Surgical decompression shows significant benefit for neurogenic ED from pudendal nerve entrapment:

• In one series of 7 patients with pudendal canal syndrome, ED improved in 6 of 7 patients (86%) within 2-6 months post-decompression 2
• For dorsal nerve injury at the inferior pubic ramus, normal erections were restored in 67% (2/3) of patients with erectile dysfunction 3
• Complete recovery of erogenous sensation occurred in 83% (5/6) of patients with sensory loss 3
• Sensory branch neurectomy successfully treated brachytherapy-induced pudendal nerve injury 5

Clinical Context

While the provided guidelines focus primarily on diabetic neuropathy causing erectile dysfunction 6 and general ED evaluation 6, they do not specifically address traumatic or compressive pudendal nerve injury. However, diabetic neuropathy remains the most common cause of penile neuropathy overall 4.

Important distinction: The ADA guidelines note that diabetic autonomic neuropathy causes erectile dysfunction through autonomic pathways 6, whereas pudendal nerve injury causes ED through direct sensory and motor nerve damage—these are different mechanisms requiring different treatments.

Common Pitfalls

• Don't assume all genital numbness with ED is psychogenic—the presence of sensory changes with erectile dysfunction should prompt evaluation for pudendal nerve pathology 1, 3
• Don't overlook trauma history—injury along the inferior pubic ramus or chronic perineal trauma (cycling, straining) can cause pudendal nerve entrapment 2, 3
• Don't skip electrophysiological testing when pudendal neuropathy is suspected, as it confirms the diagnosis and localizes the lesion 2, 4