Can nerve impingement from lumbar (L) 2-3 cause penile pain?

Can L2-L3 Nerve Impingement Cause Penile Pain?

Yes, L2-L3 nerve root impingement can cause penile pain, though this is an uncommon presentation that requires careful evaluation to distinguish from more typical causes of penile pain and to rule out pudendal nerve involvement.

Anatomical Basis and Clinical Presentation

The L2-L3 nerve roots contribute to the genitofemoral and ilioinguinal nerves, which provide sensory innervation to the genital region. However, the clinical presentation differs from typical radiculopathy patterns:

• L2-L3 radiculopathy classically manifests as numbness, tingling, and burning pain in the lateral aspect of the thigh, not primarily penile pain 1
• The L2-L3 dermatome does not typically include the penis as a primary distribution 1
• When penile pain occurs with L2-L3 pathology, consider referred pain patterns or atypical presentations 2

More Likely Causes of Penile Pain

Pudendal Nerve Compression (Primary Consideration)

Pudendal nerve entrapment is the most common neuropathic cause of chronic penile pain and should be your primary diagnostic consideration 3, 4:

• The dorsal nerve of the penis is a terminal branch of the pudendal nerve (derived from S2-S4, not L2-L3) 5, 6
• Compression typically occurs at the inferior border of the pubis, between the sacrotuberous and sacrospinous ligaments, or in the Alcock canal 3
• Pinprick sensory testing of the six pudendal nerve branches (dorsal penile/clitoral nerves, perineal nerves, and inferior rectal nerves) diagnoses pudendal neuropathy in 92% of cases 3

Clinical Features Distinguishing Pudendal from Lumbar Pathology

• Pudendal neuropathy presents with penile pain, decreased glans sensitivity, genital paresthesias, and sometimes erectile dysfunction 5, 6
• Associated symptoms may include perineal or rectal pain, not isolated to lateral thigh 3
• History of cycling, pelvic trauma, or athletic activities during youth increases suspicion 5, 4

Diagnostic Algorithm

Step 1: Clinical Examination

• Perform pinprick sensory testing of all six pudendal nerve branches bilaterally 3
• Assess for motor deficits: hip flexion weakness suggests L2-L3 radiculopathy 1
• Test patellar reflexes and femoral stretch test for L2-L4 involvement 7
• Examine for lateral thigh sensory changes (L2-L3 distribution) 1

Step 2: Pattern Recognition

If penile pain is isolated without lateral thigh symptoms, pudendal neuropathy is more likely than L2-L3 radiculopathy 5, 3:

• L2-L3 radiculopathy: lateral thigh pain/numbness ± hip flexor weakness 1, 7
• Pudendal neuropathy: penile/perineal pain ± erectile dysfunction ± rectal symptoms 3, 6

Step 3: Imaging Strategy

• MRI of the lumbosacral spine if lateral thigh symptoms or hip flexor weakness present 2, 1
• MRI of the lumbosacral plexus (rating 9/9) for suspected pudendal nerve pathology, requiring orthogonal views with T1, T2, and fat-saturated sequences 1
• Consider both cervical and lumbar imaging for atypical presentations with multiple dermatomal involvement 2

Step 4: Electrodiagnostic Studies

• Obtain EMG/nerve conduction studies to differentiate radiculopathy from plexopathy or peripheral nerve lesions 1
• Two neurophysiologic tests recommended before considering surgical intervention for pudendal neuropathy 3

Management Approach

Conservative Treatment (First-Line)

Initiate conservative management for 14 weeks before considering surgical options 3:

• Nerve protection strategies (avoid prolonged sitting, cycling modifications) 5, 3
• Neuropathic pain medications 5
• Series of three pudendal nerve perineural injections at 4-week intervals 3

Surgical Consideration

Neurolysis is recommended only after conservative treatment failure 3, 6:

• For pudendal nerve: transgluteal approach with decompression at compression sites 3
• For dorsal penile nerve: decompression at inferior pubic ramus canal 6
• Success rates: 83% complete recovery of sensation, 67% restoration of erectile function 6

Critical Pitfalls to Avoid

1. Do not assume L2-L3 pathology causes isolated penile pain—this is an atypical presentation requiring broader differential 2, 1
2. Do not miss pudendal nerve entrapment—perform systematic pinprick testing of all six branches 3
3. Do not overlook trauma history—cycling, pelvic injury, or athletic activities are key historical features 5, 4
4. Do not rush to surgery—14 weeks of conservative management is required first 3

Red Flags Requiring Urgent Evaluation

• Progressive neurological deficits 2
• Bilateral symptoms suggesting myelopathy 2
• New bladder or bowel dysfunction 2
• Loss of perineal sensation 2

In summary, while L2-L3 nerve impingement theoretically could contribute to genital region symptoms through referred pain patterns, isolated penile pain is far more likely due to pudendal nerve pathology (S2-S4 distribution). Your diagnostic approach should prioritize pudendal nerve assessment with pinprick testing and consider lumbosacral plexus imaging rather than focusing solely on L2-L3 pathology 1, 3.