Can treatments for pudendal neuropathy caused by straining during bowel movements also improve symptoms of decreased libido, reduced orgasm intensity, and altered urination?

Treatment of Pudendal Neuropathy and Associated Sexual/Urinary Symptoms

Treatments for pudendal neuropathy from chronic straining can improve libido, orgasm intensity, and urinary symptoms, but the evidence is strongest for urinary dysfunction, with sexual symptoms showing more variable responses.

Primary Treatment Approach

Biofeedback therapy is the first-line treatment for pudendal neuropathy caused by chronic straining, with success rates exceeding 70% for defecatory disorders and associated pelvic floor dysfunction 1. This retrains proper pelvic floor coordination and addresses the underlying dyssynergia that perpetuates nerve injury 1.

Preventing Further Nerve Damage

• Aggressive constipation management prevents progression of pudendal neuropathy by eliminating the chronic straining that causes ongoing nerve injury 1
• Stimulant laxatives (senna, bisacodyl) are safe for long-term use and do not damage intestinal neurons—the straining itself causes the actual nerve damage 1
• Proper defecation positioning using a footstool and avoiding prolonged straining helps prevent additional pudendal nerve injury 1

Expected Symptom Improvements

Urinary Symptoms (Strongest Evidence)

Pudendal nerve stimulation (PNS) demonstrates objective improvements in bladder function, with maximum cystometric capacity increasing from 153.3±49.9 to 331.4±110.7 ml and maximum pressure decreasing from 66±24.3 to 36.8±35.9 cmH2O 2. Daily urinary incontinence episodes decreased from 7±3.3 to 2.6±3.3, with 8 of 15 patients achieving complete continence 2.

• Altered urination symptoms (nocturia, frequency, urgency, weak stream) respond to treatment of the underlying autonomic neuropathy 3
• Bladder dysfunction evaluation should be performed for patients with recurrent urinary tract infections, incontinence, or palpable bladder 3

Sexual Function (More Variable Evidence)

Sexual dysfunction from diabetic autonomic neuropathy includes decreased libido, reduced arousal, and inadequate lubrication in women, plus erectile dysfunction in men 3. However, the evidence specifically linking pudendal neuropathy treatment to improved sexual function is limited.

• Pudendal nerve perineural injections with bupivacaine and corticosteroid provide pain relief in pudendal neuropathy patients, with 80.4% reporting reduced pain 4
• Pain reduction correlates with the number of nerve branches successfully anesthetized (average 0.66 point pain reduction per additional branch) 4
• Sexual dysfunction symptoms may improve indirectly through pain reduction, though direct evidence for libido and orgasm intensity improvement is not established in the provided guidelines

Bowel Function

Eight of 12 patients with pudendal nerve stimulation reported significant improvement in bowel function 2. For complete cauda equina syndrome with bowel dysfunction, PNS showed 63% of constipation-predominant patients and 100% of incontinence-predominant patients achieving ≥50% symptom improvement 5.

Treatment Algorithm

1. Start with biofeedback therapy for pelvic floor dysfunction from chronic straining 1
2. Aggressively treat constipation with safe long-term laxatives to prevent ongoing straining and nerve damage 1
3. Consider pudendal nerve perineural injections (bupivacaine + corticosteroid) for pain control if conservative measures fail 4
4. Evaluate for pudendal nerve stimulation in refractory cases, particularly when urinary symptoms predominate 2
5. Assess for anorectal testing if symptoms persist, as "tension" lasting years likely represents pudendal neuropathy or learned pelvic floor dyssynergia 1

Critical Caveats

• Unilateral pudendal neuropathy occurs in 72% of neuropathy cases, so normal mean pudendal nerve terminal motor latency does not exclude the diagnosis 6
• Pudendal nerve blocks should not be used as diagnostic tests since complete pain relief occurs in only 39.2% and all 6 nerve branches are anesthetized in only 13.2% of patients 4
• Pain relief from perineural injections correlates with immediate bupivacaine response, and long-term steroid benefit appears associated with this immediate anesthesia 4
• Sacral nerve stimulation may be considered for fecal incontinence, though pudendal nerve stimulation targets the pudendal nerve more directly 3, 2, 7

Quality of Life Considerations

Treatment should prioritize pain reduction and functional improvement over specific sexual or urinary metrics, as pain relief strongly correlates with overall symptom improvement 4. The number of successfully anesthetized pudendal nerve branches during perineural injections predicts both immediate pain relief and likely long-term benefit from corticosteroid 4.