Does Pudendal Neuralgia Require Pain for Diagnosis?
Yes, pain is absolutely required for the diagnosis of pudendal neuralgia—it is the defining characteristic of this condition. Without pain (or related sensations like burning or discomfort), the diagnosis cannot be made.
Pain as the Essential Diagnostic Criterion
Pain along the pudendal nerve distribution is present in 100% of patients with pudendal neuralgia, making it the cardinal and non-negotiable feature of this diagnosis 1.
The pain is characteristically neuropathic in quality—described as sharp, burning, or severe—and follows the anatomical territory of the pudendal nerve's terminal branches 2, 3.
The diagnosis is entirely clinical, based on the presence of neuropathic pain in the correct anatomical distribution 2.
Classic Pain Characteristics That Define the Condition
Beyond simply having pain, pudendal neuralgia has specific pain patterns that help confirm the diagnosis:
Pain is aggravated by sitting in 97% of patients, which is nearly pathognomonic for this condition 1.
Pain is relieved by standing or lying down in 89% of patients, creating a characteristic positional pattern 1.
The pain must be located in the perineum, gluteal region, or along the course of the pudendal nerve to qualify as pudendal neuralgia 4, 2.
Important Diagnostic Nuances
While "pain" is the standard descriptor, some patients may describe their symptoms as "pressure," "burning," or "discomfort" rather than using the word "pain" explicitly—but these are still pain-equivalent sensations that fulfill the diagnostic requirement 5, 6.
The most well-recognized subtype is pudendal nerve entrapment (PNE), which must meet the five Nantes criteria and demonstrate clear response to local anesthetic injection 2.
No paraclinical testing is required for diagnosis—perineal electromyography should no longer be systematically proposed, though pelvic MRI may be obtained to exclude tumors or anatomical anomalies 2.
Common Diagnostic Pitfalls
Pudendal neuralgia is misdiagnosed in 83% of patients initially, often because clinicians fail to recognize the characteristic sitting-aggravated pain pattern 1.
Do not confuse pudendal neuralgia with central pelvic hypersensitization, where neuropathic pudendal pain is poorly systematized and associated with other diffuse pelvic pains 2.
Neurophysiologic testing is normal in 35% of confirmed pudendal neuralgia cases, so normal electromyography does not exclude the diagnosis 1.
Why Pain Cannot Be Absent
The very definition of neuralgia is pain along a nerve distribution. Without pain or pain-equivalent sensations:
The patient would have pudendal nerve dysfunction or neuropathy, not neuralgia 2.
There would be no indication for the treatments used in pudendal neuralgia, all of which target pain relief as their primary outcome 3, 1.
The condition would not meet any recognized diagnostic criteria, as pain improvement is the universal measure of treatment success across all therapeutic modalities 3.