What clinical criteria, besides reduced sexual function, are required to diagnose pudendal neuropathy (pudendal neuralgia)?

Diagnostic Criteria for Pudendal Neuropathy (Pudendal Neuralgia)

The diagnosis of pudendal neuropathy requires five essential clinical criteria (the Nantes criteria), with diminished sexual function being only one component of the broader pain presentation, not a standalone diagnostic criterion. 1

The Five Essential Nantes Criteria

To diagnose pudendal neuralgia by pudendal nerve entrapment, all five of the following must be present:

1. Pain in the anatomical territory of the pudendal nerve - This includes the perineum, genitals, and/or rectum, which may manifest as sexual dysfunction but extends beyond just sexual symptoms 1, 2

2. Pain worsened by sitting - This is a hallmark feature that distinguishes pudendal neuralgia from other pelvic pain conditions 1, 3

3. The patient is NOT woken at night by the pain - Pain that awakens patients at night is a red flag suggesting alternative diagnoses such as tumor compression 1, 2

4. No objective sensory loss on clinical examination - The absence of demonstrable sensory deficits on physical exam is required; presence of hypoesthesia suggests an atypical presentation requiring imaging 1, 2

5. Positive anesthetic pudendal nerve block - A clear response to local anesthetic injection confirms the diagnosis 1, 4

Important Clinical Context

Sexual dysfunction in pudendal neuropathy is part of the broader pain syndrome, not an isolated diagnostic criterion. The pain typically presents as neuropathic in character and follows the distribution of the pudendal nerve's terminal branches, which innervate the perineum and genitals. 1, 4

Additional Supportive Features (Not Required)

While not essential for diagnosis, these features strengthen clinical suspicion:

• Pain that increases throughout the day and decreases with standing or lying down 3
• Urinary difficulties (hesitancy, frequency) 3
• Defecation difficulties 3

Critical Exclusion Criteria (Red Flags)

The following findings make pudendal nerve entrapment UNLIKELY and warrant imaging (pelvic MRI) to exclude other pathology: 2

• Pain that wakes the patient at night 2
• Excessively neuropathic pain associated with hypoesthesia 2
• Specifically pinpointed pain suggesting neuroma 2
• Pain associated with neurological deficit 2
• Purely coccygeal, gluteal, or hypogastric pain 1
• Exclusively paroxysmal pain 1
• Exclusive pruritus 1

Diagnostic Workup

No specific paraclinical testing is required when the five Nantes criteria are met. 4 However, pelvic MRI should be obtained to exclude tumoral pathology or anatomical anomalies, particularly when red flags are present. 4, 2 Perineal electromyography should no longer be systematically proposed as it is not diagnostically useful. 4

MRI with diffusion-weighted imaging (DWI) can visualize pudendal nerve abnormalities and identify associated pathologies in patients with chronic pudendal neuralgia, though diagnosis remains primarily clinical. 5

Common Diagnostic Pitfall

The most critical error is failing to recognize that pudendal neuralgia is a clinical diagnosis based on the complete constellation of the five Nantes criteria, not on any single symptom like sexual dysfunction alone. 1 Sexual dysfunction is merely one manifestation of pain in the pudendal nerve territory and must be accompanied by the characteristic sitting-aggravated pattern, absence of nocturnal awakening, normal sensory exam, and positive nerve block to confirm the diagnosis.