How can I differentiate pelvic‑floor muscle guarding from pudendal‑nerve neuropathy in a patient with altered deep sexual sensation and mild bladder discomfort after a prolonged straining episode three years ago, while continence and superficial perineal sensation remain intact?

Differentiating Pelvic Floor Muscle Guarding from Pudendal Neuropathy After Chronic Straining

Your symptoms—deep, pressure-like discomfort with muted sexual sensation but preserved continence and superficial perineal touch—are far more consistent with pelvic floor muscle guarding (hypertonicity) than pudendal neuropathy, and you should pursue pelvic floor physiotherapy as first-line treatment before considering nerve-specific interventions. 1

Key Distinguishing Features

Pain Quality and Character

• Muscle guarding presents as deep, tense, pressure-like or "heaviness" sensations that feel inner and diffuse, exactly matching your description of discomfort that you cannot determine is numbness or tension 1
• Pudendal neuropathy typically causes sharp, burning, or electric-shock quality pain in the specific anatomical territory of the pudendal nerve 2
• Your inability to characterize the sensation as clearly numb versus tense strongly suggests muscular tension rather than nerve injury 1

Sensory Examination Findings

• Critical distinction: Pudendal neuralgia by the Nantes criteria requires no objective sensory loss on clinical examination, meaning superficial touch sensation must be completely normal 2
• You report that "most of the normal touch sensations around the perineal region are still there," which actually argues against classic pudendal neuralgia 2
• Muscle guarding commonly preserves superficial sensation while altering deep proprioceptive and sexual sensations 1

Sitting Intolerance Pattern

• Pudendal neuralgia characteristically worsens with sitting and is one of the five essential Nantes diagnostic criteria 2
• Muscle guarding may worsen with prolonged sitting due to muscle fatigue rather than nerve compression 1
• The mechanism differs: nerve compression versus muscular fatigue 1

Nighttime Pain

• Essential criterion: Pudendal neuralgia patients are not woken at night by pain 2
• If you experience nighttime pain, this excludes pudendal neuralgia by Nantes criteria 2

Sexual Dysfunction Pattern

• Your description of "muted deep inner sexual arousal" with preserved superficial sensation fits the pattern of muscular hypertonicity affecting deep pelvic proprioception 1
• Pudendal neuropathy would more likely cause complete loss of genital sensation or burning dysesthesias in the nerve's anatomical territory 2

Diagnostic Algorithm

Step 1: Apply Nantes Criteria for Pudendal Neuralgia

You must meet all five essential criteria to diagnose pudendal neuralgia 2:

1. Pain in the anatomical territory of the pudendal nerve (perineum, genitals, anus) 2
2. Pain worsened by sitting 2
3. Patient is NOT woken at night by pain 2
4. No objective sensory loss on clinical examination 2
5. Positive anesthetic pudendal nerve block 2

Your case fails criterion #4 because you describe altered sensation, and you have not had criterion #5 tested 2. This makes pudendal neuralgia unlikely.

Step 2: Assess for Muscle Guarding Features

• Deep, pressure-like, aching discomfort (present in your case) 1
• Difficulty characterizing sensation as numbness versus tension (present in your case) 1
• Pelvic floor muscle tenderness on digital examination (requires physical exam) 1
• History of chronic straining—a known risk factor for pelvic floor dysfunction 3

Step 3: Physical Examination Requirements

• Digital pelvic floor examination to assess for muscle tenderness, spasm, and hypertonicity 1
• Pinprick sensory testing of the entire pudendal nerve territory (six branches bilaterally) to objectively document any sensory loss 4
• Assessment of pelvic floor muscle contraction and relaxation ability 1

Step 4: Imaging Considerations

• MRI pelvis with dynamic maneuvers is recommended when physical exam findings are discordant with symptoms or when conservative therapy fails 1, 5
• MRI can directly visualize muscular hypertonicity and rule out structural pathology 1, 5
• MRI is not first-line; pursue after completing 3 months of physiotherapy 1

Treatment Pathway

First-Line: Pelvic Floor Physiotherapy (90-100% Success Rate)

You should begin comprehensive pelvic floor physiotherapy immediately, as it achieves 90-100% success rates in resolving muscle guarding. 1

Specific protocol 1:

• Daily pelvic floor (Kegel) exercises taught by trained pelvic floor physical therapist
• Isolated contractions held for 6-8 seconds
• 6-second rest intervals between contractions
• Performed twice daily for approximately 15 minutes per session
• Minimum 3-month trial required before declaring treatment failure 1

Adjunctive Conservative Measures

• Adopt correct toilet posture: buttock support, foot support (e.g., Squatty Potty), comfortable hip abduction to prevent co-activation of pelvic floor muscles during defecation 1
• Biofeedback therapy using perineal surface EMG electrodes to learn muscle relaxation 1
• Manual physical therapy targeting pelvic floor and hip musculature 1
• Aggressive management of constipation, which commonly coexists with and worsens pelvic floor tension 1

When to Pursue Imaging

• After failure of 3-month physiotherapy trial 1
• If physical examination findings do not match symptom severity 1, 5
• To rule out structural pathology (tumors, anatomical anomalies) if clinically suspected 1

Critical Pitfalls to Avoid

Do NOT Pursue Pudendal Nerve Interventions Prematurely

• Do not undergo pudendal nerve blocks, radiofrequency ablation, or surgical decompression unless you strictly meet all five Nantes criteria 2
• Pudendal nerve blocks have variable success: only 13.2% of patients achieve complete anesthesia of all six nerve branches, and 39.2% achieve complete pain relief 4
• Unilateral pudendal neuropathy can occur (72% of neuropathy cases are unilateral), but this requires objective electrophysiologic testing, not just symptoms 6

Avoid Premature or Inappropriate Imaging

• Do not pursue MRI before completing a 3-month trial of pelvic floor physiotherapy 1
• Standard pelvic MRI without dynamic maneuvers has no validated role for functional pelvic floor assessment 5
• If imaging is needed, request MRI pelvis with dynamic maneuvers or MR defecography, not standard static MRI 5

Recognize Overlapping Syndromes

• Vulvodynia and pudendal neuralgia can coexist and shadow each other's symptoms 7
• Pelvic floor dysfunction often involves multiple compartments (bladder, bowel, sexual) that require concurrent evaluation 1, 3
• Your bladder discomfort and sexual dysfunction should be addressed together within the pelvic floor physiotherapy framework 1

Monitoring Treatment Success

• Improvement in symptom severity and frequency 1
• Ability to sit for longer periods without discomfort 1
• Reduction of pelvic floor muscle tenderness on repeat examination 1
• Restoration of sexual sensation and arousal 1

Timeline and Prognosis

• Expect gradual improvement over 3 months of consistent physiotherapy 1
• If no improvement after 3 months, reassess with MRI and consider referral to pelvic pain specialist 1
• Chronic straining from 3 years ago is a recognized risk factor for pelvic floor dysfunction, and your symptoms are consistent with this etiology 3