In a patient with deep pressure‑like perineal discomfort, reduced sexual sensation, mild bladder irritation after a single prolonged straining event three years ago, intact continence and normal superficial perineal sensation, is this consistent with pudendal neuropathy, pudendal neuralgia, or pelvic‑floor muscle hypertonicity?

Clinical Distinction: Pudendal Neuropathy vs. Pudendal Neuralgia vs. Pelvic Floor Hypertonicity

Your patient's presentation—deep pressure-like perineal discomfort, reduced sexual sensation, and mild bladder irritation following a single prolonged straining event three years ago, with intact continence and normal superficial sensation—is most consistent with pelvic floor muscle hypertonicity rather than pudendal neuralgia or pudendal neuropathy. 1, 2

Understanding the Terminology

You are correct that pudendal neuralgia and pudendal neuropathy represent distinct entities:

• Pudendal neuralgia is a specific neuropathic pain syndrome characterized by burning, shooting, or electric-shock-like pain in the distribution of the pudendal nerve terminal branches 3, 4
• Pudendal neuropathy refers to nerve dysfunction (which may or may not be painful) with demonstrable neurophysiological abnormalities 3, 5
• Pelvic floor muscle hypertonicity involves sustained muscle tension and protective guarding patterns that can mimic nerve pathology 1, 2

Why Your Patient Does NOT Have Pudendal Neuralgia

Pudendal neuralgia requires meeting the Nantes criteria, which include 3, 4, 6:

• Neuropathic pain quality: Burning, shooting, stabbing, or electric-like sensations—not the "deep pressure" your patient describes
• Pain worsens with sitting and improves with standing/lying: Your patient's symptoms appear constant rather than position-dependent
• No sensory loss: While your patient has normal superficial sensation, pudendal neuralgia typically presents with altered sensation in specific dermatomal distributions 3
• Positive response to pudendal nerve block: This diagnostic criterion is essential for confirming pudendal neuralgia 3, 5
• Pain does not wake patient from sleep: A key distinguishing feature 6

The absence of classic neuropathic pain descriptors and the presence of deep pressure sensations argue strongly against pudendal neuralgia 3, 4.

Why Your Patient Does NOT Have Pudendal Neuropathy

Pudendal neuropathy would demonstrate 3, 5:

• Objective neurophysiological abnormalities: Increased sacral latency, abnormal pudendal nerve terminal motor latency, or neurogenic changes on perineal floor electromyography 5
• Motor dysfunction: Weakness of pelvic floor muscles or sphincter dysfunction—your patient has intact continence 5
• Sensory deficits in specific distributions: Your patient has normal superficial perineal sensation 3

The preservation of continence and normal superficial sensation makes pudendal neuropathy highly unlikely 3, 5.

Why Pelvic Floor Muscle Hypertonicity Fits Best

Your patient's presentation aligns precisely with pelvic floor hypertonicity 1, 2:

• Mechanism: Sustained muscle tension affecting the perineal region following the straining event creates protective guarding patterns that persist beyond the healing period 1
• Symptom profile: Deep pressure-like discomfort (rather than neuropathic pain), reduced sexual sensation from muscle tension, and mild bladder irritation are characteristic of muscle hypertonicity 1, 2
• Preserved function: Intact continence and normal superficial sensation indicate the problem is muscular rather than neurogenic 1, 2
• Temporal pattern: Symptoms developing after a single traumatic straining event and persisting for three years without progression suggests a functional muscle disorder rather than progressive neuropathy 1

Diagnostic Approach

Skip electrophysiological testing—perineal electromyography should no longer be systematically proposed for these presentations 3. Instead:

• Perform digital rectal examination: Assess for pelvic floor muscle tenderness, hypertonicity, and trigger points 1, 2
• Consider anorectal manometry only if needed: This can identify elevated anal resting tone and altered rectal sensory thresholds that confirm muscle hypertonicity, but proceed directly to treatment if the clinical picture is clear 1, 2
• Obtain pelvic MRI only to exclude structural pathology: Rule out tumors or anatomical anomalies, but this is not required for diagnosis of muscle hypertonicity 3

Treatment Algorithm

First-Line: Pelvic Floor Physical Therapy (Mandatory)

Refer immediately to a pelvic floor physical therapist with specific experience in anorectal disorders 1, 2:

• Treatment components: Internal and external myofascial release techniques, gradual desensitization exercises, muscle coordination retraining, and warm sitz baths 1
• Frequency: 2-3 sessions per week 1
• Duration: Minimum 3 months, with gradual improvement expected over 6-12 months 1
• Success rate: 70-76% of patients with refractory anorectal symptoms achieve adequate relief 1

Critical distinction: In patients with pelvic floor tenderness, traditional Kegel (strengthening) exercises should be avoided because they worsen symptoms—manual physical therapy techniques aimed at releasing trigger points are the appropriate alternative 2.

Adjunctive Measures

• Topical lidocaine 5% ointment: Apply to affected areas for symptom control during rehabilitation 1
• Biofeedback therapy: Enhances rectal sensory perception and helps restore normal anorectal coordination, addressing the altered sensation patterns 1
• Warm sitz baths: Promote muscle relaxation 1

What NOT to Do

• Never pursue additional surgical interventions: Further surgery would likely worsen any neuropathic component rather than improve it 1
• Avoid manual anal dilatation entirely: This carries a 30% temporary and 10% permanent incontinence rate 1
• Do not use strengthening exercises: Pelvic floor strengthening (Kegel) exercises will exacerbate symptoms in the presence of muscle hypertonicity 2

Prognostic Factors for Success

Better outcomes are associated with 1:

• Shorter symptom duration before starting therapy: Your patient is three years out, which may reduce success rates
• Higher patient motivation and consistent attendance: Emphasize the importance of adherence
• Absence of comorbid depression: Screen for and address any psychological comorbidities 2
• Better preserved baseline sensation: Your patient's normal superficial sensation is favorable

Expected Timeline

Altered sensations and dysesthesia typically improve significantly over 6-12 months with appropriate pelvic floor therapy, with improvement being gradual but substantial when therapy is consistently applied 1. The three-year duration of symptoms may prolong recovery, but substantial improvement remains achievable 1.

Common Pitfall

The most critical error is misdiagnosing pelvic floor muscle hypertonicity as pudendal neuralgia and pursuing nerve-directed treatments (blocks, radiofrequency, surgery) when the primary pathology is muscular 1, 2, 3. Your instinct to clarify the distinction is correct and will guide appropriate treatment.