What specific clinical details (timeline of the initial straining injury three years ago, fistulotomy seven months ago, sensory and motor findings, bladder symptoms, neurophysiologic studies, imaging, medications, and comorbidities) should I provide to my physician to differentiate a compressive pudendal nerve lesion from permanent nerve damage?

Key Clinical Details to Document for Differentiating Pudendal Nerve Compression from Permanent Damage

Timeline and Mechanism of Injury

Document the exact sequence and timing of your symptoms from the initial straining injury three years ago through the fistulotomy seven months ago, as the temporal relationship between trauma and symptom onset helps distinguish acute compression from chronic nerve damage. 1

• Record whether symptoms began immediately after the straining injury or developed gradually over weeks to months, as acute onset suggests direct trauma while delayed onset indicates progressive compression 1
• Note any changes in symptom severity or distribution after the fistulotomy, as surgical trauma can cause new nerve injury patterns distinct from pre-existing compression 2
• Document the maximum time point when symptoms were worst, as nerve compression typically reaches peak disability within 2-4 weeks, whereas permanent damage shows stable deficits 3

Sensory Examination Findings

Bring a detailed map of sensory changes tested with a safety pin across all six pudendal nerve branches: dorsal nerve of penis/clitoris, perineal nerves (medial and lateral), and inferior rectal nerves (right and left), as this pinprick examination diagnoses pudendal neuropathy in 92% of cases. 1

• Document whether numbness, tingling, or pain follows the specific anatomical distribution of pudendal nerve branches, as compression causes dermatomal patterns while permanent damage may show patchy or incomplete sensory loss 1
• Record any hyperesthesia (increased sensitivity) versus hypoesthesia (decreased sensitivity) in the perineum, genitals, and perianal region 1
• Note whether symptoms worsen with sitting and improve with standing or lying down (Nantes criteria), as this positional variation strongly suggests ongoing compression rather than fixed nerve damage 4

Motor and Autonomic Dysfunction

Document any weakness in pelvic floor muscles, changes in rectal or urinary sphincter control, erectile dysfunction, or altered orgasmic sensation, as these motor and autonomic findings indicate the severity and extent of nerve involvement. 5, 1

• Record specific bladder symptoms: urgency, frequency, hesitancy, incomplete emptying, or urinary retention 5
• Note bowel dysfunction: constipation, fecal urgency, or incontinence 5
• Document sexual dysfunction: erectile problems, ejaculatory changes, vaginal numbness, or dyspareunia 1
• Report any hyperacusis (sound sensitivity) or taste disturbances, though these are more typical of facial nerve lesions 6

Pain Characteristics

Describe the exact location, quality, and triggers of your pain, including whether it is burning, stabbing, or aching; whether it radiates; and whether it is relieved by pudendal nerve blocks, as response to diagnostic blocks strongly suggests reversible compression. 7, 4

• Document whether pain is unilateral or bilateral, as bilateral symptoms may suggest systemic causes like Guillain-Barré syndrome or require exclusion of central pathology 3
• Record whether pain is worse with sitting on hard surfaces and relieved by sitting on a toilet seat (relief with perineal suspension) 4
• Note any ipsilateral ear or facial pain, which would suggest a different nerve territory and require exclusion of other diagnoses 6

Neurophysiologic Studies

Bring results of pudendal nerve motor latency testing and electromyography (EMG) of pelvic floor muscles, as these studies quantify nerve damage severity and help predict recovery potential. 8, 1

• Electroneuronography (ENoG) results showing >90% amplitude reduction compared to the contralateral side suggest severe axonal loss with poor prognosis for spontaneous recovery 8
• EMG findings of active denervation (fibrillations, positive sharp waves) indicate ongoing nerve damage, while chronic changes (large polyphasic motor units) suggest permanent reinnervation 8
• Document the timing of these studies relative to symptom onset, as testing performed within 3 weeks of acute injury may be misleading due to ongoing Wallerian degeneration 8

Imaging Results

Provide MRI reports of the lumbosacral plexus with and without gadolinium contrast, as nerve enhancement, thickening, or compression at specific anatomical sites (sacrospinous ligament, sacrotuberous ligament, Alcock canal) confirms the diagnosis and localizes the lesion. 8

• MRI findings of nerve enlargement or T2 hyperintensity suggest active compression or inflammation that may be reversible 8
• Document any masses, hematomas, endometriosis, or anatomical variants (aberrant nerve pathways through ligaments) that could cause extrinsic compression 1, 4
• Note whether imaging shows muscle denervation changes (T2 hyperintensity in pelvic floor muscles), which indicates chronic nerve damage 8

Response to Conservative Treatment

Document your response to nerve protection strategies (avoiding prolonged sitting, using cushions), medications (gabapentin, pregabalin, tricyclic antidepressants), physical therapy, and pudendal nerve blocks, as failure of conservative treatment after 14 weeks suggests the need for surgical evaluation. 1, 2

• Record the number and results of CT-guided or fluoroscopy-guided pudendal nerve blocks with corticosteroids, as immediate relief confirms the diagnosis but long-term failure (>85% of cases) indicates mechanical compression requiring surgery 7
• Note any improvement with pelvic floor physical therapy, as this suggests muscle-related compression rather than fixed anatomical entrapment 2

Comorbidities and Risk Factors

List all relevant medical conditions including diabetes, anxiety, depression, prior pelvic surgeries, trauma history, and any systemic inflammatory conditions, as untreated anxiety/depression correlates with poor surgical outcomes (p<0.002) and diabetes increases neuropathy risk. 2, 6

• Document any history of Lyme disease, sarcoidosis, or other systemic inflammatory conditions that could cause neuropathy 6, 3
• Note pregnancy history or recent childbirth, as these are risk factors for pudendal nerve injury 6
• Record current medications, particularly anticoagulants that might increase hematoma risk or immunosuppressants that could cause neuropathy 6

Critical Red Flags Requiring Urgent Evaluation

Report any progressive weakness, bilateral symptoms, involvement of other nerve territories (leg weakness, foot drop), or bowel/bladder dysfunction developing acutely, as these suggest cauda equina syndrome, Guillain-Barré syndrome, or other serious pathology requiring emergency imaging and treatment. 3, 8

• Bilateral pudendal symptoms with ascending weakness and absent reflexes suggest Guillain-Barré syndrome and require urgent hospitalization 3
• New-onset severe back pain with saddle anesthesia and urinary retention indicates cauda equina syndrome requiring emergency MRI and possible surgical decompression 8
• Recurrent symptoms on the same side after initial recovery warrant MRI to exclude tumor or other structural lesions 6