Pudendal neuralgia is a chronic neuropathic pelvic pain that is often misdiagnosed and
inappropriately treated. The Nantes criteria provide a basis for the diagnosis of pudendal
neuralgia due to pudendal nerve entrapment. The 5 essential diagnostic criteria are pain
situated in the anatomical territory of the pudendal nerve, worsened by sitting, the patient
is not woken at night by the pain, and no objective sensory loss is detected on clinical
examination. The fifth criterion is a positive pudendal nerve block. We have also clarified
a number of complementary diagnostic criteria and several exclusion criteria that make
the diagnosis unlikely. When pudendal neuralgia due to pudendal nerve entrapment
is diagnosed according to the Nantes criteria, no further investigation is required and
medical or surgical treatment can be proposed. Nevertheless, a number of warning signs
suggesting other possible causes of pudendal neuralgia must not be overlooked. These
warning signs (red flags) are waking up at night, excessively neuropathic nature of the
pain (for example, associated with hypoesthesia), specifically pinpointed pain, which
can suggest neuroma and pain associated with neurological deficit. In these atypical
presentations, the diagnosis of pain due to pudendal nerve entrapment should be
reconsidered and a radiological examination should be performed. The 2 cases described
in this report (tumor compression of the pudendal nerve) illustrate the need to recognize
atypical pudendal neuralgia and clarify the role of pelvic magnetic resonance imaging
(MRI), as MRI provides very valuable information for the evaluation of diseases involving
the ischiorectal fossa. The presence of red flags must be investigated in all cases of
pudendal neuralgia to avoid missing pudendal neuralgia secondary to a mechanism other
than nerve entrapment.
Key words: Pudendal nerve, pudendal neuralgia, Nantes criteria, pelvic pain, pudendal
canal, perineal pain
Reply to Re: Popeney C, Ansell V, Renney K. 2007. Pudendal nerve entrapment as an etiology of chronic perineal pain: Diagnosis and treatment. Neurourol Urodynam
