Chronic Pelvic Pain: The Neuropathic Pain Basis

Chronic pelvic pain (CPP) in both genders has been chiefly the province of surgical subspecialists. Morphologic end-organ processes have been studied for decades without significant advances in understanding the etiology of CPP or developing adequate therapeutic outcomes. The neurogenic basis of CPP has received little attention. Several peripheral nerves may be the source. The largest of these is a pudendal nerve and is the most important because it is a mixed nerve and affects sensory and motor symptoms in both the somatic and autonomic nervous systems. Nerve compression and stretch are the two most important etiologic factors. Practitioners can diagnose these painful neuropathies by a careful symptom history and physical examination. The most important diagnostic tool is sensory examination of the pudendal territory using pinprick. Various neurophysiologic tests can confirm pudendal neuropathy. The smaller peripheral nerves affect CPP. Because pudendal neuropathy is a tunnel syndrome related to cumulative, repetitive microtrauma, it can be treated accordingly. Treatment options include nerve protection, medications (analeptics, tricyclic amines), perineural infiltrations of loca