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Pudendal nerve

The pudendal nerve is a major somatic nerve originating from the ventral rami of the sacral spinal nerves S2–S4 within the sacral plexus, serving as the primary nerve supplying the perineum and external genitalia in both sexes.^[1]^[2] It is a mixed nerve carrying sensory and motor fibers, responsible for transmitting sensations from the genitals, perineum, and anus to the brain while innervating muscles essential for continence, sexual function, and pelvic floor support.^[3]^[4] The nerve emerges from the sacral plexus in the pelvis, exits through the greater sciatic foramen inferior to the piriformis muscle, passes around the sacrospinous ligament, re-enters through the lesser sciatic foramen, and travels through the pudendal (Alcock's) canal along the lateral wall of the ischioanal fossa, accompanied by the internal pudendal artery and vein.^[1] Within the canal, it divides into three principal branches: the inferior rectal nerve, which provides motor innervation to the external anal sphincter and sensory supply to the anal skin; the perineal nerve, which splits into superficial and deep divisions to innervate the perineal muscles (such as the bulbospongiosus and ischiocavernosus) and skin of the posterior scrotum/labia; and the dorsal nerve of the penis (in males) or clitoris (in females), which supplies sensory innervation to the glans, prepuce, and surrounding structures critical for sexual sensation.^[4]^[3] Motor functions include control of pelvic floor striated muscles for urethral and anal sphincter closure, facilitating micturition, defecation, and orgasm, while sensory roles encompass dermatomes over the perianal region, labia minora, vaginal vestibule, and lower vagina (or scrotum and penile shaft).^[2]^[1] Clinically, the pudendal nerve is notable for its vulnerability to entrapment or injury during childbirth, prolonged cycling, or pelvic surgery, potentially leading to pudendal neuralgia—a chronic pain syndrome—or dysfunctions like incontinence and sexual impairment.^[1] Its anatomical course near the sacrospinous and sacrotuberous ligaments makes it accessible for diagnostic blocks or neuromodulation therapies, underscoring its role in urogenital and proctologic disorders.^[4]

Anatomy

Origin and Spinal Nucleus

The pudendal nerve originates from the sacral plexus in the pelvic cavity, formed by the anterior divisions of the ventral rami of spinal nerves S2, S3, and S4.^[1] These roots converge to create the nerve's proximal trunk, which initially lies on the posterior surface of the pelvic floor before exiting the pelvis.^[3] The contributions from these sacral levels provide a mixed composition of nerve fibers, including somatic efferent fibers for motor innervation, somatic afferent fibers for sensory input, and parasympathetic components that arise from the same root levels but primarily travel via adjacent pelvic splanchnic nerves.^[5] The spinal nucleus associated with the pudendal nerve is Onuf's nucleus, a distinct cluster of somatic motor neurons located in the ventral horn (lamina IX) of the sacral spinal cord at levels S2 to S4.^[6] This nucleus, measuring approximately 4–7 mm in length, contains multipolar neurons with large Nissl bodies that specifically innervate the striated muscles of the pelvic floor, such as the external urethral and anal sphincters, via the pudendal nerve's efferent pathways.^[7] The motor neurons in Onuf's nucleus are responsible for coordinating functions like urinary and fecal continence, as well as aspects of sexual function, through their projections into the pudendal nerve.^[8] Microscopically, the pudendal nerve comprises a combination of myelinated and unmyelinated axons, reflecting its diverse functional roles. Myelinated fibers, which include large-diameter Aα and Aβ types (typically 6–20 μm) for rapid conduction in motor and touch sensation, predominate in the somatic components, while smaller myelinated Aδ fibers (2–5 μm) and unmyelinated C fibers (0.1–1.5 μm) handle pain, temperature, and some autonomic signaling.^[9] This fiber spectrum ensures efficient transmission from the sacral roots to peripheral targets, with the myelinated axons providing the structural basis for the nerve's high-fidelity somatic signaling.^[10]

Course and Relations

The pudendal nerve originates from the anterior divisions of the ventral rami of spinal nerves S2 to S4 within the sacral plexus, located on the posterior surface of the pelvic aspect of the sacrum.^[1] It emerges from the pelvis by passing through the greater sciatic foramen, inferior to the piriformis muscle, and initially courses laterally in the gluteal region.^[11] As it proceeds, the nerve passes between the sacrospinous ligament inferiorly and the sacrotuberous ligament superiorly, maintaining close proximity to these ligaments near the ischial spine.^[3] The pudendal nerve then re-enters the pelvis via the lesser sciatic foramen, traveling over the obturator internus muscle and under the sacrotuberous ligament, before hooking medially around the sacrospinous ligament.^[1] It accompanies the internal pudendal artery and vein, forming the neurovascular bundle that enters the pudendal (Alcock's) canal—a fascial tunnel formed by the obturator fascia covering the medial aspect of the obturator internus muscle.^[11] Within this canal, the nerve lies in close relation to the levator ani muscle medially and the obturator internus muscle laterally, extending through the canal for approximately 4-5 cm toward the perineum.^[3] Upon exiting the pudendal canal at the posterior border of the perineal membrane, the pudendal nerve enters the ischiorectal (ischioanal) fossa of the perineum, where it continues as the main trunk before eventual branching.^[1] This pathway positions the nerve in potential contact with adjacent structures such as the piriformis muscle proximally and the levator ani distally, influencing its anatomical relations in the pelvic floor.^[11]

Branches

The pudendal nerve typically divides into three main terminal branches within the pudendal canal: the inferior rectal nerve, the perineal nerve, and the dorsal nerve of the penis (in males) or clitoris (in females).^[1]^[12] This trifurcation occurs as the nerve progresses through the canal, with the inferior rectal nerve arising first, followed by the division into the perineal and dorsal nerves.^[13] These branches may form anastomoses with adjacent nerves, such as communications between the inferior rectal nerve and the perineal branch of the posterior femoral cutaneous nerve. The inferior rectal nerve emerges as the initial branch of the pudendal nerve within the pudendal canal and travels medially across the obturator internus muscle and the levator ani.^[1] It provides motor innervation to the external anal sphincter and sensory innervation to the skin of the anal canal and perianal region.^[14]^[15] The perineal nerve arises after the inferior rectal branch and further subdivides into superficial and deep branches upon exiting the pudendal canal into the perineum.^[13] The deep branch supplies motor innervation to the urethral sphincter, deep transverse perineal muscle, and sphincter urethrovaginalis (in females).^[15] The superficial branch innervates the bulbospongiosus and ischiocavernosus muscles, the superficial transverse perineal muscle, and gives rise to the posterior scrotal nerves (in males) or posterior labial nerves (in females), which distribute to the scrotal or labial skin.^[15]^[1] The dorsal nerve of the penis or dorsal nerve of the clitoris represents the terminal continuation of the pudendal nerve, traveling along the perineal membrane toward the urogenital diaphragm.^[13] It primarily provides sensory innervation to the skin of the glans penis or glans clitoris and the penile or clitoral shaft.^[15]^[1]

Anatomical Variations

The pudendal nerve typically originates from the ventral rami of the S2–S4 spinal nerves, but anatomical variations in its origin are documented, including high contributions from S1 or low extensions to S5 in a portion of the population.^[1] These additional root involvements alter the nerve's proximal formation within the sacral plexus, potentially affecting its overall trajectory and vulnerability. Bilateral asymmetry in root contributions to sacral nerves is common. Such asymmetries can lead to differential nerve caliber or branching patterns between sides. Branching anomalies represent another key variation, with the nerve often presenting as a single trunk in 52–62% of hemipelvises, while double or multiple trunks occur in the remainder, sometimes with the inferior rectal nerve arising as a separate trunk that pierces the sacrospinous ligament.^[12] Duplication of the inferior rectal nerve can occur, manifesting as two branches supplying the anal region. Overall, anatomical variants in the pudendal nerve's course, particularly near the sacrospinous ligament or pudendal canal, are identified in 10–15% of cases based on cadaveric and surgical studies.^[16] These variations carry clinical implications, notably elevating the risk of iatrogenic injury during pelvic surgeries such as sacrospinous ligament fixation or prolapse repairs, where atypical nerve positioning can lead to unintended compression or transection.^[1] For instance, a transligamentous course of the nerve through the sacrospinous ligament has been observed in some cases of anatomical variants.^[17] Awareness of such differences is essential for preoperative imaging and surgical planning to mitigate postoperative neuropathies.

Function

Sensory Innervation

The pudendal nerve provides sensory innervation primarily to the dermatomes of spinal segments S2-S4, encompassing the perianal skin, perineum, posterior scrotum and labia majora in males and females, as well as the glans penis and clitoris.^[1] This coverage arises through its terminal branches: the inferior rectal nerve supplies the perianal skin and lower anal canal; the perineal nerve innervates the posterior perineum, labia minora, and posterior scrotum; and the dorsal nerve of the penis or clitoris provides sensation to the external genitalia, including the glans and prepuce or hood.^[18] These distributions ensure comprehensive somatic sensory input from the external pelvic and genital regions.^[3] The nerve transmits multiple sensory modalities, including touch, pain, and temperature from the perineal and genital skin, as well as proprioceptive signals from the pelvic floor musculature.^[1] In the anal canal below the pectinate line and external hemorrhoidal area, it conveys sharp pain sensations, while in the genitalia, it plays a critical role in sexual sensation, facilitating tactile and pressure inputs that contribute to arousal and orgasmic responses, such as heightened sensitivity in the clitoral or penile glans.^[18] Proprioceptive afferents from striated pelvic floor muscles, including the external anal and urethral sphincters, allow for feedback on muscle position and tension during activities like posture maintenance.^[19] Afferent fibers from these regions travel proximally via the pudendal nerve, rejoining the ventral rami of S2-S4 roots to enter the sacral spinal cord through the dorsal horns.^[1] From there, second-order neurons ascend via the spinothalamic and dorsal column-medial lemniscus pathways to the thalamus, ultimately projecting to the somatosensory cortex in the postcentral gyrus for conscious perception and localization of sensations.^[18] Notably, the pudendal nerve contributes to the sensory limb of sacral reflex arcs essential for micturition and defecation, relaying somatic pressure signals from the perineum and external sphincters to contribute to sphincter relaxation and coordinated voiding or expulsion.^[19] These reflexes integrate pudendal afferents with pelvic parasympathetic inputs at the sacral level, ensuring rapid, involuntary responses without higher cortical involvement.^[1]

Motor Innervation

The pudendal nerve provides somatic motor innervation to several key skeletal muscles in the pelvic floor and perineum, primarily originating from motor neurons in Onuf's nucleus within the ventral horn of the sacral spinal cord at levels S2-S4.^[6] These muscles include the external anal sphincter, external urethral sphincter, bulbospongiosus, ischiocavernosus, and superficial transverse perineal muscle.^[1] The inferior rectal branch of the pudendal nerve specifically supplies the external anal sphincter, enabling voluntary control of defecation, while the perineal branch innervates the bulbospongiosus, ischiocavernosus, superficial transverse perineal, and external urethral sphincter muscles.^[1] A critical function of this motor innervation is the maintenance of continence through tonic activity of the external anal and urethral sphincters.^[20] Motor neurons in Onuf's nucleus generate sustained, low-level discharges that keep these sphincters contracted during rest, preventing involuntary leakage of urine or feces and supporting pelvic organ stability.^[6] This tonic control is essential for baseline closure pressure in the anal and urethral outlets.^[20] In sexual function, the pudendal nerve mediates rhythmic contractions of the bulbospongiosus and ischiocavernosus muscles during orgasm and ejaculation.^[21] These phasic bursts, driven by efferent signals from Onuf's nucleus, facilitate propulsion of semen through the urethra in males and contribute to clitoral and vaginal responses in females.^[21] The pudendal nerve's motor fibers consist of alpha motor neurons, which directly innervate extrafusal muscle fibers for voluntary contraction and force generation, and gamma motor neurons, which regulate intrafusal muscle spindles to maintain sensitivity and feedback during movement.^[22] Sensory feedback from pelvic muscles integrates with these motor pathways in spinal reflexes, such as the bulbocavernosus reflex, to coordinate responses.^[1]

Clinical Significance

Pudendal Nerve Block and Anesthesia

The pudendal nerve block is a regional anesthesia technique that involves injecting a local anesthetic near the pudendal nerve as it courses through the pudendal (Alcock's) canal to provide targeted analgesia to the perineum, vulva, and anus. This method is particularly valuable for procedures requiring perineal anesthesia, as it avoids the systemic effects of general anesthesia while effectively blocking sensory innervation from the S2-S4 spinal segments.^[14] Indications for pudendal nerve block primarily include labor analgesia during the second stage of vaginal delivery, where it alleviates perineal pain without prolonging labor; perineal surgeries such as episiotomy repair or vulvar procedures; and anorectal interventions like hemorrhoidectomy, which benefit from reduced postoperative pain and opioid requirements.^[23]^[24] The block is often selected when neuraxial techniques are contraindicated or unavailable, offering a safe alternative for outpatient or emergency settings.^[14] Various approaches are employed to perform the block, including the transvaginal method, which involves inserting a needle through the vaginal wall to access the nerve near the ischial spine, commonly used in obstetric settings; the transperineal approach, involving needle insertion through the perineum toward the ischial spine, often with digital guidance; and image-guided techniques utilizing ultrasound or fluoroscopy for precise targeting of the pudendal canal, enhancing accuracy and reducing risks in complex anatomies.^[14]^[25] Local anesthetics such as 1% lidocaine, providing a sensory block duration of approximately 1-2 hours suitable for short procedures, or 0.25-0.5% bupivacaine, offering 2-4 hours of analgesia for extended relief, are typically administered in volumes of 5-10 mL per side, sometimes combined with epinephrine to prolong effect and minimize vascular uptake.^[23]^[26] Potential complications are generally mild and transient, with temporary numbness or paresthesia in the perineal region occurring in most patients as the intended effect, resolving within hours; rare but serious risks include systemic toxicity from local anesthetic absorption, manifesting as seizures or cardiovascular instability if excessive doses are used. Success rates for achieving adequate analgesia in obstetric applications range from 80% to 95%, with ultrasound guidance improving outcomes to over 90% in alleviating perineal discomfort during labor.^[25]^[27] Patient selection and proper technique are crucial to optimize efficacy while minimizing adverse events.^[14]

Injury and Damage

Pudendal nerve injury encompasses a range of disruptions to the nerve's structure and function, often resulting from mechanical compression, stretching, or direct trauma in the pelvic region. Common causes include traumatic events such as stretching during vaginal childbirth, prolonged pressure from cycling, and surgical trauma during pelvic procedures. Entrapment within the pudendal canal, known as pudendal canal syndrome, occurs when the nerve is compressed by surrounding ligaments or muscles, leading to ischemia and inflammation. Iatrogenic injuries frequently arise from procedures like hysterectomy, where inadvertent nerve damage or scarring can occur. Anatomical variations, such as abnormal fixation of the nerve to the sacrospinous ligament, may predispose individuals to higher risk during these events.^[28]^[29]^[30]^[31] Symptoms of pudendal nerve injury manifest primarily in the perineal and genital areas, including sharp or burning perineal pain that worsens with sitting, sensory disturbances such as numbness or tingling, bowel or bladder incontinence due to impaired sphincter control, and sexual dysfunction like pain during intercourse or erectile difficulties. Acute presentations typically emerge immediately after the traumatic event, with intense pain and functional deficits, whereas chronic forms develop gradually from ongoing compression, featuring persistent neuropathic pain and progressive sensory loss.^[28]^[29]^[30] The pathophysiology of pudendal nerve injury follows the Sunderland classification of peripheral nerve damage, which grades severity from first-degree (neuropraxia, involving temporary conduction block without axonal disruption and full recovery expected within weeks) to second- through fourth-degree (axonotmesis, with axonal interruption but preserved endoneurial tubes, leading to Wallerian degeneration and potential regeneration) and fifth-degree (neurotmesis, complete severance requiring surgical intervention for recovery). In pudendal cases, entrapment often causes initial demyelination and ischemia in milder grades, progressing to axonal injury in severe trauma, with outcomes depending on the degree of structural integrity preserved.^[32]^[29] Incidence of pudendal nerve injury varies by population, with temporary damage observed in up to 42% of women immediately postpartum due to stretching during vaginal delivery, though persistent cases affect approximately 15-20% based on prolonged nerve latency measurements several months postpartum.^[33]^[34]^[35] Among athletes, rates are elevated, particularly in cyclists, where 7-8% of those on long-distance multiday rides report pudendal neuralgia from repetitive compression, and up to 20% of competitive cyclists experience related perineal symptoms.^[36]^[37]

Diagnostic Methods

Diagnostic methods for assessing pudendal nerve integrity and function primarily involve imaging techniques and electrophysiological tests to identify entrapment, neuropathy, or dysfunction. Magnetic resonance imaging (MRI), particularly high-resolution 3T MR neurography with pelvic views, visualizes the pudendal nerve's course through the pelvis, detecting abnormalities such as swelling, compression, or entrapment at sites like the Alcock's canal.^[38] This modality offers detailed anatomical assessment but has limited sensitivity for subtle neuropathies, with studies reporting detection rates around 70-90% for entrapment-related changes when optimized protocols are used.^[39] Ultrasound, especially dynamic transperineal scanning, provides real-time evaluation of perineal structures and correlates with pudendal nerve latency by measuring puborectalis muscle displacement during maneuvers, aiding in the diagnosis of associated incontinence or entrapment with high reproducibility (sensitivity up to 91% for displacement indicators).^[40] Electrophysiological assessments quantify nerve conduction and muscle response. The pudendal nerve terminal motor latency (PNTML) test measures the conduction time from nerve stimulation to anal sphincter contraction using a surface electrode probe inserted into the anal canal, with the patient positioned in the left lateral decubitus for optimal access.^[30] Normal latency values are typically less than 2.2 ms (mean around 1.8-2.0 ms, varying by age and sex), and prolongation indicates neuropathy.^[41] Electromyography (EMG) of pelvic floor muscles, including the anal sphincter and levator ani, records electrical activity via needle or surface electrodes to detect denervation, reinnervation, or abnormal firing patterns indicative of pudendal nerve damage. Somatosensory evoked potentials (SSEP) evaluate sensory pathways by stimulating the pudendal nerve (e.g., at the dorsal penis/clitoris) and recording cortical responses, with normal latencies around 20-25 ms for lumbar and cortical peaks, helping confirm proximal conduction delays.^[42] These methods are often combined for comprehensive evaluation; for instance, abnormal PNTML prompts MRI to localize lesions, enhancing diagnostic accuracy in conditions like pudendal neuralgia.^[30]

Associated Disorders

Pudendal neuralgia is a chronic neuropathic pain syndrome resulting from dysfunction or irritation of the pudendal nerve, manifesting as burning, stabbing, or electric shock-like pain in the perineal, genital, or anorectal regions. The condition is diagnosed using the Nantes criteria, which require pain confined to the pudendal nerve's sensory territory, worsening specifically during sitting, absence of nocturnal awakening due to pain, no objective sensory deficits on examination, and temporary relief following a pudendal nerve anesthetic block.^[43] This syndrome affects sensory and motor functions, leading to symptoms like numbness, tingling, or impaired pelvic muscle control.^[44] The prevalence of pudendal neuralgia in the general population is estimated at approximately 1 per 100,000 individuals, though it is higher among women, with a female-to-male ratio of about 7:3.^[30] It is more common in multiparous women due to cumulative effects of vaginal deliveries on pelvic floor integrity. Associated pelvic floor disorders include urinary and fecal incontinence, as well as dyspareunia, stemming from pudendal nerve-mediated denervation of the external anal sphincter, urethral sphincter, and perineal muscles.^[45] In women, pudendal neuralgia often coexists with endometriosis, where endometriotic lesions can entrap or inflame the nerve, exacerbating perineal pain and voiding dysfunction.^[46] In men, it frequently overlaps with chronic prostatitis or chronic pelvic pain syndrome, where nerve irritation contributes to urogenital pain, voiding issues, and sexual dysfunction.^[47] Alcock's canal syndrome represents a specific entrapment variant of pudendal neuralgia, occurring within the pudendal (Alcock's) canal beneath the obturator internus muscle, potentially compressing both the nerve and the accompanying pudendal artery to produce ischemic pain alongside neuropathic symptoms.^[48] Treatment typically begins with conservative measures, including pelvic floor physical therapy to address muscle hypertonicity and improve nerve gliding, followed by neuromodulation options such as sacral nerve stimulation for refractory cases, which can alleviate pain and restore function in a significant proportion of patients.^[44]

History and Etymology

The pudendal nerve was first described by Irish anatomist Benjamin Alcock in 1836, in the context of his research on the course of the internal pudendal artery and the anatomy of the external genitalia.^[4]^[49] The term "pudendal" derives from the Latin "pudenda," referring to the external genitalia, which originates from "pudendum," meaning "parts to be ashamed of."^[11]

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Prevalence of pudendal neuropathy in fecal incontinence ... - PubMed
Results: Pudendal neuropathy (defined as PNTML > 2.2 ms or FD > 1.65) was found in 67 patients (69.8 percent) and was more common in females (75 percent) than ...Missing: neuralgia | Show results with:neuralgia
[48]
Evidence for the innervation of pelvic floor muscles by the pudendal ...
Pudendal nerve blockade decreases vaginal pressures, increases length of urogenital hiatus, and decreases electromyography activity of the puborectalis muscle.
[49]
Recognition and treatment of endometriosis involving the sacral ...
The signs suggestive of intrapelvic nerve involvement include perineal pain or pain irradiating to the lower limbs, lower urinary tract symptoms, ...Missing: association | Show results with:association
[50]
[Prostatitis syndromes and sporting activities] - PubMed
CP/CPPS may be often caused by pudendal nerve entrapment (PNE). Prostatitis-like urogenital neuropathic pain together with voiding and sexual dysfunctions are ...
[51]
Alcock canal syndrome due to obturator internus muscle fibrosis
Alcock canal syndrome is a rare entrapment neuropathy of the pudendal nerve. We report a case of perineal neuralgia where pudendal nerve compression was due ...