Nerve injury to those nerves that enter the pelvis posteriorly

• Pudendal nerve (anal, perineal/vulvar, penis/clitoris, scrotal/testicular pain), e.g. nerve entrapment syndromes, pelvic floor muscle dysfunction, direct trauma.

• Inferior cluneal nerve (buttock pain extending to inner thighs/perineum), e.g. direct trauma, sitting for prolonged times, nerve entrapment.

• Perineal branches of the posterior femoral cutaneous nerve (perineal pain), e.g. direct trauma, sitting for prolonged times, nerve entrapment.

• Posterior femoral cutaneous nerve (posterior thigh pain), e.g. direct trauma, sitting for prolonged times, nerve entrapment.

The pain syndromes associated with injury of the posterior nerves in the region of the piriformis, superior gemellus, obturator internus and inferior gemel-lus muscles (the "posterior triangle") merit special mention as they have not been well described to date. Injury and disease processes in this area may involve one or more of these nerves with associated neuropathic symptoms. The sensory abnormalities that occur may be a result of involvement of the following nerves: sciatic, inferior cluneal, pudendal, posterior femoral cutaneous and the perineal branches of the posterior femoral cutaneous nerve.

Many perineal pains are now categorized as pudendal neuralgia. However, making such a diagnosis is not easy as many mechanisms may be involved, including damage to other nerves (as listed above) and the muscle hyperalgesias. For true pudendal neuralgia, the pain should be perceived in the distribution of the pudendal nerve or one of its branches. Other sensory/ motor abnormalities may support the diagnosis such as numbness or paresthesia in an appropriate distribution or the absence of a bulbocavernosal reflex. Pudendal nerve conduction tests in the absence of hypoesthesia rarely help with the diagnosis. It has been suggested that bulbocavernosal electromyographs may be more helpful. Classically the pain is said to be worse with sitting and relieved by standing (or sitting on a toilet seat). However, such variations in pain may be associated with other "posterior triangle" nerves and the muscle hyperalgesias. The more pronounced the nerve damage, the less likely that there will be a variation in the pain with direct pressure over the nerves as the pain will be more constant. Thorough clinical examination by an experienced practitioner may help to distinguish the different types of pain. Selective nerve blocks of the pudendal nerve at the ischeal spine, under X-ray guidance and with neurotracing recognition of the nerves, is an essential part of making the diagnosis, but may also be therapeutic. Deeper injections under CT guidance may also help localize the source of the pain.

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