A practical summary of current evidence on diagnosis and treatment
Pudendal Nerve Entrapment Syndrome (PNES) is a chronic neuropathic condition in which the pudendal nerve is compressed along its course through the pelvis. A 2025 review by Kaur, Leslie and Singh brings together the current evidence on how PNES is best identified and treated — and confirms that misdiagnosis remains the single biggest obstacle to good outcomes.
Causes: mechanical and non-mechanical
Mechanical causes include ligamentous compression between the sacrospinous and sacrotuberous ligaments, entrapment inside Alcock's canal, post-surgical scarring (particularly after mesh procedures), and repetitive microtrauma from cycling, childbirth or prolonged sitting. Non-mechanical contributors include diabetic microangiopathy, herpes zoster reactivation and post-radiation neuropathy.
Diagnosis: converging lines of evidence
No single test proves PNES. Diagnosis relies on the Nantes criteria — perineal pain in the pudendal territory, worsening with sitting, no night waking, no objective sensory loss, and relief after a diagnostic pudendal block — supplemented by MR neurography and, where available, pudendal nerve motor latency testing. A well-designed diagnostic block remains the most reliable single indicator.
Treatment: a graded pathway
Conservative care comes first: pelvic floor physiotherapy, activity and ergonomic modification, and short pharmacological courses aimed at neuropathic pain (gabapentinoids, tricyclics or SNRIs). Approximately half of patients improve significantly within 6–12 months of consistent conservative treatment.
Image-guided pudendal nerve blocks — with or without corticosteroid — serve both a diagnostic and a therapeutic purpose. For patients who fail these measures and show clear entrapment on imaging, surgical decompression via the transgluteal, transperineal or laparoscopic approach becomes the definitive option.
What patients should take from this
PNES is a treatable condition when it is correctly identified. Patients who have been dismissed with vague diagnoses of 'pelvic pain' deserve a structured work-up that includes Nantes criteria assessment, dedicated pudendal MR neurography, and evaluation by a clinician experienced specifically in pelvic nerve pathology.