Pudendal Nerve Neuralgia: An Overlooked Cause of Chronic Scrotal Pain

For many men, chronic scrotal or perineal pain can be frustrating and difficult to diagnose. When testicular ultrasound and urological assessments fail to reveal a cause, attention often turns to less well-known nerve-related conditions. One such culprit is pudendal nerve neuralgia, a form of nerve pain that can lead to persistent discomfort in the scrotum, perineum, penis, or anal region.  Pudendal neuralgia is very common, but in the past has been overlooked and remains poorly treated.  

Common Causes of Chronic Scrotal Pain

Chronic scrotal or pelvic pain in men can arise from a wide variety of sources. Some of the more common causes include:

• Inguinal hernias or hernia repair complications
  
• Epididymitis or orchitis (infections)
  
• Referred pain from lumbar disc or musculoskeletal dysfunction
  
• Nerve entrapment syndromes — including ilioinguinal, genitofemoral, or pudendal nerve irritation
• Post-vasectomy pain syndrome (more likely with traditional vasectomy)—learn more on our Post‑Op Recovery Advice page

We are increasingly learning that, pudendal neuralgia is often the cause of these symptoms but it has been under-recognised in the past and continues to be under treated. Yet, for men with otherwise unexplained pelvic pain—especially those with cycling-related discomfort or sacroiliac (SI) joint issues— pudendal neuralgia may be a key contributor.

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The Pudendal Nerve: A Key Player in Pelvic Pain

The pudendal nerve originates from the sacral plexus (nerve roots S2–S4) and travels a complex path through the pelvis. It passes between the sacrotuberous and sacrospinous ligaments, through Alcock’s canal, and ultimately innervates key areas of the male pelvis including:

• The perineum
  
• The scrotum
  
• The penis
  
• The external anal sphincter
  

Because of its long and winding route, the pudendal nerve is susceptible to irritation or compression at multiple points.

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Pudendal Neuralgia and the Role of the Back and SI Joints

One of the more overlooked contributors to pudendal nerve irritation in men is dysfunction of the lumbar spine and sacroiliac (SI) joints.

• SI joint instability or asymmetry can cause pelvic tilt or torsion, placing tension on the ligaments near the pudendal nerve’s path.
  
• Lumbar disc pathology, particularly at the L5–S1 level, can result in muscular compensation patterns that increase pressure on pelvic floor structures.
  
• Activities like prolonged sitting, cycling, or heavy lifting may exacerbate these mechanical issues, triggering nerve irritation.
  

Symptoms of pudendal neuralgia typically include:

• Burning, aching, or stabbing pain in the scrotum, penis, or perineum
  
• Pain that worsens with sitting and improves when standing or lying down
  
• A sense of tightness or “golf ball” sensation in the rectal or perineal area
  

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Treatment Options: Focus on Physiotherapy and Movement

Unlike infections or surgical conditions, pudendal neuralgia requires a multidisciplinary approach, often led by pelvic health physiotherapists with experience in men’s pelvic pain.

1. Physiotherapy

A physiotherapist trained in pudendal neuralgia can assess pelvic alignment, SI joint function, and nerve mobility. Treatment strategies may include:

• SI joint mobilisation
  
• Trigger point release (especially in the obturator internus, piriformis, and pelvic floor)
  
• Neural gliding techniques
  
• Postural correction
  

2. Stretching and Movement Therapy

Consistent stretching can relieve nerve tension and rebalance pelvic mechanics. Helpful exercises often include:

• Piriformis stretch
  
• Hamstring and hip flexor stretches
  
• Gluteal release
  
• Pelvic tilting and diaphragmatic breathing
  

It’s crucial to avoid aggressive core exercises or high-tension pelvic floor movements early in treatment, as these may exacerbate symptoms.

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Expert Help: Physios with a Special Interest in Pudendal Neuralgia

One notable practitioner in Australia is Peter Dornan, a Brisbane-based physiotherapist with decades of experience treating male pelvic pain. His work has been pivotal in raising awareness of pudendal neuralgia in men and promoting non-surgical management approaches.

Seeking out a physiotherapist with a special interest in men’s pelvic health and pudendal neuralgia is essential. Not all pelvic physios treat men or are trained in this niche area.

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Final Thoughts

Chronic scrotal pain can have a profound impact on a man’s quality of life. If infection and surgical causes have been ruled out, pudendal neuralgia should be considered, especially in men with a history of lower back pain or stiffness. 

Early intervention with a knowledgeable physiotherapist can often bring significant relief and help men return to a normal, active life. If you’re seeking clarity or support, don’t hesitate to contact our team for expert advice and personalised care options.