The Nantes criteria for pudendal neuralgia, explained

The Nantes criteria describe pudendal neuralgia caused by entrapment (compression) of the pudendal nerve. They were developed to help clinicians recognise the condition consistently and to avoid confusing it with other causes of pelvic pain.

They are organised in four groups:

1. Essential criteria: all five should be present.
2. Complementary criteria: supporting signs that make the diagnosis more likely.
3. Exclusion criteria: findings that point to another cause.
4. Associated signs that do not rule it out: symptoms that can occur with pudendal neuralgia but are not specific to it.

1. Pain in the area supplied by the pudendal nerve, from the anus to the penis or clitoris.
2. Pain that is mainly felt when sitting.
3. Pain that does not wake you at night.
4. No objective loss of sensation on clinical examination. If a clear area of numbness is found, another cause is more likely, such as a problem at the level of the sacral nerve roots.
5. Pain relief after a diagnostic pudendal nerve block with local anaesthetic.

The nerve block criterion is important. A temporary, clear reduction in pain after an image-guided block supports the idea that the pudendal nerve is the source. Our page on the pudendal nerve block explains how it is done.

These are not required, but each makes the diagnosis more likely:

• Burning, shooting, stabbing pain or a feeling of numbness.
• Allodynia (pain from light touch, such as clothing) or hyperpathia (an exaggerated pain response).
• A feeling of a foreign body in the rectum or vagina, sometimes described as a golf ball or a lump.
• Pain that gets worse as the day goes on.
• Pain mainly on one side.
• Pain triggered by opening the bowels.
• Marked tenderness when the ischial spine is pressed during a vaginal or rectal examination.
• Abnormal nerve test results (neurophysiology) in men or in women who have not given birth.

These findings suggest that something other than pudendal nerve entrapment is causing the pain:

• Pain only in the coccyx (tailbone), buttock, pubic area or lower abdomen.
• Itching (pruritus) as a main symptom.
• Pain that only comes in sudden attacks, with no background pain.
• Imaging findings that can explain the symptoms.

Some symptoms commonly occur with pudendal neuralgia but do not by themselves confirm or exclude it:

• Buttock pain when sitting.
• Pain spreading down the back of the leg, which can look like sciatica.
• Pain in the inner thigh or above the pubic bone.
• Urinary frequency or pain when the bladder is full.
• Pain during or after sex, or after ejaculation.
• Erectile dysfunction.
• Normal nerve test results.

If you are unsure whether your pain is coming from the pudendal nerve or the sciatic nerve, see pudendal neuralgia symptoms and our article on the deep gluteal space.

The criteria are a guide, not a scoring system that replaces clinical judgement. A specialist will usually combine:

• A detailed history, including when the pain started, what makes it worse and how sitting affects it.
• An examination, including gentle internal examination to check for tenderness along the nerve and tension in the pelvic floor muscles.
• Tests to exclude other causes, such as imaging of the spine or pelvis. MR neurography can sometimes show the course of the nerve and possible sites of compression.
• One or more diagnostic nerve blocks.

In Dr Bollens' clinical experience, compression often occurs at the level of the piriformis muscle, not only in Alcock's canal. The assessment therefore looks at the whole course of the nerve.

Many people with pudendal neuralgia see several doctors before anyone names the problem. Pain in the perineum is often first treated as a bladder, prostate, bowel or gynaecological condition. Knowing the criteria can help you describe your symptoms clearly: where the pain is, how sitting affects it, whether it wakes you at night and whether you have had a nerve block. Writing these points down before an appointment makes it easier for a clinician to recognise the pattern. If you have been told your tests are normal but your pain continues, see our page on pelvic pain misdiagnosis.

• They do not tell you exactly where the nerve is compressed.
• A good response to a nerve block supports the diagnosis but does not guarantee that surgery will help.
• Some people have nerve pain with a slightly different pattern, for example pain that is not clearly worse when sitting. They may still have a nerve problem and deserve a careful assessment.

• Labat JJ, Riant T, Robert R, et al. Diagnostic criteria for pudendal neuralgia by pudendal nerve entrapment (Nantes criteria). Neurourol Urodyn. 2008;27(4):306-10. PubMed
• Kaur J, Leslie SW, Singh P. Pudendal Nerve Entrapment Syndrome. StatPearls. NCBI Bookshelf
• Levesque A, Bautrant E, Quistrebert V, et al. Recommendations on the management of pudendal nerve entrapment syndrome: a formalised expert consensus. Eur J Pain. 2022;26(1):7-17. PubMed
• Dickson E, Higgins P, Sehgal R, et al. Role of nerve block as a diagnostic tool in pudendal nerve entrapment. ANZ J Surg. 2019;89(6):695-699. PubMed