For men
Pudendal neuralgia in men.
Most men we see have taken three or more courses of antibiotics for 'chronic prostatitis' with negative cultures. The prostate was never the problem. Sitting-provoked perineal pain in men is, far more often than recognised, a pudendal nerve problem.
How it presents
The pattern is consistent and distinguishable from prostate disease once you look for it.
- Burning, aching pain or discomfort in the perineum, scrotum, penis or rectum
- Pain that builds the longer you sit, relieved by standing
- Golf-ball or lump sensation in the rectum or perineum
- Urinary urgency, hesitancy, incomplete emptying
- Post-ejaculatory pain, sometimes lasting days
- Reduced penile sensation or erectile dysfunction
Why 'chronic prostatitis' is usually the wrong label
Category III prostatitis (CPPS) is defined by the absence of infection. It is a description of symptoms, not a cause. Repeated antibiotics for a sterile condition delay diagnosis by years.
If your cultures are negative, antibiotics have not helped, and pain is worse when sitting, the pudendal nerve and pelvic floor should be assessed directly.
Common causes in men
Male cases are usually mechanical, athletic or post-surgical.
- Long-distance cycling and spinning (cyclist's syndrome)
- Prolonged sitting, driving, desk work, gaming
- Heavy squatting and deadlifting with pelvic floor bracing
- Hernia repair with mesh, prostatectomy, haemorrhoid or fistula surgery
- Falls onto the buttocks or coccyx
- Chronic constipation and straining
The dorsal nerve of the penis — penile numbness, burning and lost sensation
The dorsal penile nerve is the terminal sensory branch of the pudendal nerve. It travels through Alcock's canal and along the top of the penis, supplying most of the sensation of the shaft and glans. When this branch is irritated or compressed, the symptoms are felt in the penis rather than deep in the pelvis, which is why many men are investigated for erectile or prostate problems before the nerve is ever considered.
Dorsal penile neuralgia is not a separate disease from pudendal neuralgia; it is a distribution of it. Some men have perineal pain with penile symptoms, others have penile symptoms almost alone, particularly after cycling or a saddle-related injury.
- Numbness or reduced sensation in the glans or shaft, often one-sided
- Burning, electric or shooting pain along the top of the penis
- Pins and needles, or hypersensitivity to touch and clothing
- Weaker or less firm erections despite normal desire and normal hormones
- Delayed, blunted or painful orgasm, sometimes with post-ejaculatory ache
- Symptoms provoked by cycling, prolonged sitting or pressure on the perineum
What causes dorsal penile nerve damage
The mechanisms mirror those of pudendal neuralgia, but the compression point sits more distally. Saddle pressure in cyclists is the pattern we see most often; symptoms that once resolved within hours after a ride but now persist for days suggest the nerve is no longer recovering between exposures.
Pelvic or genital surgery, circumcision-related scarring, a fall onto the perineum and straddle injuries can also involve the dorsal branch. Where symptoms follow a clear event and do not settle within a few weeks, assessment is reasonable rather than premature.
Getting an answer
A dedicated assessment reviews your symptom pattern and history, examines for tenderness at the ischial spine, orders MR neurography where indicated, and uses an image-guided pudendal nerve block to confirm the nerve as the pain generator.
Where entrapment is confirmed, decompression surgery addresses the cause. Where it is not, medical and physiotherapy management is the honest recommendation, and we give it.
Common questions
What does pudendal neuralgia feel like in men?
Men describe burning, aching or electric pain in the perineum, scrotum, penis or rectum that increases the longer they sit and settles on standing. A sensation of sitting on a golf ball, post-ejaculatory pain and urinary urgency are common.
Is chronic prostatitis actually pudendal neuralgia?
In many men, yes. True bacterial prostatitis is uncommon and responds to antibiotics. Men with negative cultures, repeated antibiotic courses and sitting-provoked perineal pain very often have pudendal neuralgia or pelvic floor dysfunction rather than prostate disease.
Can pudendal neuralgia cause erectile dysfunction?
Yes. The dorsal nerve of the penis is a pudendal branch, so compression can cause reduced sensation, weaker erections, altered or painful orgasm, and post-ejaculatory pain. These symptoms often improve as the nerve recovers.
Can it be caused by prostate surgery?
Pelvic surgery, such as prostatectomy, hernia repair with mesh, or haemorrhoid or fistula surgery, can injure or entrap the pudendal nerve in scar tissue. Persistent new perineal pain after such surgery should be assessed as a possible nerve injury, not written off as normal healing.
What tests do men need?
Urine culture and prostate assessment to exclude infection, a focused clinical examination of the pudendal nerve territory, MR neurography when entrapment is suspected or surgery is planned, and an image-guided diagnostic pudendal nerve block.
What is the dorsal nerve of the penis?
The dorsal penile nerve is the terminal sensory branch of the pudendal nerve. It runs along the top of the penis and carries most of the sensation from the shaft and glans, which is why pudendal problems so often show up as penile symptoms rather than pain deep in the pelvis.
What are the symptoms of penile nerve damage?
Commonly reported symptoms include numbness or reduced sensation in the glans or shaft, burning or electric pain along the top of the penis, pins and needles, hypersensitivity to touch or clothing, weaker or less firm erections despite normal desire, and altered, delayed or painful orgasm. Symptoms are often described as one-sided and may be provoked by cycling or prolonged sitting.
Can dorsal penile nerve damage be reversed?
It depends on the mechanism. Where the cause is compression from cycling, sitting or scar tissue and it is addressed early, sensation frequently improves after load reduction, physiotherapy or a nerve block. Where compression has been long-standing, recovery after decompression tends to be gradual, often over 6 to 18 months, and cannot be guaranteed in every case.
Speak with a pudendal nerve specialist.
Dr Renaud Bollens leads a specialist practice dedicated to chronic pelvic pain, with centers in Dubai and Belgium.