Physical therapy for pudendal neuralgia: what to expect

The pudendal nerve passes through and close to several pelvic muscles, including the obturator internus, the levator ani and, in the buttock, the piriformis. When these muscles stay tight for long periods, they can press on or irritate the nerve.

Many people with pudendal neuralgia have an overactive pelvic floor, meaning the muscles do not fully relax. Physical therapy aims to release that tension, restore normal movement of the nerve and reduce the protective guarding that builds up around chronic pain.

International guidance on chronic pelvic pain, including from the European Association of Urology, supports pelvic floor physical therapy as part of first-line care before invasive treatment is considered.

A pelvic floor physical therapist will usually:

• Take a detailed history of your pain, bladder, bowel and sexual function.
• Assess posture, hips and breathing.
• Examine the pelvic floor, often with an internal (vaginal or rectal) examination, to check muscle tone, tender points and how well the muscles relax. You can always ask to stop or to skip the internal part.
• Agree a plan with you.
• Manual therapy: gentle release of tight muscles and tender points, inside and outside the pelvis.
• Nerve mobilisation: gentle movements that help the nerve glide.
• Down-training: learning to relax the pelvic floor, often with breathing exercises and sometimes biofeedback.
• A home programme of stretches and relaxation.
• Advice on sitting, posture, work and exercise. See how to sit with pudendal neuralgia.

Treatment often combines:

• Strengthening the pelvic floor by default. Kegel exercises are usually not advised when the pelvic floor is overactive, because squeezing can increase pain.
• Aggressive internal pressure that leaves you much worse for days. Some soreness after a session is common, but lasting flares should be reported.
• Generic core or Pilates programmes in place of specialist care. They are not the same as pelvic floor rehabilitation.

Our article on exercises to avoid goes into more detail.

There is no fixed timeline. Many therapists plan a block of weekly sessions over a few months and review progress along the way. Improvement is often gradual. A useful sign is a steady increase in how long you can sit, or fewer and shorter flares.

Physical therapy does not help everyone. In one survey of people with pudendal neuralgia, many reported little benefit and some reported that symptoms got worse. This is one reason why the right therapist and the right approach matter, and why progress should be reviewed rather than continued indefinitely.

Progress usually depends as much on what happens at home as on the sessions themselves.

• Practise relaxation daily. A few minutes of slow belly breathing, letting the pelvic floor drop on each breath in, is often part of the home programme.
• Reduce sitting load. Use a cut-out cushion, stand for phone calls and break up long periods of sitting.
• Keep moving gently. Walking and swimming are usually better tolerated than cycling or heavy gym work.
• Use heat if it helps. Some people find a warm bath or heat pack eases muscle tension.
• Track your symptoms. A short weekly note of sitting time, flares and sleep helps you and your therapist see real change.

If you have given physical therapy a fair trial and symptoms have not improved enough, your specialist may suggest further steps. These can include:

• **A diagnostic, image-guided pudendal nerve block**, to confirm whether the nerve is the source of pain.
• Medication for nerve pain. See medications for pudendal nerve pain.
• Botulinum toxin injections into tight muscles, such as the piriformis, in selected cases.
• Surgical decompression, considered only when conservative treatment has failed and the diagnosis is well supported. See pudendal nerve decompression.

In Dr Bollens' clinical experience, physical therapy remains important after surgery too. It helps restore mobility, reduces muscle guarding and helps prevent scar tissue from tethering the nerve as it heals.

Ask whether the therapist:

• Has specific training in pelvic floor and pelvic pain care.
• Is comfortable treating nerve pain, not only incontinence.
• Offers internal assessment where appropriate, and explains it clearly.
• Communicates with your doctor.

If you are in the UAE, consultations with the Pelvic Institute are available at our partner location, the Koster Clinic in Dubai. Online consultations with Dr Bollens are also possible.

• European Association of Urology. EAU Guidelines on Chronic Pelvic Pain. uroweb.org
• FitzGerald MP, Payne CK, Lukacz ES, et al. Randomized multicenter clinical trial of myofascial physical therapy in women with interstitial cystitis/painful bladder syndrome and pelvic floor tenderness. J Urol. 2012;187(6):2113-8. PubMed
• Niedenfuehr JM, Stevens DM, King LM. Pelvic floor physical therapy is self-reported as a minimally effective, and sometimes harmful, treatment for pudendal neuralgia: a cross-sectional study. Int J Sex Health. 2024;36(4):627-635. PubMed
• 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
• Leslie SW, Antolak S, Feloney MP, et al. Pudendal Neuralgia. StatPearls. NCBI Bookshelf