Pudendal neuralgia or sciatica? How to tell the difference
Pudendal neuralgia and sciatica are both nerve pain, both can start in the buttock and both can get worse when you sit. It is not surprising that one is sometimes mistaken for the other. But they involve different nerves, usually affect different areas and are treated differently. This page explains the main differences, where they overlap and which tests help tell them apart.
Two different nerves
The sciatic nerve is the largest nerve in the body. It is formed from nerve roots in the lower back, runs through the buttock and down the back of the thigh, and supplies much of the leg and foot.
The pudendal nerve is much smaller. It runs from the lower part of the spine through the deep buttock and pelvis to the perineum. It supplies the skin and muscles between the anus and the genitals.
Both nerves pass through the deep gluteal space, close to the piriformis muscle. That shared route is one reason the symptoms can overlap.
Where the pain is felt
| Sciatica | Pudendal neuralgia | |
|---|---|---|
| Main area | Buttock, back of thigh, often below the knee into the calf or foot | Perineum, anus, vulva, penis or scrotum |
| Typical feeling | Shooting or burning pain down the leg, sometimes with tingling or weakness | Burning, stabbing or electric pain, sometimes a foreign body feeling in the rectum or vagina |
| Sitting | Can be worse when sitting | Usually clearly worse when sitting, better standing or lying |
| Night | Can disturb sleep | Typically does not wake you at night |
| Bladder, bowel, sexual symptoms | Not typical, unless there is a serious spinal problem | Can be present, such as urgency, pain with bowel movements or pain with sex |
Why they get confused
- Both can cause buttock pain when sitting.
- Pudendal neuralgia can spread down the back of the leg. The Nantes criteria list pain referred like sciatica as an associated sign that does not rule pudendal neuralgia out.
- Both nerves can be compressed in the buttock, especially near the piriformis muscle. Some people have both nerves involved at the same time.
- Spine scans can show common, age-related changes that are blamed for symptoms, even when the problem is elsewhere.
In Dr Bollens' clinical experience, compression of the pudendal nerve at the piriformis muscle is more common than compression in Alcock's canal. This is one reason buttock pain and perineal pain can appear together.
Clues that point away from the spine
When sciatica is caused by a disc or narrowing in the lower back, the pain is often affected by bending, lifting or coughing. Pain that is mainly driven by sitting or by hip rotation, with a normal or near-normal spine scan, suggests the problem may be in the buttock or pelvis instead. Our article on deep gluteal syndrome explains this in more detail.
How doctors tell them apart
A specialist will usually:
- Map exactly where the pain is, including whether it reaches the genitals or anus.
- Examine the back, hips and nerves of the leg, including reflexes, strength and sensation.
- Examine the pelvis, which may include a gentle internal examination to check tenderness along the pudendal nerve.
- Compare symptoms with the Nantes criteria for pudendal neuralgia.
- Review imaging: an MRI of the lumbar spine for sciatica, and sometimes MR neurography to look at the nerves in the pelvis and buttock.
- Use diagnostic injections: a pudendal nerve block for the pudendal nerve, or an injection around the piriformis muscle or deep gluteal space.
How treatment differs
Sciatica from the spine is often treated with time, activity advice, physical therapy and pain relief. Spinal injections or spinal surgery are considered in selected cases.
Pudendal neuralgia is usually treated first with pelvic floor physical therapy, sitting changes, nerve pain medication and image-guided nerve blocks. Decompression surgery is considered only when conservative care has not helped and the diagnosis is well supported.
When the piriformis muscle is involved, Dr Bollens' approach starts with conservative care, such as posture correction, targeted stretching and, in some cases, botulinum toxin injections. When these are not enough, an endoscopic release of the piriformis can be considered. See piriformis surgery. Surgery is carried out at partner hospitals in Dubai and Belgium.
When to seek urgent care
Seek emergency care if back or leg pain comes with loss of bladder or bowel control, numbness around the genitals or anus, or new weakness in the legs.
Sources
- Davis D, Taqi M, Vasudevan A. Sciatica. StatPearls. NCBI Bookshelf
- Leslie SW, Antolak S, Feloney MP, et al. Pudendal Neuralgia. StatPearls. NCBI Bookshelf
- Hicks BL, Lam JC, Varacallo MA. Piriformis Syndrome. StatPearls. NCBI Bookshelf
- Hernando MF, Cerezal L, Pérez-Carro L, et al. Deep gluteal syndrome: anatomy, imaging, and management of sciatic nerve entrapments in the subgluteal space. Skeletal Radiol. 2015;44(7):919-34. PubMed
- 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
Common questions
Can pudendal neuralgia cause leg pain?
Yes, pain can spread to the buttock and the back of the thigh. Pain mainly in the perineum or genitals points more towards the pudendal nerve.
Can I have sciatica and pudendal neuralgia at the same time?
Yes. Both nerves pass through the deep buttock and can be compressed there.
Why is my spine MRI normal when I have sciatica-like pain?
The cause may be outside the spine, for example in the deep gluteal space or along the pudendal nerve.
Does sitting help tell them apart?
Pain that is clearly worse on sitting and eases when standing is typical of pudendal neuralgia, but sciatica can also be worse when sitting, so sitting alone is not enough.
Which doctor should I see?
A clinician experienced in pelvic and deep gluteal nerve pain. See pelvic pain misdiagnosis for other conditions that are often confused.
Speak with a pudendal nerve specialist.
Dr Renaud Bollens leads a specialist practice dedicated to chronic pelvic pain, with centers in Dubai and Belgium.