When the Tests Are Clear but the Pain Remains: Understanding Diffuse Genital Pain and Pudendal Neuralgia

Imagine living with chronic genital pain - pain that interferes intimacy, sitting, and basic daily life. Now imagine being told that every test is normal and it's "probably psychological". Unfortunately, this is the reality for many people - especially women - suffering from diffuse genital pain. But there's another, very real explanation: nerve entrapment , particularly involving the pudendal nerve. And it often goes undiagnosed, not because it's rare, but because the tools we rely on - imaging and nerve testing - are simply not good at detecting it.

The Trouble With "Normal" Test Results : People with chronic genital pain often undergo a long list of evaluations:

  1. Pelvic imaging
  2. Gynecological exams
  3. Urological studies
  4. Nerve conduction tests
  5. Even exploratory surgeries

Yet, all too often, nothing shows up. In these cases. some providers may suggest a psychogenic cause - implying that the problem is in the patient's head. This is not only dismissive, but usually inaccurate. In reality, many of these cases are due to neurogenic causes - especially pudendal neuralgia or genital nerve irritation - which do not show up well on imaging or standard diagnostics. 

Why Nerve Entrapments Often Go Undetected

There are two major reasons:

  1.  Imaging isn't reliable for small peripheral nerve treatments. A clear MRI doesn't rule out compression or irritation of the pudendal nerve.
  2. Nerve tests are limited. For pelvic nerves like the pudendal, electrodiagnostic studies are technically difficult and often inconclusive. These tests are still useful for ruling out tumors or systematic neuropathies, but they often fail to confirm pudendal neuralgia directly.

What's Really Going On The Pudendal Pathway: Pudendal neuralgia is often misundertstood as a single-site problem at Alcock's canal. In reality, it's usually more complex:

  1. First site of irritation: Where the pudendal nerve passes between the priformis and superior gemellus muscles.
  2. Second site: Compression in Alock's canal, between the obturator internus and falciform process. This "double-crush" mechanism explains why pelvic floor rehab alone often fails. It misses the actual source of the problem: the deep hip muscles and their relationship to the nerve.

Key Signs of Pudendal Neuralgia: If a patient has all normal test results but presents with the following, pudendal neuralgia should be considered:

  1. Hemispheric or bilateral genital pain
  2. Pain worsens with sitting and driving, especially on hard surfaces
  3. Increased discomfort with hip exercises or stretching
  4. Pain triggered by pressure on the deep buttock muscles
  5. Painful intercourse without gynecological explanation
  6. Pain reduced by sitting on a toilet seat
  7. Bladder pain during micturition
  8. Rectal pain during defecation
  9. Bowel, bladder and sexual dysfunction

If provocative tests of the piriformis or obturator internus reproduce their symptoms, that's a strong clinical clue - even if their scans are normal.

How to Actually Help: A More Targeted Approach  Here's what can make a difference:

  1. Strengthen the right muscles
    • Carefully build strength in the piriforms and obturator internus to reduce nerve compression.
  2. Change the way they sit
    • Avoid prolonged sitting on hard surfaces
    • Avoid leaning forward while sitting (this stretches and compresses the external rotators).
  3. Manage stress and clenching habits
    • Many patients - especially those without trauma - develop symptoms due to chronic pelvic clenching linked to stress.
    • Techniques for nervous system regulation and tension release are essential.

 

FINAL THOUGHTS:

If your patient (or you) is dealing with genital pain that has no clear cause, don't stop at "the tests are normal". Look deeper. Understand the nerve pathways. Pay attention to biomechanics and movement triggers. Because pain that doesn't show up on a scan is still real - and it deserves real treatment.

Want to learn more? We specialize in the assesment and treatment of Pain with nerve manipulation, it is gentle and pain free techniques. Contact us to explore an evaluation or integrated therapy plan.