Pudendal Neuralgia in a Tertiary Pain Clinic: Presentation, Treatment, and Factors Associated with Neuromodulation in 224 Adults

Pudendal neuralgia is an under-recognized cause of chronic, disabling neuropathic perineal pain affecting both women and men. Real-world data on its presentation, its treatment within a specialty pain service, and the factors that accompany escalation to interventional therapy are scarce. We hypothesized that an iatrogenic (postsurgical) origin and relief after a diagnostic pudendal nerve block would identify the patients who reach neuromodulation. We performed a retrospective manual review of the complete electronic records of all adults with documented pudendal neuralgia, pudendal neuropathy, or pudendal nerve entrapment managed at a single tertiary pain clinic between 2009 and 2026. Demographics, clinical presentation, presumed etiology, treatments, and outcomes were abstracted from the free-text record. Ascertainment was in two stages: variables were first identified by structured text screening of the free-text record, and the two variables most susceptible to false-positive screening, a postsurgical etiology and receipt of neuromodulation, were then verified against the source charts by manual review of every screen-positive record. The chart-verified definitions are used throughout. Associations between binary variables were tested by the chi-squared test, with odds ratios (OR) and 95% confidence intervals (CI); factors associated with neuromodulation were assessed by multivariable logistic regression. Among 224 patients (138 women [61.6%], 86 men [38.4%]; median age 48.5 years, interquartile range 35–64), pain was worse when sitting in 57.6% and burning in 39.3%, and involvement was bilateral in 21.9%. Text screening identified a possible postsurgical onset in 46.4%, but chart re-adjudication confirmed a named operation preceding the pain in only 31 patients (13.8%), of whom 6 had undergone a clearly non-pelvic procedure; confirmed postsurgical onset was therefore less frequent than documented entrapment features (24.1%) and comparable to childbirth (15.9% of women). Care was heavily interventional: 59.4% received a pudendal nerve block, 28.6% pulsed radiofrequency, and 9.4% underwent surgical decompression. Neuromodulation was documented in the record of 64 patients (28.6%), but an electrode was placed in only 26 (11.6%) and a permanent device implanted in 18 (8.0%): spinal cord stimulation in 14, sacral neuromodulation in 2, dorsal root ganglion stimulation in 1, and pudendal nerve stimulation in 1. Three factors were independently associated with documented neuromodulation: relief after a diagnostic block (adjusted OR 4.88, 95% CI 1.91–12.46%), a refractory course (2.92, 1.52–5.60%), and chart-confirmed postsurgical onset (2.83, 1.17–6.82%); c-statistic 0.76. In an exploratory model restricted to the 18 implanted patients, a refractory course (7.40, 1.98–27.61%) and postsurgical onset (4.24, 1.29–13.94%) remained associated with the outcome whereas relief after a block did not (5.90, 0.72–48.31%). In routine pain-clinic practice, pudendal neuralgia is managed along an interventional pathway, but device implantation is considerably less common than the frequency with which neuromodulation is discussed. A confirmed postsurgical onset is less common than text screening suggests, yet is disproportionately associated with escalation. Being observational, these findings describe how care proceeds rather than establishing cause. Pudendal neuralgia is a long-lasting pain in the area between the legs, caused by irritation or injury of the pudendal nerve. It affects women and men, is often worse when sitting, and is not well known, so people may wait a long time before anyone identifies the cause. We looked back at the records of 224 adults treated for this condition at a specialist pain clinic in Israel over 16 years, to learn what brought the pain on and which treatments people received. When we first searched the records by computer, it looked as though almost half had developed pain after an operation, but when we read each chart by hand, we could confirm an operation before the pain in about one in seven. Reading the charts also changed what we found about implanted devices: the records mentioned this treatment for about 1 in 4 people, but a device was actually fitted in about 1 in 12, and most of those were spinal cord stimulators. Most people were treated with injections that numb the nerve. Those whose pain had not responded to earlier treatments, and those whose pain began after an operation, were the most likely to go on to a device. Pain relief after a numbing injection went together with a device being discussed, but not clearly with one being fitted. Because we looked back at existing records rather than running a trial, our findings describe what happened in practice rather than proving what causes what.