The Forgotten Pudendal Nerve: The Tiny Nerve That Can Turn Sitting into Suffering

A Patient’s Story

Let’s call him Arjun. He’s 27, works a desk job, and cycles to the gym three times a week because he read it’s good for his heart. About eight months ago, he started noticing a strange ache in his penis and the area between his legs — not quite pain, more like a dull burning, worse by the end of a long day at his desk. He assumed it was from too much cycling and took a break. It didn’t help much. Over the next few months it got worse: burning, tingling, sometimes like sitting on a small stone even when there was nothing there. Sitting made it worse. Standing or lying down made it better. Sleep was, oddly, fine — the pain never woke him at night.

Arjun saw a urologist first, since the pain was in his penis and around his groin. Tests for infection came back clean. He was told it might be “chronic prostatitis” and given antibiotics. They didn’t help. He saw another doctor, who suspected anxiety. Nearly a year after his symptoms started, he was finally referred to a pelvic health physiotherapist, who asked one simple question that nobody else had: “Does it get worse when you sit, and better when you stand?”

That one question cracked the case open. Arjun had pudendal neuralgia — irritation of a nerve most people have never heard of, tucked deep in the pelvis, quietly responsible for a surprising amount of unexplained pelvic and genital pain.

Arjun’s story isn’t unusual. It’s actually the norm. Most people with this condition are misdiagnosed at least once, often several times, before anyone puts the pieces together. So let’s talk about what’s really going on — in plain language.

Meet the Nerve

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Deep in your pelvis, there’s a nerve called the pudendal nerve. It starts near the base of your spine(S1,S2,S3) and travels through a narrow passage between two ligaments(Sacrotuberous and Sacrospinous ligaments), loops around a small bony point (the ischial spine — basically the bone you feel when you sit on a hard bench), and threads through a tight tunnel before spreading out to supply feeling and muscle control to your genitals, the skin between your legs, and your pelvic floor muscles.

Think of it like a phone charging cable that has to be threaded through a very narrow gap in a wall. Most of the time it fits fine. But if that gap gets even a little tighter — from tight muscles, swelling, scarring, or constant pressure — the cable gets pinched. That pinch is what causes the pain.

Pudendal nerve pain areas. MRI, magnetic resonance imaging; CT, computed tomography; PNMTL, perineal branch of the posterior femoral cutaneous nerve.

What Causes It

The nerve doesn’t get irritated for no reason. It’s almost always a response to something squeezing or stretching it. Common causes include:

Sitting for long periods, especially on hard or narrow surfaces

Cycling, because a bicycle seat puts direct pressure exactly where this nerve runs

Tight or overworked pelvic floor muscles, which squeeze the nerve as it passes through

Childbirth, which can stretch or injure the nerve

Pelvic surgery, which can cause scarring near the nerve

Falls or direct trauma to the tailbone or pelvis

Chronic constipation, from repeated straining

Notice that almost all of these come down to one thing: pressure or tension on a nerve that needs room to move freely.

Why It’s So Often Misdiagnosed

Because this nerve supplies such a wide area — genitals, perineum, and rectum — its pain gets mistaken for all sorts of other problems: prostate infections, bladder problems, vulvar pain, tailbone pain. People often see several different specialists before anyone recognizes the pattern.

The biggest clue, the one question that often solves the mystery, is this: does the pain get worse with sitting, and better with standing or lying down? If yes, pudendal neuralgia should be on the list of possibilities.

Modern Life Doesn’t Help

Here’s the uncomfortable truth: the way most of us live today is almost perfectly designed to aggravate this nerve.

Think about a typical day.

We sit down to eat breakfast.

We sit in the car or the train.

We sit at a desk for eight or more hours, often slouched in a chair that wasn’t built with our bodies in mind.

We sit through lunch.

We sit in meetings. We drive home and sit some more, then sit on the couch in the evening.

Somewhere in all that sitting, the area around the nerve is under constant, quiet pressure — hour after hour, day after day, year after year.

A few specific modern habits make things worse:

• Office chairs that put pressure directly on the area between the sit bones for hours at a stretch, especially when we slouch
• Cycling, where the seat presses directly on the nerve’s pathway — a well-known cause, so well known it even has a nickname, “cyclist syndrome”
• Constantly tensing the core or pelvic floor, a habit some people pick up from fitness advice that says “engage your core” without ever teaching how to relax it again
• Poor posture from sitting, which can subtly tighten the exact space the nerve passes through
• Low-fibre diets and dehydration, common in busy desk-bound lives, which lead to constipation and repeated straining

None of this means sitting or cycling are dangerous for everyone. Most people sit all day with no problems at all. But for some people — especially those with tight pelvic floor muscles, past pelvic trauma, or certain anatomy — modern lifestyle habits are exactly the kind of repeated, low-level pressure that can wake this nerve up and keep it irritated.

A Little History

This condition isn’t new, even though most people have never heard of it. The first real medical description dates back to 1915, when a doctor treating soldiers during the First World War noticed a strange pattern: pain around the perineum and urinary urgency, but with completely normal urine tests. He correctly linked it to irritation of the pudendal nerve — but the discovery was mostly forgotten for decades.

The condition resurfaced properly in 1987, when a doctor in France described a cyclist with classic symptoms, which is why it was nicknamed “cyclist syndrome” for years. It wasn’t until 2008 that doctors agreed on a clear set of diagnostic criteria (called the Nantes criteria) to help recognize it consistently. Even now, many doctors still don’t learn much about it in training, which is a big part of why it takes so long for people to get properly diagnosed.

How Physiotherapy Helps

Here’s the good news: in most cases, the nerve itself isn’t permanently damaged. It’s irritated and overly sensitive, like a smoke alarm that’s gone off so many times it now beeps at steam from the shower. The goal of physiotherapy is to calm that alarm down and take pressure off the nerve, not to “fix” something broken.

Common physiotherapy approaches include:

1. Teaching the pelvic floor muscles to relax — many people with this condition have pelvic floor muscles that are chronically clenched without realizing it. Learning to release them is often the single most helpful step.
2. Gentle hands-on therapy to ease tension in the pelvic floor, hips, and surrounding tissue.
3. Changing sitting posture and equipment — different chairs, cushions with the center cut out, and adjusted cycling setups to take pressure off the area.
4. Calming an overactive nervous system — gradual, gentle strategies to reduce how easily the nerve fires off pain signals.
5. Breathing exercises, since the diaphragm and pelvic floor work as a team — relaxing one often helps relax the other.
6. Correcting posture and movement patterns that may be putting uneven pressure on the pelvis.

Progress is usually slow. Nerves take time to calm down and heal, often months rather than days. In more difficult cases, physiotherapy is combined with other treatments such as medication, nerve block injections, or, occasionally, surgery.

The Takeaway

Pudendal neuralgia is proof that a small, deeply hidden nerve can cause big, life-disrupting problems — and that modern habits like prolonged sitting and cycling can quietly set the stage for it. The good news is that once it’s correctly identified, most people improve significantly with patient, targeted treatment.

If sitting has become something you have to plan around rather than something you do without thinking, it might be worth asking a pelvic health physiotherapist that one simple question that finally helped Arjun: does it get worse when you sit, and better when you stand?