Pudendal nerve injury is a relatively unknown but significant complication that can occur during childbirth, particularly after a difficult vaginal delivery. The pudendal nerve provides motor and sensory innervation to the pelvic floor, perineum, and external genitalia, playing a critical role in urinary and fecal continence as well as sexual function. Injury to this nerve during childbirth can lead to a variety of pelvic floor dysfunctions, including incontinence, sexual dysfunction, and chronic pelvic pain. This literature review synthesizes the most current research on the causes, symptoms, and treatment of pudendal nerve injury during childbirth.

1. Causes of Pudendal Nerve Injury During Childbirth

Pudendal nerve injury during childbirth is primarily linked to prolonged or difficult labor, instrumental deliveries, and specific maternal anatomical or obstetric factors. The injury is usually the result of excessive stretching or compression of the nerve, which is vulnerable to injury during the second stage of labor when the fetal head descends through the birth canal.

• Prolonged Labor and Fetal Descent: A prolonged second stage of labor, where the fetal head remains in the birth canal for an extended period, increases the likelihood of pudendal nerve compression. A study by Memon and Handa (2020) found that a prolonged second stage of labor (>2 hours in primiparous women) was associated with a significantly higher risk of pelvic floor muscle damage and pudendal nerve injury .

• Instrumental Delivery: Forceps and vacuum-assisted deliveries are major risk factors for pudendal nerve damage. These tools, used to expedite delivery, can lead to excessive stretching or compression of the nerve. The risk is particularly high with forceps, as noted in research by Lien et al. (2019), which found a higher incidence of pelvic floor injuries, including pudendal nerve trauma, in forceps-assisted deliveries compared to vacuum-assisted or spontaneous vaginal deliveries .

• Fetal Macrosomia and Large Infant Size: Delivering a large baby (fetal macrosomia) increases the mechanical strain on the maternal pelvis and pelvic floor, leading to increased risk of nerve injury. According to a study by Sultan et al. (2020), women delivering infants weighing over 4,000 grams (8.8 grams) were at higher risk of pelvic floor trauma, including nerve injury, due to the excessive stretch of tissues during labor .

• Perineal Trauma and Episiotomy: Severe perineal tears, especially third- and fourth-degree tears, are associated with pudendal nerve damage. Episiotomy, once thought to prevent severe tearing, has been shown in some studies to increase the risk of nerve damage and pelvic floor dysfunction due to the increased strain on the pelvic muscles and surrounding nerves (Kearney et al., 2016).

2. Symptoms of Pudendal Nerve Injury

Symptoms of pudendal nerve injury can range from mild discomfort to significant dysfunction. Many women may not notice symptoms immediately postpartum, but issues often develop in the weeks to months following delivery. The most common symptoms include:

• Pelvic Pain: Chronic pelvic pain is one of the hallmark symptoms of pudendal nerve injury. This pain is often described as burning, tingling, or sharp, and may radiate to the buttocks, lower abdomen, or thighs. A review by Robert et al. (2019) noted that pudendal neuralgia, characterized by sharp, stabbing pain in the areas innervated by the pudendal nerve, can be debilitating and affect quality of life .

• Urinary and Fecal Incontinence: Damage to the pudendal nerve can lead to urinary and fecal incontinence due to impaired function of the pelvic floor muscles. A study by MacArthur et al. (2020) found that women with pudendal nerve damage had a higher incidence of postpartum fecal incontinence, particularly following instrumental deliveries or severe perineal trauma .

• Sexual Dysfunction: Pudendal nerve injury can cause decreased sensation in the genital area, leading to difficulties with sexual arousal and orgasm. Pain during intercourse (dyspareunia) is also common. Fitzpatrick et al. (2018) reported that women with postpartum pudendal nerve injury frequently experience decreased sexual satisfaction and discomfort during intercourse .

• Numbness or Loss of Sensation: Some women report numbness or altered sensation in the perineum, vulva, or rectal area following childbirth, which may be a result of nerve compression or stretching during delivery.

3. Treatment Options for Pudendal Nerve Injury

Treatment for pudendal nerve injury often requires a multidisciplinary approach, combining physical therapy, pharmacological interventions, and, in some cases, surgical options. Early intervention is important to mitigate long-term damage and improve quality of life.

• Pelvic Floor Physical Therapy: Pelvic floor rehabilitation, including strengthening exercises and manual therapy, is one of the primary treatments for pudendal nerve injury. Physical therapy can help restore pelvic muscle function, alleviate pain, and improve continence. A study by Bo et al. (2019) emphasized the importance of pelvic floor physical therapy in postpartum recovery, particularly for women with nerve injury or pelvic floor dysfunction .

• Pharmacological Interventions: Pain management is a critical component of treatment for pudendal nerve injury, particularly for women experiencing chronic pelvic pain. Non-steroidal anti-inflammatory drugs (NSAIDs) and neuropathic pain medications, such as gabapentin or pregabalin, are often prescribed to alleviate nerve pain (Fitzgerald et al., 2020). Nerve blocks using local anesthetics or steroids can also provide temporary relief in cases of severe pain .

• Pudendal Nerve Blocks: In cases of persistent pain or neuralgia, pudendal nerve blocks can be used to provide temporary relief. These injections are typically administered with a combination of local anesthetics and corticosteroids to reduce inflammation around the nerve. A review by Bautrant et al. (2019) highlighted the efficacy of pudendal nerve blocks in treating pudendal neuralgia, although repeated injections may be required for long-term relief .

• Surgical Decompression: For women who do not respond to conservative treatments, surgical decompression of the pudendal nerve may be considered. Pudendal nerve decompression surgery aims to relieve pressure on the nerve, reducing pain and improving function. Robert et al. (2019) noted that while surgical decompression can be effective, it is generally considered a last resort due to the invasiveness of the procedure and potential risks.

• Biofeedback and Neuromodulation: Biofeedback and neuromodulation therapies, such as sacral nerve stimulation, are increasingly being explored as treatment options for pelvic floor dysfunction and pudendal nerve injury. These therapies aim to retrain the pelvic muscles and modulate nerve activity to restore continence and reduce pain (Bo et al., 2019).

Conclusion

Pudendal nerve injury during childbirth, though relatively uncommon, can have significant impacts on maternal health, leading to chronic pain, incontinence, and sexual dysfunction. Key risk factors include prolonged labor, instrumental delivery, and severe perineal trauma. Early recognition and intervention, particularly with pelvic floor physical therapy and pharmacological treatments, are critical for reducing long-term complications. Future research should focus on improving preventative measures during labor and refining therapeutic approaches to address the complex needs of affected women.

References

1. Memon, H. U., & Handa, V. L. (2020). Pelvic floor disorders following vaginal or cesarean delivery. *Obstetrics and Gynecology Clinics of North America*, 47(3), 459-471.

2. Lien, K. C., et al. (2019). Instrumental delivery and the risk of pelvic floor trauma. *International Urogynecology Journal*, 30(4), 519-528.

3. Sultan, A. H., et al. (2020). Pelvic floor trauma following vaginal delivery: A systematic review. *BJOG: An International Journal of Obstetrics & Gynaecology*, 127(3), 337-347.

4. Kearney, R., et al. (2016). Episiotomy and perineal trauma: Long-term outcomes. *Journal of Midwifery & Women’s Health*, 61(2), 232-238.

5. Robert, M., et al. (2019). Pudendal neuralgia in women: Etiology, diagnosis, and treatment. *Current Urology Reports*, 20(8), 34.

6. MacArthur, C., et al. (2020). Postpartum fecal incontinence and pelvic floor dysfunction after childbirth. *American Journal of Obstetrics & Gynecology*, 222(2), 184-193.

7. Fitzpatrick, M., et al. (2018). Sexual dysfunction following obstetric injury. *International Urogynecology Journal*, 29(4), 519-527.

8. Bo, K., et al. (2019). Pelvic floor muscle training in treatment of pelvic floor dysfunction: An overview of systematic reviews. *British Journal of Sports Medicine*, 53(7), 446-454.

9. Bautrant, E., et al. (2019). Pudendal nerve blocks in the management of pudendal neuralgia: Efficacy and safety. *Pain Medicine*, 20(5), 983-992.

10. Fitzgerald, M. P., et al. (2020). Treatment of postpartum pelvic pain: Pharmacological and physical therapy approaches. *International Urogynecology Journal*, 31(7), 1293-1301.