Treatment of Cyclist’s Syndrome (Pudendal Neuralgia) with Osteopathic Manipulative Therapy Techniques: A Review
Chapter 1: Introduction
Cycling in North America has grown in popularity since the sudden arrival of the COVID-19 pandemic in early 2020. As community centers, gyms, and fitness studios have been forced to close during the global lockdown, sales in March of 2020 for children’s bikes have risen 56% and 121% for adult leisure bike sales, in comparison to 2019 figures.1 Relatable figures are also presented with indoor stationary bikes. Peloton Interactive Inc., an American exercise equipment and media company, reports quarterly revenues to have soared 66%, and paid digital subscriptions have risen 64% following the onset of the COVID-19 pandemic.2 As cycling is a relatively inexpensive and widely used form of transportation, a greater number of adults have opted to ride their bikes to work as a means of exercise, social distancing, and a form of stress relief. Trek Bikes and the research firm, Engine Insights, surveyed over a thousand American adults and reported nearly 63% of Americans feel bike riding helps relieve stress and anxiety during the COVID-19 pandemic, and 27% of Americans that own a bike turn to bike riding for mental health management and to destress.3
This sudden rise in cyclists increases the number of cycling related injuries. Recreational and professional ridders alike suffer from various acute and overuse injuries, with most injuries to recreational riders being associated with overuse or improper fit of bicycles. Whereas professional racers suffer from injuries associated with high speed cycling, which predispose riders to muscle stains, collisions, and falls.4, 5 Within the overuse injuries category, the most common regions affected in cyclist are the neck, back, hand/wrist, buttock/perineum, hip, knee, and foot/ankle.6,7
The purpose of this review is to examine the available literature on osteopathic manipulative treatment on pudendal neuralgia in cyclists, and further explore osteopathic manipulative treatment in an athletic setting of recreational and competitive cycling.
Chapter 2: Discussion
Overuse injuries to the buttock and perineum region are most commonly a result of poor saddle positioning or poor choice in shape and design. The rider’s preference and purpose of the bike will determine the type of saddle needed. Traditional saddles fitted on road bikes often feature a solid frame and long-nose shape, whereas recreational bike saddles differ in design, featuring a short-nose and wide seat for optimal comfort.
More serious riders and racers may upgrade their bikes and choose to replace the manufacturer’s saddle for a more supportive aftermarket option. Designs of these saddles can vary in shape and general features; with a long or short-nose, center grooves, holes, and different padding options. Current trends in 2020 lean towards short-nosed performance saddles, which originated with ridders looking to optimize soft-tissue comfort while leaning forward.9 Comfort for cyclists can mean the difference in an enjoyable ride and a potential overuse injury.
Saddle Pressure in Cycling
Saddle pressure on the perineum region has been extensively researched in literature. Ridding positon and saddle design being major factors with regards to comfort and performance. Saddles fitted to road bikes tend to fall under traditional design; firm, narrow, and long-nose. Though not specifically designed for comfort, traditional sport/racing saddles have been associated with providing more than two times the pressure in the perineal region than the saddles without a protruding nose.10, 11, 12
Male and female ridders can experience discomfort along the perineum and ischial tuberosities. Carpes et al.13 describe the different saddle pressure in relation to workload in both men and women. Plain saddle average pressure for men is correlated with workload. As one increases, so does the other. Using a ‘holed’ saddle resulted in increased pressure to the perineum in both men and women, as workload increased.
Potter et al.14 found a correlation between saddle pressure and hand positioning on handle bars. In both male and female ridders, a hand resting position along the top of the handle bars (‘tops’ position) is associated with increased posterior pressure on the ischial tuberosities. When in a crouched position, with hands resting on the lower scooped handle bar (‘drops’ position), the center of pressure shifts forward onto the ischial tuberosities, with males having increasingly more anterior compression compared to females.
Capes et al.16 found similar results to Potter et al. They suggest trunk positioning / lumbar flexion to be a risk factor with regards to perineal compression, and that it varies between male and female cyclists. They found that when lumbar flexion is at 600 and 900, there is no significant difference in perineal pressure for women using a solid or ‘holed’ saddle. However, a more upright ridding position for men was found to decrease pressure when the cyclists use a ‘holed’ saddle versus a solid design.
Cyclists that train and compete over long distances (i.e. road racers), hold their trunks in an increasingly flexed position to reduce aerodynamic drag and maximize average speed17. As previously suggested, increased lumbar flexion has its drawbacks for long distance and frequent ridders. Common symptoms include: constant rubbing in the perineal region, which can result in chafing, perineal folliculitis and furuncles, subcutaneous perineal nodules, pudendal neuropathy, male impotence, traumatic urethritis, and a variety of vulvar trauma.18, 19 The poor cushioning and firm structure of these saddles can cause intense and prolonged compression of the pudendal nerve, most common following repeated and multi-day rides, which may result in transient impotence.20
Anderson et al.21 surveyed 169 amateur cyclists taking part in an annual non-stop 540-km bicycle tour, and the occurrence of symptoms of neurological injuries as a result of this event.
Numbness of the genitals that lasted for a day or more was reported in 21% of male participants, and 6% of those participants have symptoms lasting between 1 week to four months’ post event. Nine of the 169 amateur ridders were female, none of which reported any neurological injuries.
Baran et al.22 revealed similar findings, suggesting perineal numbness and erectile dysfunction to be the most commonly reported symptoms in the male population due to compression of the pudendal nerve as a result of long distance cycling. Sommer et al.,23 noted that 61% of male cyclists, in a study of 40 healthy participants, experienced numbness in the genital region, along with 19% experiencing erectile dysfunction after weekly cycling distances of more than 400km.
Cyclist’s Syndrome (Pudendal Neuralgia)
Pressure on the perineum from bike saddles can result in the compression of the pudendal nerve. Recreational and professional cyclists alike, that long-distance ride frequently refer to this as “cyclist’s syndrome.”24 Symptoms of this condition vary from pain and/or numbness with prolonged sitting in the perineum, rectum, labia, vagina, scrotum, and penis. In more severe cases, pain can be present during intercourse in females, and erectile dysfunction in males. 25
The pudendal nerve originates from the S2-S4 nerve roots, traveling behind the sacrospinous ligament and medial to the spine of the ischium. Within the gluteal region, the nerve passes between the sacrospinous and sacrotuberous ligaments, and moves towards the inner surface of the obturator internus muscle. The nerve enters the pudendal (Alcock’s) canal below the pubic bone and splits into three branches upon its exit; the inferior rectal nerve, perineal nerve, and the dorsal nerve of the clitoris in females, and dorsal nerve of the penis in males. 26, 27 The pudendal nerve provides somatic motor efferent fibers to the urethral rhabdosphincter, external anal sphincter, and select perineal muscles. The sensory afferent fibers innervate the majority of the perineum as well as the urethra, rectum, clitoris in females, and penis in males.28, 29
Pudendal neuralgia via compression of the pudendal nerve is commonly examined in three mechanisms of injury: compression in an acute or chronic lesion, stretch injury as a result of childbirth, or transection injury.30, 31, 32, 33Though pudendal neuralgia is documented in both sexes, six out of ten cases are observed in women, with pain usually arising insidiously, sometimes preceded by a phase of paresthesia in the same territory. Prolonged sitting or driving appears to be predisposing factors, with the most common being cycling.34 The primary mechanisms leading to these symptoms in both genders is suggested to be perineal compression of the pudendal nerve within the Alcock’s canal.35, 36, 37, 38, 39, 40
In 2009, Filler et al.41 described a collective report of 200 patients experiencing pudendal neuralgia, and evaluated primary locations of nerve entrapment. Four primary types were discovered based on location of entrapment: Type I, entrapment at the exit of the greater sciatic notch in concert with piriformis muscle spasm; Type II, entrapment at the level of the ischial spine, sactotuberous ligament, and lesser sciatic notch entrance; Type III, entrapment in association with obturator internus muscle spasm at the entrance of Alcock canal; Type IV, distal entrapment of terminal branches.
Osteopathic Manipulative Treatment
Osteopathic manipulative treatment therapy is a non-invasive therapy defined as: the therapeutic application of manually guided forces to improve physiologic function and/or support homeostasis that has been altered by somatic (body framework) dysfunction. Osteopathic manipulative therapy methods include a collection of techniques that apply a set of distinct unified principles that guide individualized treatments including high-velocity low-amplitude thrusts, muscle energy, cranial, counterstrain, myofascial release, facilitated positional release, facial ligamentous release, lymphatic, and soft tissue therapy.42 These techniques can be further categorized as either direct or indirect. Direct techniques consist of the practitioner moving the body into positions of laxity to facilitate neurological resetting and local tissue relaxation. Indirect techniques consist of the practitioner moving the body into restricting positions to facilitate improved motion.43
The range of techniques practitioners use in daily practice can be quite broad. Johnson et al.,44 describes a 2003 questionnaire of 955 practicing osteopathic manipulative practitioners and the likelihood of using various osteopathic manipulative treatment techniques in practice. Use of soft tissue, high-velocity low-amplitude thrusts, and muscle energy were among the most preferred, with cranial, facilitated positional release, and fascial ligamentous release used the least. Technique preferences for specific demographics were also present, as female and older practitioners were most likely to use indirect techniques, whereas male and younger practitioners preferred direct techniques.
Somatic dysfunction, as diagnosed by osteopathic practitioners, is characterized using the mnemonic TART: Tissue texture abnormalities, Asymmetry, Restriction of Motion, and Tenderness. Any of these must be present for diagnosis.45Screening tests such as static posture, gait, range of motion, and static palpation, are used to assess patients, determine location of somatic dysfunction, and better direct treatment. A proper diagnosis and reliving somatic dysfunction enables a practitioner to promote health and wellness in a patient presenting with acute or chronic symptoms.
A proper diagnosis of pudendal neuralgia is difficult due to the similarities of symptoms with prostatitis, prostate or testicular cancer, and ovarian cysts or dyspareunia in females. Patients are often misdiagnosed and present with a history of seeing multiple physicians, with no evidence of disease, normal urogynecological and colorectal evaluations, and failed multiple pharmacological treatments.46, 47 There is limited literature identifying pudendal neuralgia as a positive source of perineal pain. Nates criteria is the most recognized and utilized method in the diagnosis of this condition, though not widely used. This system uses five essential diagnostic criteria: (1) pain in the anatomical territory of the pudendal nerve, (2) worsened by sitting, (3) the patient is not woken at night by the pain, (4) no objective sensory loss on clinical examination, and (5) positive anesthetic pudendal nerve block.48, 49
Patients seeking relief of pudendal neuralgia symptoms are often given an assortment of treatment options, varying between behavioral modifications, physiotherapy, analgesics and nerve block, surgical pudendal nerve decompression, radiofrequency, and spinal cord stimulation.50, 51 Manual therapists, such as pelvic floor physiotherapists, chiropractors, and osteopaths, provide less invasive options to treating neuropathies that are often as effective and generally more readily available than a surgical alternative.
Durante et al.52 describe one case treating a 41-year-old male competitive Ironman athlete with diagnosed “cyclist syndrome” presenting with constant penis and perineal pain from a 12–24-hour ride. The patient was treated over a four-week period, twice weekly, where the main treatment was soft tissue techniques on the obturator internus muscle. The first treatment initially further aggravated the patient’s symptoms. By the second week, his pain had decreased from a 9/10 on the numerical pain scale, to a 5/10. The following two weeks of treatment continued with the same soft tissue approach, further progressing the decline in pain to a 1/10. The patient quickly returned to his regular cycling training without any residual perineal pain.
Crow53, produced similar results in a 24-year-old water polo player with a 6-months history of impotence following multiple hits to the groin and testicles during a water polo match. The osteopathic manipulative therapy approach consisted of ischiorectal fossa, prostatic, and perineal release. Forces applied were to achieve a stretch of the obturator internus, as well as the iliococygeus muscle of the levator ani. In addition to the impotence, somatic dysfunction was identified at the thoracolumbar region, and was treated using high velocity-low amplitude techniques. In a follow-up treatment later that same week, the patient reported his impotence had completely resolved following the initial treatment. This suggests fascial restrictions may play a role in impotence in patients with a history of trauma to the groin and pudendal nerve.
Lafave et al.54 documented in detail a unique case treating a 31-year-old bareback rodeo cowboy with pudendal nerve entrapment over four consecutive days, during a lucrative and prestigious invitation-only rodeo competition. Osteopathic manipulative treatment therapy consisted of myofascial release, osteo-articular mobilization, and cranial and visceral release techniques. The initial treatment primarily targeted the release of the root of the mesentery and ischial intraosseous lesion, which provided the patient with a 50% improvement in symptoms. The second treatment focused on the sigmoid colon, posterior abdominal wall, iliopsoas muscle, and thoracolumbar fascia, which provided an additional 25% in relief. The third day targeted the release of the pelvic floor musculature, including balancing the three diaphragms, and harmonizing the primary respiratory mechanism within the cranio-sacral system. The final day of treatment further worked on mobility of the pelvic girdle and viscera, and normalized the remnant cranio-sacral and spinal lesions. On the fourth day, the patient reported no pain or other symptoms following treatment.
According to Olson,55 a 43-year-old female patient with consistent pudendal nerve pain, and saddle-like paresthesia over a year and a half had a complete resolution of symptoms over 5 weeks of therapy. Diagnosed with pudendal neuralgia, the patient was treated over a one-month period, starting with sessions twice weekly for three weeks, followed by weekly appointments over the last two weeks. The practitioner used a combination of myofascial release, and instrument-assisted soft-tissue mobilization techniques directed to the pelvic musculature, focusing primarily on the right obturator internus. Treatment included chiropractic manipulative therapy on the lower back and pelvis when segmental restrictions were noted at each visit. Over the 5-weeks of therapy, the patient reported that her paresthesia had completely resolved.
Similar literature in treating patients of non-athletic backgrounds presenting with pudendal neuralgia described relatable results using osteopathic manipulative therapy for this condition. Origo et al.56 describes the case management of a 40-year-old female who struggled with intense pelvic pain over a year. Diagnosed with functional pudendal nerve entrapment, she was treated with osteopathic manipulative treatment techniques over five consecutive weekly treatments. Sessions included a combination of direct and indirect techniques over the pelvic region. The first two treatments targeted pelvic floor release: balanced ligamentous tension technique to the sacroiliac joints, fascial unwinding of the hypogastric region, lumbar-sacral decompression, and internal direct sacro-coccygeal mobilization. The following three sessions continued with fascial unwinding techniques to the thoracic diaphragm, pelvic floor, and crural fascia. Balance ligamentous tension techniques of the sacrotuberous ligament were used in combination with tension balancing of the extracranial fascia and the dura mater for both the skull and sacral base. Upon completion of the fifth session, the patient reported substantial improvement in activities of daily living, and at the 6-month follow-up, outcome measures confirmed a stable progressive reduction of disability and fear of movement, conducive to a full recovery of the patient’s functionality.
Origo et al.57 examined the treatment of chronic coccydynia with osteopathic manipulative therapy compared to physical therapy and pharmacological treatments, and further on the effect of osteopathic manipulative therapy on lower back and radicular pain associated with coccydynia. A total of 50 patients fell into these categories, and received three sessions of osteopathic manipulative therapy over a five-week period. Sessions were a combination of direct and indirect techniques which included balance ligamentous tension techniques of the sacroiliac joints, pelvic floor myofascial release, fascial unwinding, and intra-rectal mobilization techniques. The report’s findings showed in all subjects a successful reduction in pain and a higher significant reduction in disability.
Chapter 3: Conclusion
This literature review illustrates the difficulty in diagnosing pudendal neuralgia and the limited evidence based literature available to treat this condition with traditional non-invasive manipulative techniques. Compression of the pudendal nerve in many cases were most common in the Alcock canal and along the obturator internus muscle. As osteopathic manipulative therapy utilizes a range of soft tissue techniques, such as counterstrain and myofascial release, which have been shown to reduce tenderness and compression of pudendal nerve roots in the sacroiliac region.58
Manual therapies, such as pelvic floor physiotherapy, chiropractic, and osteopathy, tend to follow the lead of medical practitioners, such as urologists and gynecologists, when it comes to pelvic pain and numbness. Patients are often misdiagnosed and given unnecessary and ineffective pharmaceutical and surgical solutions prior to seeking out more noninvasive options for pain relief.
In sports, such as professional cycling, support teams consisting of trainers, coaches, medical doctors, physiotherapists, and massage therapists are more readily available. This may be the reason as to why there are fewer reported incidences of overuse injuries, such as ‘cyclist’s syndrome’, among professional cyclists. Professional cyclists’ bike setup is continuously monitored and adjusted to each ridder, and regular manual therapy is readily available and utilized to keep the athletes in top physical form throughout the season.
Orientation of the pudendal nerve and its branches along the deep structures of the perineum is particularly susceptible to compression in a sitting position. Cyclists using traditional saddles are provided with minimal cushioning and a protruding nose design that over time compress the perineal region resulting in potential symptoms of pain, numbness and impotence, especially in males.
Injury to the pudendal nerve seen in recreational and competitive cyclists is commonly experienced but often short lived. Individuals that ride long distances are more susceptible to pudendal neuralgia due to repetitive and prolonged compression of this nerve.
Nates criteria is the most current and up to date diagnostic technique for diagnosing pudendal nerve compression, but it is still not a 100% effective due to overlapping symptoms with other pelvic floor conditions. However, once diagnosed, osteopathic manipulative treatment techniques may provide quick and long lasting relief of symptoms. That said, current literature on ‘cyclist’s syndrome’ and the treatment of pudendal neuralgia using osteopathic manipulative therapy is scarce. Further research on this condition in recreational and professional cyclists is needed along with the use of more non-invasive practices such as osteopathic manipulative therapy.
Perhaps with the rise in popularity of cycling in North America this past year, an increase in pudendal neuralgia cases may present itself, providing an opportunity for practicing manual osteopathic practitioners to further study the effects of osteopathic manipulative therapy on cycling related injuries such as ‘cyclists syndrome’.
References:
1. Joe Lindsey, “More People are Cycling During COVID-19. That Matters,” Outside, last modified May 13th, 2020, [online], Available at: https://www.outsideonline.com/2412755/more-people-cycling-coronavirus-pandemic#close
2. Mark Gurman, “Peloton Sales Jump 66% on COVID-19 Boost for Home Workouts,” BNN Bloomberg, last modified May 6th, 2020, [online], Available at: https://www.bnnbloomberg.ca/peloton-sales-jump-66-on-covid-19-boost-for-home-workouts-1.1432460
3. The Treck Blog, “Data Indicates Americans are Turning to Cycling for Mental and Physical Health as Well as Alternative Means of Essential Transportation During COVID-19,” last modified April 16th, 2020, [online], Available at: https://blog.trekbikes.com/en/2020/04/16/national-study-reveals-u-s-cycling-behaviors-during-coronavirus-pandemic/
4. Gloria C. Cohen, “Cycling Injuries,” Canadian Family Physician (1993), 39:628-632 [online] Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2379777/
5. Matthew J. Thompson, Frederick P. Rivara, “Bicycle-Related Injuries,” American Family Physician (2001), 63(10):2007-14. [online] Available at: https://www.aafp.org/afp/2001/0515/p2007.html
6. Alta Van der Walt, Christina Janse van Rensburg, Lizelle Fletcher, Catharina Cornelia Grant, Andrew John Van der Walt, “Non-traumatic Injury Profile of Amateur Cyclists,” South Africa Sports Medicine Association (2014), 24(4):119-122. doi:10.7196/sajsm.555
7. Jonathan T. Bravman, Robin H. Dunn, “Cycling,” Sports-related Fractures, Dislocations and Trauma,(2020),doi:10.1007/978-3-030-36790-9
8. “How to Choose a Bike Seat”. REI CO-OP, [online] Available at: https://www.rei.com/learn/expert-advice/bike-saddles.html, Accessed August 28th, 2020
9. “The 13 Best Bike Saddles of 2020 (So Far)”, last modified May 29, 2020. https://www.bicycling.com/bikes-gear/a24787969/best-bike-saddles/
10. Brian D. Lowe, Steven M. Schrader, Michael J. Breitenstein, “Effect of Bicycle Saddle Designs on the Pressure to the Perineum of the Bicyclist,” Medicine & Science in Sports & Exercise, (2004),36(6), 1055–1062. doi:10.1249/01.mss.0000128248.40501.73
11. Steven M. Schrader, Michael J. Breitenstein, Brian D. Lowe, “Cutting off the Nose to Save the Penis,” Journal of Sexual Medicine (2008), 5(8), 1932-1940. doi:10.1111/j.1743-6109.2008.00867.x
12. Ricardio Munarriz, Vincent Huang, Jayant Uberoi, Scott Maitland, Terry Payton, Irwin Goldstein, “Only the Nose Knows: Penile Hemodynamic Study of the Perineum-Saddle Interface in Men with Erectile Dysfunction Utilizing Bicycle Saddles and Seats with and without Nose Extensions,” Journal of Sexual Medicine (2005), 2(5), 612-9. doi:10.1111/j.1743-6109.2005.00089.x
13. Felipe P. Carpes, Frederico Dagnese, Julio F. Kleinpaul, Elisandro de A. Marin, Carlos B. Mota, “Effects of Workload on Seat Pressure While Cycling with Two Different Saddles,” The Journal of Sexual Medicine (2009) 6(10), 2728-2735. doi:10.1111/j.1743-6109.2009.01394.x
14. James J. Potter, Julie L. Sauer, Christine L. Weisshaar, Darryl G. Thelen, Heidi-Lynn Ploeg, “Gender Differences in Bicycle Saddle Pressure Distribution During Seated Cycling,” Medicine & Science in Sports & Exercise (2007) 40(6), 1126-1134. doi:10.1249/MSS.0b013e3181666eea
15. “How Important is a Bike Fit? And How is a Bike Fit is Done?,” Cyclist’s Life, last modified May 21, 2015, - https://cyclistslife.wordpress.com/2015/05/21/how-important-is-a-bike-fit-and-how-is-a-bike-fit-done/
16. Felipe P. Carpes, Frederico Dagnese, Julio F. Kleinpaul, Elisandro de A. Martins, Carlos B. Mota, “Bicycle Saddle Pressure: Effects of Trunk Position and Saddle Design on Healthy Subjects,” Urologia Internationalis, (2009), 82, 8-11. doi:10.1159/000176017
17. Andrew Hamilton, “Cyclists: Positon Yourself for Performance,” Peak Performance, [online] Available at: https://www.peakendurancesport.com/endurance-injuries-and-health/cyclists-know-your-place/, Accessed August 28th, 2020
18. Morris B. Mellion, “Common Cycling Injuries,” Sports Med (1991), 11:52-70. doi:10.2165/ 00007256-199111010-00004
19. Vincent S. Ricchiuti, Christopher A. Haas, Allen D. Seftel, Thomas Chelimsky, Irwin Goldstein, “Pudendal Nerve Injury Associated with Avid Bicycling,” The Journal of Urology (1999), 162(6), 2099-2100. doi:10.1016/s0022-5347(05)68116-5
20. Martin Schwellnus, Wayne Derman, “Common Injuries in Cycling: Prevention, Diagnosis and Management,” Journal of the South African Academy of Family Practice/Primary Care (2005), 47(7):14-19. doi:10.1080/20786204.2005.10873255
21. Kjeld V. Anderson, Gunnar Bovim, “Impotence and Nerve Entrapment in Long Distance Amateur Cyclists,” Acta Neurologica Scandinavica,(1997) 95(4), 233–240. doi:10.1111/j.1600-0404.1997.tb00104.x
22. Caner Baran, Gregory C. Mitchell, Wayne J.G. Hellstrom, “Cycling-Related Sexual Dysfunction in Men and Women: A Revie,” International Society for Sexual Medicine (2014) 2:93-101. doi:10.1002/smrj.32
23. F. Sommer, D. Konig, C. Graft, U. Schwrzer, C. Bertram, T. Klotz, U. Engelmann, “Impotence and Genital Numbness in Cyclists,” International Journal of Sports Medicine (2001), 22(6), 410-413. doi:10.1055/s-2001-16248
24. The Institute for Advanced Reconstruction, “Cyclists Beware: Getting to the Bottom of Pudendal Neuralgia, aka “Cyclists Syndrome.” Last modified 2018 [online] Available at: https://www.advancedreconstruction.com/getting-to-the-bottom-of-pudendal-neuralgia-aka-cyclists-syndrome/
25. Health Organization for Pudendal Education (HOPE), “Pudendal Neuralgia Symptoms.” Last modified July 3rd, 2014 [online] Available at: http://www.pudendalhope.info
26. T. Ignacio Montoya, Lewis Calver, Kellie S. Carrick, Jennifer Prats, Marlene M. Corton, “Anatomic Relationships of the Pudendal Nerve Branches,” American Journal of Obstetrics & Gynecology (2011), 205(5):504.e1-5. doi:10.1016/j.ajog.2011.07.014
27. Pedro A. Maldonado, Kathleen Chin, Alyson A. Garcia, Marlene M. Corton, “Anatomic Variations of pudendal Nerve within Pelvis and Pudendal Canal: Clinical Applications,” American Journal of Obstetrics & Gynecology(2015), 213:727.31-6. doi:10.1016/jajog.2015.06.009
28. Karl B. Thor, Craig Donatucci, “Central Nervous System Control of the Lower Urinary Tract: New Pharmacological Approaches to Stress Urinary Incontinence on Women,” The Journal of Urology (2004), 172(1), 27-33. doi:10.1097/01.ju.0000118381.04432.22
29. Paul Rea, Essential Clinically Applied Anatomy of the Peripheral Nervous System in the Limbs 1st Ed., Academic Press, 2015
30. Waseem Khoder, Douglass Hale, “Pudendal Neuralgia,” Obstetrics and Gynecology Clinics of North America (2014), 41(2), 443-452. do:10.1016/j.ogc.2014.04.002
31. Sang-Jeon Lee, Jin-Woo Park, “Follow-up Evaluation of the Effect of Vaginal Delivery on the Pelvic Floor,” Diseases of the Colon & Rectum (2000), 43(11), 1550-1555. doi:10.1007/bf02236737
32. Steven J. Alevizon, Michael A. Finan, “Sacrospinous Colpopexy: Management of Postoperative Pudendal Nerve Entrapemnt,” Obstetrics & Gynecology (1996), 88(4), 713-715. doi:10.1016/0029-7844(96)00127-5
33. Daniele Origo, Andrea G. Tarantino, Luca Vismara, Alessandro Nonis, “Osteopathic Manipulative Treatment In Chronic Coccydynia: A Case Series,” Journal of Body Work & Movement Therapies (2017), doi:10.1016/j.jbmt.2017.06.010
34. Andrew P. Baranowski, Paul Abrams, Magnus Fall. Urogenital Pain in Clinical Practice. New York: London, 2007
35. Frank Oberpenning, Stephan Ludwig Roth, Dietrich B. Leusmann, H van Ahlen, Lothar Hertle, “The Alcock Syndrome: Temporary Penile Insensitivity Due to Compression of the Pudendal Nerve within the Alcock Canal,” The Journal of Urology (1994) 151(2):423-5. doi:10.1016/s0022-5347(17)34970-4
36. Michaeal Hibner, Nita Desai, Loretta J. Robertson, May Nour, “Pudendal Neuralgia,” Journal of Minimally Invasive Gynecology, (2010), 17(2), 148-153. doi: 10.1016/j.jmig.2009.11.003
37. Stephan Hruby, Johannes Ebmer, A. Lee Dellon, Oskar C. Aszmann, “Anatomy of Pudendal Nerve at Urogenital Diaphragm – New Critical Site For Nerve Entrapment,” Urology (2005), 66(5), 949-952. doi:10.1016/j.urology.2005.05.032
38. R. Robert, D. Prat-Pradal, J. J. Labat, M. Bensignor, S. Raoul, R. Rebai, J. Leborgne. “Anatomic Basis of Chronic Perineal Pain: Role of the Pudendal Nerve,” Surgical and Radial Anatomy (1998) 20(2), 93-98 doi:10.1007/BF01628908
39. Christopher E. Ramsden, Michael C. McDaniel, Robert L. Harmon, Kenneth M. Renney, Alexis Faure, “Pudendal Nerve Entrapment as Source of Intractable Perineal Pain,” American Journal of physical Medicine & Rehabilitation (2003), 82(6), 479-484. doi:10.1097/01.PHM.0000069196.15353.7D
40. James Kennedy, “Neurologic Injuries in Cycling and Bike Riding,” Physical Medicine and Rehabilitation Clinic of North America (2008), 20(1), 241-248. doi:10.1016/j.pmr.2008.10.015
41. Aaron Filler, “Diagnosis and Treatment of Pudendal Nerve Entrapment Syndrome Subtypes: Imaging, Injections, and Minimal Access Surgery,” Neurosurg Focus (2009); 26(2):E9. doi:10.3171/FOC.2009.26.2.E9
42. Chevy Chase, Glossary of Osteopathic Terminology, Educational Council on Osteopathic Principles of the American Association of Colleges of Osteopathic Medicine 3rd Ed., 5550 Friendship Blvd. Suite 310, 201 0
43. David R. Beatty, To Shan Li, Karen M. Steele, Zachary J. Comeaux, John M. Garlitz, James W. Kribs, William W. Lemley, The Pocket Manual of OMT: Osteopathic Manipulative Treatment for Physicians 2nd Ed. Lewisburg, West Virginia, 2010
44. Shirley M. Johnson, Margot E. Kurtz, “Osteopathic Manipulative Treatment Techniques Preferred by Contemporary Osteopathic Physicians” The Journal of the American Osteopathic Association (2003), 103(5), 219-224 [online] Available at: https://jaoa.org/article.aspx?articleid=2092828 Accessed August 30th, 2020
45. Boyajian-O’Neill, L. A., & Cardone, D. A. (2008). Practical Application of Osteopathic Manipulation in Sports Medicine. The Sports Medicine Resource Manual (2008), 437–443. doi:10.1016/b978-141603197-0.10034-5
46. Kobi Stav, Peter Dwyer, Les Roberts, “Pudendal Neuralgia Fact or Fiction?,” Obstetrical and Gynecological Survey (2009); 64(3):190-9. doi:10.1097/ogx.0b013e318193324e.
47. Rocco S. Calabro, Giuseppe Gervasi, Silvia Marino, Pasquale N. Mondo, Placido Bramanti, “Misdiagnosed Chronic Pelvic Pain: Pudendal Neuralgia Responding to Novel use of Palmitoylethanolamide,” Pain Medicine(2010), 11(5), 781-784. doi:10.1111/j.1526-4637.2010.00823.x
48. Jean-Jacques Labat, Thibault Riant, Roger Robert, Gerard Amarenco, Jean-Pascal Lefaucheur, Jerome Rigaud. “Diagnostic Criteria for Pudendal Neralgia by Pudendal Nerve Entrapment (Nantes Criteria),” Neurourology and Urodynamics (2008), 27:306-310. doi:10.1002/nau.20505
49. Stephane Ploteau, Claire Cardaillac, Marie-Aimee Perrouin-Verbe, Thibault Riant, Jean-Jacques Labat, “Pudendal Neuralgia Due to Pudendal Nerve Entrapment: Warning Signs Observed in Two Cases and Review of the Literature” Pain Physician (2016), E449-E454. [online] Available at: https://www.researchgate.net/publication/299396231_Pudendal_Neuralgia_Due_to_Pudendal_Nerve_Entrapment_Warning_Signs_Observed_in_Two_Cases_and_Review_of_the_Literature
50. Foad Elahi, Daniell Callahan, Jeremy Greenlee, Tammy L. Dann, “Pudendal Entrapment Neuropathy: A Rate Complication of Pelvic Radiation Therapy,” Pain Physician (2013) 16:E793-E797. [online] Available at: https://pdfs.semanticscholar.org/537c/10a359e6d0e06324e518d92a7bbaf8ab182c.pdf?_ga=2.254807949.422288188.1597606291-1071148544.1595615695
51. Faustino R. Perez-Lopez, Fidel Hita-Contreras, “Management of Pudendal Neuralgia,” Climacteric (2014) 17(6), 654-656. doi:10.2109/13697137.2014.912263
52. Jaclyn A. Durante, Ian G. MacIntyre, “Pudendal Nerve Entrapment in an Ironman Athlete: A Case Report,” The Journal of the Canadian Chiropractic Association (2010) 54(4), 276–281. [online] Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2989401/
53. William Thomas Crow. “Manipulative Treatment for Idiopathic Impotence in a 24-year-old Water Polo Player,” International Journal of Osteopathic Medicine (2006), 9(2), 66-71. doi:10.1016/j.ijosm.2006.01.002
54. Mark R. Lafave, Bonnie Sutter, “Pudendal Nerve Entrapment in a Bareback Rodeo Cowboy: A Case Study,” International Journal of Osteopathic Medicine (2012), 15(2), 78-82. doi:10.1016/j.ijosm.2012.03.002
55. Harold M. Olson, “Diagnosis and Conservative Chiropractic Care of Chronic Idiopathic Pudendal Nerve Entrapment Causing Saddle-Like Paresthesia and Restless Genital Syndrome: A Case Study,” Journal of the Spine(2016) 5(6), 346. doi:10.4172/2165-7939.1000346
56. Daniele Origo, Andrea G. Tarantino, “Osteopathic Manipulative Treatment in Pudendal Neuralgia: A Case Report,” Journal of Bodywork & Movement Therapies (2018), doi:10.1016/j.jbmt.2018.02.016
57. Abdul H. Sultan, Mitchael A. Kamm, “Pudendal Nerve Damage During Labour: Prospective Study Before and After Childbirth,” British Journal of Obstetrics and Gynecology (1994), 10(1), 22-28. doi: 10.1111/j.1471-0528.1994.tb13005.x
58. Shannon M. Campbell, Richard R. Winkelmann, Stevan Walkowski, “Osteopathic Manipulative Treatment: Novel Application to Dermatological Disease,” The Journal of Clinical and Aesthetic Dermatology (2012), 5(10): 24-32. [online] Available at: https://jcadonline.com/osteopathic-manipulative-treatment-novel-application-to-dermatological-disease/