In our practice pudendal neuralgia is defined as pain in the area of innervation of pudendal nerve. Pudendal nerve entrapment is compression of the nerve by scar tissue, ligaments, or surgical material. Pudendal neuralgia may be caused by pudendal nerve entrapment, but other conditions described in this manual may lead to pudendal neuralgia. Diagnosis of pudendal nerve entrapment is difficult, and it is often made by exclusion of those other conditions leading to pudendal pain (pudendal neuralgia). Most patients with pudendal nerve entrapment have a traumatic event that causes the onset of pain. Pelvic MRI may be helpful in ruling out other conditions causing pain and CT-guided pudendal nerve blocks narrow down the diagnosis to the pudendal nerve. Conservative treatments include avoidance of nerve reinjury, physical therapy, nerve blocks, and oral medications such as gabapentin or pregabalin. Patients may also benefit from nerve ablation procedures (pulse radiofrequency and cryoablation) and nerve stimulators. For patients who have failed all the conservative treatments, surgical decompression is an option with good outcomes.

Pelvic pain is a much more common condition than perceived by the medical and general community. Because it affects the most private aspects of human life such as sexuality and reproduction, patients are not willing to discuss it with their families, friends, and loved ones. Medical providers are also very likely to dismiss the symptoms and blame it on a psychological or psychiatric condition. Chronic pelvic pain is real, it is common, and it is almost always due to some identifiable disease or injury. Patients with pelvic pain need to be heard and treated with dignity and respect, and the majority of them can be helped.

Polypropylene mesh implants have been widely used for treatment of urinary incontinence and pelvic organ prolapse. Although they have been shown to be effective in the treatment of these conditions, they also have considerable cost complications including significant and long-lasting pain. Those meshes have been allowed to the market by the FDA without proper research and recently mesh for treatment of pelvic organ prolapse has been taken off the market. In my opinion, the part of the mesh that causes pain is the part that attaches to muscles or pierces through them; therefore it is important to remove that part when treating patients with pain resulting from mesh implants. This is especially important in transobturator meshes where the groin part has to be removed. Meshes that attach to the sacrospinous ligament have a risk of injuring the pudendal nerve, and patients who have developed pain after placement of such a mesh should be treated like patients with pudendal nerve entrapment.

Pelvic pain is one of the most difficult human conditions to diagnose and treat. The pelvis is composed of a complicated network of somatic and visceral nerves; connective tissues; as well as reproductive, urinary, and gastrointestinal organs. Pain in the pelvis can thus be from any of these areas. In order to diagnose and treat patient correctly it is very important to have a knowledge of all nongynecologic and gynecologic conditions leading to pelvic pain. Despite this knowledge, diagnosis may still be very difficult. Often very reexamining history and medical records may be helpful. In many patients pelvic floor is a main contributing factor to pelvic pain.

Postoperative pain is a common problem in gynecology and other surgical specialties. The risk of postsurgical pain is higher in patients undergoing surgery for pain conditions or who have pain elsewhere in the body. Patients need to be appropriately counseled and prepared for surgery. Using an enhanced recovery after surgery (ERAS) protocol, preoperative gabapentin as well as regional blocks for anesthesia and postoperative pain control may minimize the risk of postsurgical pain. One of the most devastating problems after surgery is onset of central sensitization and complex regional pain syndrome that may be caused by inadequate postoperative pain management, and pain management is becoming more and more difficult because of changing laws regarding opioid prescription administration.