Referred pain and the pudendal trident: why the diagnosis goes astray

In pudendal neuralgia, the painful area that is perceived does not necessarily correspond to the location of the mechanical conflict. Pain may be referred toward the organ or cutaneous territory innervated by a terminal branch of the nerve, even though that territory may be anatomically healthy. This logic explains a major part of diagnostic wandering: investigations focus on “the end of the wire” instead of identifying the constraint along the nerve pathway (Labat et al., 2008/2023).

© Blue Portance — Knowledge Base · Non-commercial reproduction permitted with source citation

1. Referred pain: a neuro-functional principle

Referred pain corresponds to a situation in which the nervous system attributes the painful signal to a peripheral territory (skin, mucosa, organ), while the irritation is located higher along the nerve pathway. This mechanism is particularly marked for the pudendal nerve due to its mixed structure and the complexity of its innervation territories (Labat et al., 2008/2023).

In practical terms, this means that “urinary,” “rectal,” or “genital” pain may reflect nerve irritation, without infection, without fissure, and without detectable organ lesions. The symptom is real, but the perceived location should not be interpreted as the location of the conflict (Labat et al., 2008/2023).

Key point

An evaluation focused solely on the painful area (bladder, rectum, vestibule, penis/clitoris) may miss the essential issue: the pudendal nerve is a “network” whose signal can manifest at a distance.

2. The pudendal trident: three branches, three territories

The pudendal nerve divides into three major terminal branches, often described as a trident. Each branch innervates a distinct territory and may produce a specific clinical presentation (Robert et al., 1998; Labat et al., 2008/2023).

Pudendal trident: rectal, perineal, and dorsal branches and referred pain territories
Pudendal trident: innervation territories and referred pain. The rectal, perineal, and dorsal branches distribute pain to different areas. Pain perceived in a terminal territory does not imply a local conflict; irritation may be located higher along the nerve pathway (Robert et al., 1998; Labat et al., 2008/2023).
  • Rectal branch (inferior rectal nerve): anorectal pain, deep burning sensations, foreign-body feeling, discomfort aggravated in the sitting position.
  • Perineal branch: perineal burning, urinary symptoms without objective infection, urethral or vestibular pain.
  • Dorsal branch (dorsal nerve of the clitoris/penis): hypersensitivity, electric shock sensations, contact-related pain, altered fine genital sensitivity.

Territories may overlap: a single irritation can produce a mixed presentation, increasing the risk of organ-centered interpretation (Labat et al., 2008/2023).

3. Typical clinical presentations and false leads

Referred pain explains very common situations: a person consults for an “organ-related” symptom, yet examinations are reassuring. The issue is not the absence of pain, but the absence of local lesions (SBNFA™ Model, Part IV, 2026).

  • Urinary burning with negative tests: a presentation may mimic cystitis, whereas irritation may involve the perineal branch of the pudendal nerve (Labat et al., 2008/2023).
  • Rectal pain without fissure or lesion: the rectal branch can generate very intense sensations without visible abnormalities (Robert et al., 1998).
  • Genital pain on contact: hypersensitivity and neuropathic pain may be confused with dermatological conditions, while the dorsal branch is involved (Labat et al., 2008/2023).
Key takeaway

A symptom is not “psychological” simply because examinations are normal. It may be neuropathic: the nervous system is signaling a constraint that imaging or local examination does not reveal (SBNFA™ Model, Part IV, 2026).

4. Why diagnostic wandering is so frequent

Pudendal neuralgia lies at the intersection of multiple specialties: urology, gynecology, proctology, dermatology, neurology, pain medicine. Each specialty observes the problem from the perspective of the “terminal organ.” Without a mechanistic framework, evaluation becomes fragmented, diagnoses accumulate, and pain becomes chronic (Labat et al., 2008/2023; SBNFA™ Model, Part IV, 2026).

This wandering has direct consequences: repeated investigations, inappropriate treatments, loss of confidence, followed by the installation of protective hypertonia and central sensitization. These chronicization mechanisms are developed in the dedicated page (SBNFA™ Model, Part IV, 2026).

Scientific references

  1. Labat, J.-J., Riant, T., Robert, R., et al. (2008; updated 2023). Diagnostic criteria for pudendal neuralgia by pudendal nerve entrapment (Nantes criteria). Clinical references on territories, referred pain, and posture dependence.
  2. Robert, R., Prat-Pradal, D., Labat, J.-J., et al. (1998). Anatomical basis of pudendal nerve entrapment. Surgical and Radiologic Anatomy. Anatomical basis of the pathway, terminal branches, and conflict zones.
  3. Blue Portance — SBNFA™ Model. (2026). NEURO-ANATOMY — Part IV: Diagnostic wandering. Mechanistic framework: fragmented care pathways, invalidation, chronicization.
Navigation

← Back to Pudendal Neuralgia Hub
← Back to Sitting-related Pain
← Back to the Knowledge Base

Note: This content explains mechanisms. It does not constitute a medical diagnosis or a therapeutic recommendation.