MRI in Chronic Pudendal Neuralgia: Diagnostic Criteria and Associated Pathologies

Background/Objectives: Chronic pudendal neuralgia is a relatively rare condition in the general population, with an incidence of 1%. Although diagnosis of pudendal neuralgia is mainly clinical, Magnetic Resonance Imaging (MRI) is commonly performed to obtain further information. However, clear criteria and guidelines for MRI diagnosis and the clinical-radiological correlation are still not definite. Methods: We reviewed 81 patients with chronic pudendal neuralgia, studied by an MRI designed protocol for a pelvis and pelvic floor examination. A key element of the protocol was the use of a diffusion-weighted imaging (DWI) technique with echo planar imaging (EPI) sequence (b-values of 0, 100, and 600) for the neurographic evaluation of the nerve. Results: MRI examination revealed DWI abnormalities in 42/81 patients. Pudendal nerve abnormalities were unilateral in 33/42 patients and bilateral in 9/42. Moreover, in 23/42 patients, pathologies related to a high probability of neuropathy have been identified. Conclusions: This study highlights the role of pelvic MRI as a valuable imaging modality in the evaluation of patients with chronic pudendal neuralgia. In the study protocol we propose, an essential role is played by the DWI technique, which improves the visual definition of the pudendal nerve and related anatomical structures. By focusing on anatomical visualization and structured image interpretation, our work provides a practical imaging-oriented contribution to a field in which standardized MRI evaluation is still lacking.