Aetiology of pelvic neuropathies in women: a narrative review

Pelvic neuropathy is an under-recognised contributor to chronic pelvic pain in women, yet a structured overview of its identifiable causes has been lacking. In this narrative review we searched PubMed, Embase and Web of Science from inception to 1 March 2024 for clinical studies describing pelvic neuropathy in women with a defined or inferable aetiology, and synthesised them thematically. We included 306 studies (215 case reports, 53 case series, 24 retrospective and 14 prospective cohort studies) describing 2,413 women. Five recurring aetiological categories emerged: iatrogenic injury (the most frequent), nerve invasion or traction by disease processes (notably endometriosis and tumours), pregnancy- and childbirth-related injury, external trauma, and compression by muscular, vascular, benign or malignant structures. Aetiologies of particular relevance to gynaecological practice included nerve-invasive endometriosis, which characteristically produces cyclical (catamenial) symptoms, and obstetric neuropathies, which are usually self-limiting. Specific neuropathic syndromes-piriformis, May-Thurner, pelvic congestion and Alcock's canal (pudendal) syndrome-were inconsistently defined across studies. Diagnostic strategies and reporting quality varied widely, neuropathy was frequently recognised late, and the evidence base was dominated by case reports and small series; the overall certainty of evidence is therefore low and no randomised controlled trials were identified. Greater awareness of nerve-specific injury mechanisms-particularly endometriosis-related and obstetric neuropathies-together with standardised diagnostic pathways, is needed to improve recognition and outcomes for women with neuropathic pelvic pain.