Welcome to Part 2!
This follow-up article continues where Part 1 left off, and examines structures in the sacroiliac and hip regions that may contribute to testicular pain. The focus is on how these structures interact with one another to produce testicular pain, and the techniques an orthopedic therapist might use to create lasting relief for the patient.
Topics discussed in this article:
- Pudendal nerve: A major source of testicular pain and other pelvic symptoms.
- SI joints: Affect tension of ligaments along the pudendal nerve’s path.
- Obturator internus: Potential compressor / irritator of the pudendal nerve.
- Hip adductors: Fascially continuous with obturator internus & iliopsoas.
- Acupuncture & dry needling: Possible tools to treat testicular pain.
- Putting it all together.
- When to refer to a pelvic health physio.
- Final note on Pudendal Neuralgia: Choose your words carefully.
A 2012 Australian cohort study  used sacroiliac mobilization, home exercises, and postural advice to treat males with pelvic pain and other pelvic symptoms. All subjects had been cleared of possible urological causes for their symptoms by a urologist. The only other selection criterion was objective signs of SIJ irritability and restriction.
On average, the 25 men included in this study had been in pain for 4 years (some for much longer), with pain averaging 5/10. Among other symptoms, 20 of these men reported testicular pain. Physical therapy treatment averaged 4.4 visits. At 3-month follow-up, only 5 of the 25 men reported ongoing pain, averaging 1/10; of these, 3 men reported testicular pain. Nine men had experienced some recurrence of symptoms during the follow-up period, but reported that the home exercise program had been effective in relieving the symptoms. None of the subjects reported seeking further treatment.
Aside from signs of SIJ dysfunction, these men all had something in common: their “pelvic pain and other pelvic symptoms” were attributable to compression or irritation of the pudendal nerve. So that’s where our discussion begins.
1) The Pudendal Nerve
The anatomy of the pudendal nerve is illustrated in Figure 1. The pudendal nerve arises from the sacrum, and takes a relatively complicated path along the bottom of the pelvis to cover the whole pelvic floor from front to back. As will be discussed, there are multiple locations along its path where the pudendal nerve may become compressed or irritated, resulting in testicular pain or other symptoms.
Figure 1: Anatomy of the pudendal nerve. Adapted from image by Mikael Häggström, used with permission.
The pudendal nerve innervates the skin and skeletal muscles of the perineal region, including the penis, scrotum and external sphincters. In addition to motor and sensory supply, the nerve also provides autonomic innervation. This autonomic component allows involuntary control of pelvic floor muscle tone, continence, perspiration, sexual function, etc.  It also makes the area sensitive to stress: Increased stress can cause flare-ups in symptoms in this area, and vice versa, potentially leading to a vicious cycle. [3, 4]
Symptoms of Pudendal Nerve Involvement
Compression or irritation of the pudendal nerve can produce Pudendal Neuralgia: pain/dysesthesia in the scrotum or anywhere else in the nerve’s territory, including the penis, perineum &/or anus.  Pain is usually described as burning, stabbing and /or shooting.  Symptoms are often worsened by activities that involve extreme hip flexion (e.g. sitting, deep squats, lunges) which increases neurodynamic tension within the nerve. Symptoms are often relieved by standing or lying down.  Because of this nerve’s many functions, there can also be other troubling symptoms in the pelvic neighborhood, including sexual/erectile dysfunction, pain during ejaculation, pain during urination, urinary urgency, incontinence, etc. 
Talking about pudendal nerve symptoms may be outside of the comfort zone for many orthopedic PTs. In usual practice, discussion about bowel and bladder function or saddle paraesthesia is typically reserved for lower quadrant safety questions. PT undergraduate training teaches vigilance for pudendal symptoms as potential red flag indicators of cauda equina syndrome, but provides little insight into other biomechanical sources for neuropathic symptoms in this area.
In this article, we’re considering men that have been medically cleared, and have been suffering with testicular pain and possibly other pelvic floor symptoms for some time. If there are new erectile, urinary or bowel symptoms, or a significant worsening of old symptoms since the last medical workup, referral back to the doctor is a necessary step to rule out possible medical causes. Erectile dysfunction, for example, may be an early marker for certain diseases such as diabetes and cardiovascular disease. 
If your patient has been medically investigated and there is no medical explanation for his testicle pain or other pudendal nerve symptoms, the 2012 study suggests that basic orthopedic PT interventions could dramatically change his life in a few visits.  Examining the sacroiliac joints would be an excellent place to start.
2) Sacroiliac Joint (SIJ) Dysfunction as a Contributor to Testicular Pain
The SIJ does not directly refer pain to the pelvic floor or the testicles. Studies show SIJ pain is most intensely felt about the SIJ, with or without referral into the lateral thigh.  However, SIJ biomechanics and the position of the sacrum relative to the innominates directly affects the tension in two overlapping ligaments that the pudendal nerve passes between: The sacrotuberous ligament (STL) and the sacrospinous ligament (SSL).
The pudendal nerve arises ventrally at S2 to S4, about 3 cm below the SIJ, as shown above in Figure 1. It descends anterior to the STL, then near the ischial spine it crosses between the STL and SSL.  This area is crowded by the tendon of obturator internus (OI) which makes a right-angle turn around the back of the ischium between these ligaments,  as shown in Figure 2, below. If the ligaments or OI tendon are pulled tight, compression and friction on the pudendal nerve in this area becomes increasingly likely.
Mechanically, the STL and SSL limit sacral nutation relative to the innominates. If the innominates are posteriorly rotated on the sacrum (i.e. sacral nutation) these ligaments are pulled tight, potentially compressing and irritating the pudendal nerve sandwiched between them. For this reason, the SIJ complex becomes a key focus for physical therapy intervention in pudendal neuralgia symptoms of any type, including testicular pain. 
The SIJ’s should be screened for a full spectrum of potential SIJ dysfunction: pain provocation, malposition and motion restrictions. SIJ provocation tests are diagnostically useful when tested in clusters and multiple positives are present.  The STL can be stressed directly using the Sacroiliac Rocking Test (Knee-to-Shoulder Test). In this test the supine patient’s hip is passively flexed and adducted, bringing the knee towards the contralateral shoulder, and observing for reproduction of symptoms.  Lee  cautions against using the sacral sulcus depth to assess sacral rotation, and recommends using the inferior lateral angles instead. Dornan  emphasizes careful palpation for SIJ stiffness in various planes, especially in the case of significant chronicity, or when more obvious findings are not present.
Findings of even subtle asymmetry, hypomobility, stiffness, or malposition can reflect biomechanical compensations that may contribute to SSL and STL tension and result in persistent pressure on the pudendal nerve.
“What we are searching for is evidence that one or both of the innominates may be significantly rotated on the sacrum, a situation which may cause compression to be placed on the pudendal nerve…. Theoretically, a strong enough force on the pelvis in any direction could change the mechanics in relation to the path of the nerve.” Peter Dornan 
Treatment will depend on SIJ findings. General treatment goals will be to restore symmetry and optimize biomechanics. Release articular or myofascial restrictions that contribute to dysfunctional movement or position. The techniques used will depend on an individual therapist’s skillset: manual mobilization, manipulation, myofascial techniques, dry needling, etc. While there are many possible SIJ presentations that can lead to pudendal neuralgia, posterior rotation of the innominates on the sacrum is the most common.  The 2012 study details a manual technique to mobilize innominate anterior rotation relative to the sacrum, reducing STL and SSL tension and alleviating pressure on the pudendal nerve. 
Therapeutic exercises that promote mobility, motor control and stability of the lumbosacral area facilitate maintenance of mobility and alignment. Educating the patient regarding optimal posture is essential, as postural factors can act as both cause and aggravator of pudendal symptoms. Slouched sitting is a particular problem because of the sustained innominate posterior rotation load it creates. [1, 2]
3) Obturator Internus (OI)
After passing between the STL and SSL and behind the ischial spine, the pudendal nerve travels along the inferomedial surface of the ischial tuberosity and ischiopubic ramus. The posterior part of this path, along the ischial tuberosity, is encased in a fascial tunnel between layers of the aponeurosis of OI, known as the Pudendal Canal (or Alcock’s Canal),  as shown above in Figure 1. Within or upon leaving this tunnel, the pudendal nerve divides into several branches, one of which innervates the scrotum and the underside of the penis. A separate branch of the pudendal nerve continues anteriorly, and can be compressed against the ishiopubic ramus by a poor fitting bicycle seat, resulting in numbness or pain in the dorsum and sides of the penis.
OI is a “usual suspect” for many pelvic floor issues. It is a hip abductor, extensor and external rotator in all ranges of hip flexion,  but performs these actions from a relatively inaccessible spot deep inside the pelvis. In men and women alike, it is frequently found hypertonic and triggered up. Elevated tone in OI can tighten the pudendal canal, putting increased pressure on the pudendal nerve. A simple test for OI involvement is to put the muscle on a stretch (hip flexion, adduction and internal rotation) and observe any increase in symptoms as the muscle tightens and potentially compresses the nerve. 
"With courage and permission, you can get valuable work done on the belly of the obturator internus." Myers & Earls 
In each of the techniques described below, the therapist starts by palpating the patient’s ischial tuberosity, then slowly and gently slides the fingers superiorly along its medial aspect, being careful not to stretch the skin. While applying gentle pressure to the muscle, OI contraction will be palpable under the fingers by resisting hip external rotation at the knee.
- Myers [14, 15] describes OI myofascial treatment in sidelying. Once the treating hand is in position on the muscle, the therapist partially hooks the fingertips into the obturator internus and gently stretches it inferiorly. As the tissue is engaged, the patient is asked to slowly rotate his leg medially to facilitate release.
- Lee  describes a “release with awareness” approach in crook lying with a bolster supporting the patient’s knees. While gently palpating the muscle, OI is shortened with passive external hip rotation, and gentle axial force is applied along the length of the femur to center the femoral head. The patient is then cued to soften OI: “let the sitz bones go wide” or “let the hip come away from the pelvis”. Once the muscle has relaxed, gentle passive hip internal rotation is used to lengthen OI.
Whatever technique you choose, multiple sources caution against being overly aggressive when treating muscles in this region. Wise & Anderson  recommend allowing the technique to increase the patient’s pain by an increment of only 1/10.
“…Applying heavy palpation, over-vigorous or prolonged treatments can re-trigger an already over-reactive neural system, creating an even more complex pain cycle. I personally don't apply trigger point massage or even deep tissue massage to any pudendal neuralgia patient, although I concede, with care (and experience), it may be a useful technique.” Peter Dornan 
Similar cautions should be observed in prescribing self-release techniques or stretching exercises to the patient. Small therapy balls can help to facilitate self-release of OI. With the patient in crook lying, the ball can be placed just medial to the ischial tuberosity, while patient allows sitz bones to go wide.  As an alternative technique, the patient lies supine on floor with calves supported on the seat of a chair. From here, a ball can be positioned just posterior to OI’s tendon just posterior to the greater trochanter.  An effective self-stretch for OI starts in crook lying, with hip adduction and internal rotation then added to the affected side.
OI is fascially linked to both the hip adductors and the iliopsoas. These muscles form a segment in the continuous fascial complex Myers calls the Deep Front Line.  Tension or irritability in any of these components (or indeed, in any of the other myofascial components of the Deep Front Line) can cause tension, irritability and symptoms in the other components.
4) Hip Adductors
Pain along the adductor compartment of the medial thigh is common in testicular pain. The fascial connections between the hip adductors with other potentially involved structures is one possible reason. Releasing tension in the adductors using myofascial techniques can therefore have impact on OI and iliopsoas components to the patient’s presentation (and vice versa) potentially reducing nerve irritability and associated testicular symptoms.
In addition, branches of the ilioinguinal and genitofemoral nerves (discussed in Part 1) innervate sections of the anteromedial thigh near the groin crease. Any proximal pressure on these nerves that produces testicular pain can also cause symptoms in these areas of the thigh.
Many orthopedic PTs are trained in needling of some sort: traditional (TCM) acupuncture, anatomical acupuncture and /or myofascial dry-needling (IMS, GTT, etc). Depending on your skillset, each of these techniques can have potential value in treating testicular pain.
To treat testicular pain from a TCM acupuncture perspective, Maciocia  and Deadman  suggest key points along Liver, Kidney and Spleen meridians in the lower extremities, and specific Stomach and Ren points in the abdomen. From an anatomical perspective, Huatojiaji points and points along the Bladder and Du meridians in the relevant spinal areas may produce good therapeutic effects. [19, 20]
Traditional acupuncture microsystem points may also prove useful. Aung  notes points just lateral of the midline at the tip of the nose that are useful for treating testicle pain. Landgren  discusses Testicle points in both Chinese and European ear microsystems. Other ear points like Shen Men and Sympathetic may prove quite useful in reducing pain and downregulating sensitivity.
Dry needling of myofascial triggers and hypertonic fascicles in the thoraco-lumbo-sacral paraspinals, QLs, abdominals (particularly obliques) and hip adductors could be helpful in addressing irritability in myofascial structures presented in Parts 1 and 2. The tendon of iliopsoas can be needled, potential impacting muscle tone in the respective muscle, as well as the muscles that it’s fascially connected to. Needling gluteus maximus and piriformis can be helpful because of their impact on SIJ biomechanics and sacral position.
Dry needling of OI is also possible, but careful consideration should be given to nervous system irritability and reactivity as previously discussed. The tendon of OI can be needled at its insertion on the greater trochanter. In addition, for those with the appropriate training, the muscle belly can be needled superior to the ischiopubic ramus.  A recent APTA paper details the cases of two patients that responded favorably to deep needling with electrical stim of the OI muscle belly. The authors caution that this technique requires special care to avoid needling into the pudendal nerve and vessels in the pudendal canal. 
6) Putting It All Together
While there is often overlap, Parts 1 and 2 pertain to two different presentations of biomechanical testicular pain. The assessment and treatment repertoire of a typical orthopedic PT includes many techniques that can address biomechanical components involved in both of these presentations. As the 2012 study shows, even chronic cases have the potential to respond rapidly to such interventions.  So, where to start?
- It is essential that your patient is medically prescreened, and rescreened if there are new pudendal symptoms or significant worsening in such symptoms, as discussed above.
- When taking the patient’s history, ask about other symptoms in the pelvic floor. Don’t be shy! Most men with such problems have previously talked about their symptoms with multiple health professionals, and will not be surprised or embarrassed by your questions.
- Objective examination of the lumbo-sacral-hip region is essential, with attention to posture, movement patterns and biomechanics, particularly in the thoracolumbar and SIJ areas.
- If the patient’s history suggests pudendal involvement, thorough assessment and treatment of the SIJs is an appropriate starting point.
- If the patient’s history is clear of symptoms in the saddle region other than testicular pain, consideration of the structures described in Part 1 would be an appropriate place to start.
- Be cognizant of the chronicity of the condition. In most cases, men with idiopathic testicular pain have had no biomechanical intervention. Treatment of the tissues and articulations may significantly benefit the patient. However, if there is no progress, or if progress stalls, consider the possibility that a central sensitization component may need to be addressed to facilitate the patient’s recovery.
7) When to Refer to a Pelvic Health Physio
Referring the patient to a PT that treats male pelvic health is advisable if his symptoms worsen, fail to improve, or plateau despite your best efforts. Pelvic health physical therapists have knowledge and skills specific to the assessment and treatment of pelvic floor issues. Such a therapist can provide a second opinion, and assess and treat other specific pelvic floor or testicle-related issues that may be impeding progress.  In many cases, these interventions can dovetail with the therapy provided by the orthopedic PT.
8) A Final Note on Pudendal Neuralgia: Choose Your Words Carefully!
“…What we say and how we say it will affect any pain condition… We need to be very careful to give people accurate information that does not needlessly ramp up these protective responses.” Lorimer Moseley 
When discussing Pudendal Neuralgia (PN) with patients, avoid words that describe the nerve as “trapped” or “stuck”. Better word choices might include “irritation”, “pressure”, “friction” and “compression”. PN is a group of symptoms that suggest the nerve is compressed or irritated somewhere along its path. PN does not imply the nerve is trapped.
Unfortunately, there is plenty of misinformation online about Pudendal Nerve Entrapment (PNE), and many articles and information sources treat PN and PNE as synonyms. Within a few paragraphs of the mention of PNE, a discussion about surgery often ensues, even though surgery is not indicated in the vast majority of cases.  PNE is a diagnosis of exclusion, and nudging a patient towards a PNE self-diagnosis increases the likelihood of unnecessarily ramping up protective responses.
In spite of your best efforts, there’s some likelihood that “Dr. Google” will lead your patient to diagnosis himself with PNE. In this case, it’s advisable to discuss (1) that there’s no test or any other way of knowing with certainty if the nerve is actually stuck,  and (2) even if it is stuck, manual joint and soft tissue techniques stand an excellent chance of getting it moving again.
“…A leading cause of Pudendal Neuralgia is myofascial dysfunction. Indeed, hypertonic muscles, myofascial trigger points, joint dysfunction, and connective tissue restrictions can cause pudendal nerve irritation and the symptoms of pudendal neuralgia: sharp, shooting, or burning pain in the territory of the nerve.” - Stephanie Prendergast 
- Stephanie Prendergast has published an incredibly helpful series of Blog posts that tackle and demystify PN and PNE, should you or your patient wish to understand more about this. 
- Peter Dornan’s book “Pelvic Pain: A Musculoskeletal Approach for Treatment”  thoroughly explains pudendal neuralgia, possible biomechanical causes and an orthopedic PT approach to treatment. It details the pudendal nerve in a clinically relevant way, describing its relationship with other nerves, and the spectrum of symptoms a patient may present with.
- The most recent edition of Diane Lee’s “The Pelvic Girdle”  provides insight into the Integrated Systems Model, and provides a framework for assessment and treatment that can uncover and address more wide-ranging drivers of pelvic dysfunction than those discussed in this brief article.
Sincere thanks to everyone that provided guidance and support in the preparation of these articles.
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