Some Insights from Dr. Bollens
Posted: Mon Nov 02, 2026 7:20 am
The following article was written by Dr. Bollens, specifically for Health Organization for Pudendal Education. Thank you Dr. Bollens! The contact information for Dr. Bollens is listed at the following link under Belgium: https://www.pudendalhope.info/european-physicians/
ARTICLE BY DOCTOR RENAUD BOLLENS
Is it pudendal neuralgia? How to tell it apart from similar conditions, and when surgery makes sense
Based on Dr. Renaud Bollens’ clinical experience. Educational information, not a diagnosis.
Pudendal neuralgia is diagnosed mainly from the clinical picture: where the pain is, how it behaves, and how it responds to targeted tests. Many other conditions cause pelvic pain, and it is common for people to be treated for the wrong one for years. Here is how Dr. Bollens approaches the question.
What the pain pattern can tell you
Two different tests, two different injections
Conservative treatment first
Dr. Bollens’ conservative protocol includes a postural assessment with insoles, stretching of the piriformis, and Botox with local anaesthetic into the piriformis. He also uses daily Tadalafil/Cialis 5 mg for some patients.
When surgery is worth considering
Surgery is for well-selected patients in whom the diagnosis is clear and conservative treatment has not been enough. By his own account, Dr. Bollens reports success in 80 to 85% of primary decompressions, and about 50% in revision surgery after a previous operation elsewhere. These are his own figures, not results from a published study, and they describe groups, not an individual prognosis.
The route depends on where the nerve is compressed. The anterior laparoscopic route (through the abdomen) is mainly for dividing ligaments and fatty tissue and reaching Alcock’s canal. The transgluteal route reaches the piriformis muscle when it compresses the nerve. Dr. Bollens’ piriformis operation is a minimally invasive endoscopic piriformis muscle resection. In his experience, recovery after piriformis surgery is typically 3 to 6 months, and 6 to 24 months after pudendal decompression.
Questions to ask your doctor
ARTICLE BY DOCTOR RENAUD BOLLENS
Is it pudendal neuralgia? How to tell it apart from similar conditions, and when surgery makes sense
Based on Dr. Renaud Bollens’ clinical experience. Educational information, not a diagnosis.
Pudendal neuralgia is diagnosed mainly from the clinical picture: where the pain is, how it behaves, and how it responds to targeted tests. Many other conditions cause pelvic pain, and it is common for people to be treated for the wrong one for years. Here is how Dr. Bollens approaches the question.
What the pain pattern can tell you
- Pain that builds when sitting. In Dr. Bollens’ experience, pain that is clearly related to sitting points to the pudendal nerve. It is not a typical feature of piriformis syndrome, pelvic floor dysfunction or chronic pelvic pain syndrome.
- Deep pain in the buttock. Deep buttock pain, especially when it spreads to the back of the thigh, suggests that the piriformis muscle may be pressing on the nerves in the deep gluteal space. Symptoms in the perineum, the back of the thigh and below the knee together point to the three nerves that pass through this space.
- Constant pain, day and night. In Dr. Bollens’ experience, symptoms that are present around the clock suggest a significant risk that a compressed vertebra in the back is involved. With pudendal neuralgia, symptoms usually ease at night when the body is at rest.
- Pain in the groin. Robert-Maigne syndrome, a problem at the level of T12 to L1, can cause groin pain and is a separate condition.
- Posture. Uneven leg length can tilt the pelvis. This is assessed by a podiatrist or foot therapist. Hard massage of the hips can make things worse.
Two different tests, two different injections
- 1. Pudendal nerve block. A diagnostic test, not a treatment. It should be done under CT guidance by an interventional radiologist. In Dr. Bollens’ experience, CT guidance is accurate about 80% of the time, compared with about 30% with ultrasound. Pain relief during the first hours, while the local anaesthetic is working, strongly supports the diagnosis. A negative result does not rule it out, because the needle may have missed. The clinical picture matters most.
2. Piriformis Botox injection. Given together with local anaesthetic, it is both a test and a treatment. Relief in the first hours strongly suggests the muscle is involved, and Botox can relieve symptoms for up to about 6 months. It starts to work after 7 to 10 days. Botox on its own can give a false negative.
Conservative treatment first
Dr. Bollens’ conservative protocol includes a postural assessment with insoles, stretching of the piriformis, and Botox with local anaesthetic into the piriformis. He also uses daily Tadalafil/Cialis 5 mg for some patients.
When surgery is worth considering
Surgery is for well-selected patients in whom the diagnosis is clear and conservative treatment has not been enough. By his own account, Dr. Bollens reports success in 80 to 85% of primary decompressions, and about 50% in revision surgery after a previous operation elsewhere. These are his own figures, not results from a published study, and they describe groups, not an individual prognosis.
The route depends on where the nerve is compressed. The anterior laparoscopic route (through the abdomen) is mainly for dividing ligaments and fatty tissue and reaching Alcock’s canal. The transgluteal route reaches the piriformis muscle when it compresses the nerve. Dr. Bollens’ piriformis operation is a minimally invasive endoscopic piriformis muscle resection. In his experience, recovery after piriformis surgery is typically 3 to 6 months, and 6 to 24 months after pudendal decompression.
Questions to ask your doctor
- Does my pain pattern fit pudendal neuralgia, piriformis syndrome, or something else?
- Has a CT-guided pudendal nerve block been considered, and by whom?
- Has the piriformis been tested with Botox and local anaesthetic?
- Have other causes been ruled out?