The position that hurts is the biggest clue: classic pudendal neuralgia is worst sitting, eased standing (and spares the toilet seat); pelvic venous pain is worst standing, eased lying flat. Burning, electric, numb-adjacent pain speaks nerve; dragging heaviness speaks veins — and the two can genuinely coexist.
"I can't sit through a meal / a work day / a car ride" has its own corner of this community, usually mixed with vulvar pain and the suspicion nobody is looking in the right place. Two very different mechanisms produce that corner, and they're distinguishable.
The pudendal nerve, briefly
The pudendal nerve supplies sensation to the saddle area — vulva, perineum, around the anus. Where it runs through a narrow canal in the pelvis, it can be compressed or irritated, producing pudendal neuralgia: burning, electric, raw or foreign-body sensations in that territory. The pattern doctors use (the Nantes criteria) is distinctive: worse sitting, better standing or on a toilet seat (which unloads the nerve), typically not waking you at night, without true numbness on examination.
Where the veins come in
Pelvic congestion inhabits the same postcode: vulvar varices ache and burn, and congested veins run alongside the pudendal nerve's canal — dilated veins there are one recognised cause of nerve irritation. So the overlap isn't coincidence: venous congestion can produce vulvar pain of its own and provoke genuine nerve pain. Which is why the position test matters:
- Worse standing, building through the day, relieved lying down — the venous signature, even when the location is vulvar
- Worse sitting, relieved standing, burning/electric quality — nerve signature, pudendal territory
- Both patterns at once — a real and common combination; each layer deserves its own assessment rather than one label swallowing the other
Care paths, honestly
For the nerve layer: first-line care is pelvic floor physiotherapy — the muscles around the canal are usually part of the compression — plus sitting modifications (a cut-out cushion genuinely helps), nerve-calming medication where needed, and, in specialist hands, diagnostic nerve blocks that both confirm the diagnosis and treat. Pudendal-literate specialists exist (pelvic pain clinics, some physiatrists and gynaecologists); it's a named condition with a care pathway, not a mystery.
For the venous layer: the standard work-up — and if imaging shows varices in the pudendal region, that finding belongs in the nerve conversation too, since treating the congestion can be part of treating the nerve irritation.
For both: sequence with your clinicians, not by defaulting to whichever speciality you reached first. "Which parts of my pain follow sitting, and which follow standing?" is the sorting question — bring your two-column answer to the appointment.