Persistent Genital Arousal Disorder/Genitopelvic Dysesthesia (PGAD/GPD)

Content written by Irwin Goldstein MD

OVERVIEW:

Persistent genital arousal disorder/genitopelvic dysesthesia (PGAD/GPD) is an uncommonly reported women’s sexual health concern. This was first reported in peer review medical literature by Leiblum and Nathan in 2001 and was initially called Persistent Sexual Arousal Syndrome (PSAS). The name was changed because patients complained that this condition was not about traditional sexual arousal.

Genito-pelvic dysesthesia / persistent genital arousal disorder is associated with unrelenting, unwanted, persistent, intrusive, and spontaneous sensations such as pressure/discomfort, engorgement, pulsating, pounding and/or throbbing in the genital tissues such as the clitoris, labia, vagina and/or in the perineum and/or anus in the absence of conscious thoughts of sexual desire or sexual interest. Persistent genital arousal disorder is often associated with significant personal bother and distress. Women with PGAD/GPD are oftenashamed for having inappropriate genital feelings. Women with PGAD/GPD are often having suicidal thoughts.

Persistent genital arousal disorder/genitopelvic dysesthesia may be classified into primary, lifelong if the PGAD/GPD is present throughout the person’s life or into secondary, acquired if the PGAD/GPD develops variably in later life. Persistent genital arousal disorder is associated with spontaneous orgasms or feelings that orgasm is imminent or feelings that orgasmic release is needed to reduce the feelings of persistent arousal, but where symptoms are not consistently diminished by orgasmic release.

In 2009, the combination of PGAD/GPD with Restless Legs Syndrome (RLS) and/or Overactive Bladder Syndrome (OAB) and/or Urethra Hypersensitivity has been called Restless Genital Syndrome (ReGS) by Waldinger et al.

The unwanted genital sensations of Restless Genital Syndrome are typical dysesthesias or unpleasant sensations, such as burning, wetness, itching, pressure, or pins and needles, that may be, or not be, considered as a kind of pain and are often felt as an imminent orgasm in the absence of sexual desire or fantasies.

CAUSES:

The causes of persistent genital arousal disorder/genitopelvic dysesthesia are beginning to be understood. PGAD/GPD may be associated with psychological-related pathophysiologies. Women with PGAD/GPD have described that stress worsens PGAD/GPD symptoms, whereas distraction and relaxation strategies lessens PGAD/GPD symptoms.

PGAD/GPD may be associated with biologic-related pathophysiologies including vascular, neurologic, pharmacologic, and hormonal etiologies. Arterial vascular causes may be secondary to pelvic arterio-venous malformations with unregulated arterial communications to the genitalia. Venous vascular causes may be secondary to pelvic congestion syndrome with ovarian venous incompetence and large varices draining the genitalia. Central neurologic causes may be secondary to Tourette’s Syndrome, epilepsy, post-blunt CNS trauma, post-neurosurgical intervention of central arterio-venous malformation, or to cervical and lumbosacral surgical interventions. Peripheral neurologic causes may be secondary to pudendal nerve entrapment or hypersensitivity. Pharmacologic causes may be secondary to use of certain antidepressants, such as trazodone, or secondary to sudden withdrawal of selective serotonin re-uptake inhibitors (SSRIs) as occurs in sudden SSRI discontinuation syndrome. Hormonal causes may be secondary to initiation and discontinuation of hormone therapy in post-menopausal women, and excess use of herbal estrogens in over-the-counter agents. Some cases of PGAD are idiopathic, or of unknown cause.

In two studies it was found that the onset of Restless Genital Syndrome usually occurred in perimenopausal and postmenopausal women with clinical characteristics of small fiber neuropathy of the pudendal nerve including its dorsal branch to the clitoris.

PGAD/GPD may also be a result of a Tarlov cyst, Facet cyst or annular tear in the sacral spinal nerve roots causing a radiculopathy. These defects are found in lumbar and/or sacral MRIs, usually read by the radiologist as either incidental or not identified at all.

SYMPTOMS:

PGAD/GPD is associated with unrelenting, unwanted, persistent, intrusive, and spontaneous sensations such as pressure/discomfort, engorgement, pulsating, pounding and/or throbbing in the genital tissues such as the clitoris, labia, vagina and/or in the perineum and/or anus in the absence of conscious thoughts of sexual desire or sexual interest.

PGAD/GPD is also associated with varying degrees of psychologic concerns such as community alienation, distraction, worry, depression, feelings of hopelessness, insomnia, poor concentration, difficulty making decisions, irritability, agitation, and depressed mood.

Diagnostic tests: Women with PGAD/GPD should undergo detailed history, psychologic evaluation, physical examination and laboratory testing. Careful history taking is needed to document whether pharmacologic causes secondary to use of certain antidepressants, such as trazodone, or secondary to sudden withdrawal of selective serotonin re-uptake inhibitors (SSRIs) as occurs in sudden SSRI discontinuation syndrome.

Physical examination may be used to identify potential peripheral neurologic causes secondary to pudendal nerve entrapment.

Hormone blood test can be used to assess if hormonal causes or initiation and discontinuation of hormone therapy in post-menopausal women are associated with PGAD/GPD.

Clitoral ultrasound studies can be used to diagnose arterial vascular causes secondary to pelvic arterio-venous malformations with unregulated arterial communications to the genitalia. Pelvic ultrasound and transvaginal ultrasound can be used to exclude venous vascular causes secondary to pelvic congestion syndrome with ovarian venous incompetence and large varices draining the genitalia.

Neurologic consultation, EEG, CT scans, and MRI’s may be utilized to diagnose central neurologic causes from Tourette’s Syndrome, epilepsy, post-blunt CNS trauma, post-neurosurgical intervention of central arterio-venous malformation, or to cervical and lumbosacral surgical interventions.

TREATMENTS:

Therapeutic strategies have developed for women who seek management because of distress from PGAD/GPD. Psychologic-based treatments engage management of the depression or focus on efforts to maximize relaxation through strategies such as distraction and/or hypnosis. Biologic-based treatments include ice or topical anesthetic agents. Discontinuing trazodone, venlafaxine or excess herbal estrogen products may provide relief. Women with PGAD/GPD secondary to arterial-venous malformation may be cured by selective embolization. Women with PGAD/GPD secondary to pelvic venous incompetence might benefit from embolization of the incompetent ovarian vein. Some severely depressed women with PGAD/GPD may benefit using repeated electroconvulsive therapy. Surgical release of pudendal nerve entrapment has resulted in PGAD/GPD symptom improvement. Pharmacologic strategies have included use of tricyclic or SSRI antidepressants (e.g. clomipramine, paroxetine), prolactin-elevating agents (e.g. olanzapine, risperidone), anti-seizure medications (e.g. carbamazepine), use of the opioid agonist tramadol, and use of varenicline (a partial agonist at the nicotinic receptor subtype that decreases the ability of nicotine to stimulate the release of mesolimbic dopamine). An additional strategy for treating  PGAD/GPD is application of a TENS (transcutaneous electrical nerve stimulation) unit.

With the recent determination that a small defect in the sacral spinal nerve roots may be misread in the brain as persistent genital arousal, or persistent itching, minimally invasive spine surgery may cure PGAD/GPD in certain individuals. San Diego Sexual Medicine has a unique relationship with the Spine Institute of San Diego to diagnosis and treat women and men with PGAD/GPD from radiculopathy of the sacral spinal nerve roots. Go to https://www.spine-sexmed.org/ to learn more.

The International Society for the Study of Women's Sexual Health has published an up-to-date consensus guideline on PGAD/GPD.

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