Persistent Genital Arousal Disorder (PGAD)

Original Editor - User Name
Top Contributors - Khloud Shreif

Introduction

Persistent genital arousal disorder (PGAD), restless genital syndrome (ReGS), or genitopelvic dysesthesia (GD) a rare disorder defined as persistatant, unpleasant , distressing sensation of unwanted, uncontrollable genital arousal, happens in the absence of any arousal or sexual stimulus, dose not resolve by orgasm or masturbation, may last for hours or days, and usually has a negative impact on individual's life. Symptoms may be triggered by sexual cues, non-sexual cues, or it may be idiopathic. Persistent genital arousal disorder (PGAD) was described for the first time in 2001 by Sandra Leiblum and Sharon Nathan. It is relating mainly to women but it was presented in men also.

Mechanism of Injury / Pathological Process

As it was described for first time 20 years ago and it difficult to know its prevalence there is limited studies about PGAD that are individual case studies till now there is not RCT or SR studies about PGAD how to diagnose, assess, or treat.

There are different hypotheses for causes of PGAD that may be multifacorial; vascular factors, central and peripheral nervous system factors, pharmacological factors, psychosocial factors, dietary, or even idiopathetic factors.

Pharmacological factors, it was reported in a few case report studies that drugs that contain serotonergic such as antidepressant medication (SSRIs /SNRIs) may induce or worsen PGAD symptoms even at initiation or withdrawal of drug, however, there were cases in which there was a fundamental improvement of PGAD symptoms anticonvulsant or SNRI.

Nervous system factors, nerve roots compression at the level of cauda equina (roots of genetalia) this compression may be because of tarlov cysts that cause cauda equina syndrome. In a study on an online support group for patients with with PGAD(18) their MRI was collected, (12/18) there was Tarlov cysts. Compression of dorsal nerve of clitoris is another possible factor for PGAD.

Psychosocial factors, assessment of psychological factors of patient sis important for diagnoses of PGAD, may be it is not the main factor but it may play a role in the development or maintenance of symptoms, history with sexual abuse is another possible cause.

Other factors; childbirth, falling, vehicle accidents, or sacroiliac joint dysfunction. In 2022, Zhang reported a case with PGAD symptoms after many visits to neurosurgeons, neurologists, gynecologists, psychologists there was no symptoms reliefe and with physical exam there was SIJ dysfunction and here symptoms was releases after physical therapy sessions to restore joint alignment.

Clinical Presentation

• Uncontrollable genital arousal dos not affected by orgasm or masturbation.
• Symptoms may persist for hours or days in absence of sexual desire or objective stimulus.
• Pain or discomfort in the genetalia
• Tingling around clitoris.
• Genital engorgement.
• Lubrication or discharges
• Throbbing response.

Diagnostic Procedures

Pelvic MRI in cases with suspected pudendal nerve entrapment.

Lumbosacral MRI for exclusion of cauda equina syndrome.

Management / Interventions

There is a guidelines for PGAD/ GD and all we have depend on case studies, the intervention for PGAD treatment need collaboration of multidisciplinary team for diagnosis and treatment.

Pharmacological intervention

There was an improvement in PGAD symptoms with the intervention of antidepressant and anticonvulsant and there was a successful treatment for female patient with leuprolide that were case studies.

Neurolysis of dorsal nerve to clitoris

In cases with nerve compression there was complete relief of symptoms after surgery an bilateral neurolysis had better outcomes than unilateral. The dorsal nerve to clitoris is compressed mainly at the exit of the canal of Alcock and the site of compression can be detected during physical examination it will be tender and painful with palpation.

Physical Therapy

• Relaxation exercise and diaphragmatic breathing help to relax pelvic floor muscles, manual therapy and soft tissue mobilization.
• Electrotherapy for pain management (TENS, nerve neuromodulation)
• Advice for life style modification, to participate on general body conditioning exercise program, yoga, advices for bowel and bladder habits, and stress management.

A case report study in 2010 demonstrated a 27 years old female 27 weeks pregnancy, presented with PGAD symptoms she was evaluated and assessed to identify the underling cause, during pelvic floor physical therapy examination there was multiple trigger points in obtrurator internus and hypertonicity of pelvic floor muscles. The patient undregone for obtrurator internus soft tissue mobilization for about 15 minute, there was completely relieve in symptoms 14 weeks later to this session.

Differential Diagnosis

Hypersexuality, unlike PGAD it is associated with a desire to have sex and was defined as the desire and urge to engage in sexual activity.

UTI

Urinary tract infection if there was symptoms like burning and itching.

Vulvodynia, persistent vulvar pain that is usually unexplained and may be caused by irritation to peripheral nerves around the vulva.

Penoscrotodynia, related to men and is similar to vulvodynia in women, is a skin burning sensation at genital area.