Healthcare Experiences of Individuals With Persistent Genital Arousal Disorder/Genito-Pelvic Dysesthesia

Experiences of Care and Gaslighting in Patients With Vulvovaginal Disorders

Importance

Medical gaslighting, in which a patient's concerns are dismissed without proper evaluation, has been described anecdotally in vulvovaginal patient care, but has not been quantified.

Objective

To use a patient-centered instrument to measure adverse experiences in vulvovaginal care.

Design, Setting, and Participants

Common themes from National Vulvodynia Association patient testimonials were used to design a mixed-methods measure of patient experience that included both quantitative and qualitative questions. An instrument was created and submitted to officers from the National Vulvodynia Association and Tight-Lipped, another patient advocacy organization, for feedback. The measure was then completed by patients before their first appointment at a vulvovaginal disorder referral clinic from August 2023 to February 2024.

Exposure

Participation in the survey.

Main Outcomes and Measures

The primary outcome was the incidence of reported clinician behavior and consequent distress as reported on the survey instrument. Quantitative data were analyzed using simple descriptive statistics (mean [SD], median [IQR], and percentage). Narrative responses provided by patients were analyzed using the clinical-qualitative method for content analysis.

Results

A total of 520 patients completed surveys; 5 were eliminated because the patient was younger than 18 years, 6 were eliminated for duplication, 6 were eliminated because they had no past clinician, and 56 were eliminated for completely blank responses. Thus, surveys of 447 patients (mean [SD] age, 41.7 [15.2] years) were analyzed (86% response rate). Patients had a mean (SD) of 5.50 (4.53) past clinicians. Patients reported that a mean (SD) of 43.5% (33.9%) of past practitioners were supportive, 26.6% (31.7%) were belittling, and 20.5% (30.9%) did not believe the patient. In total, 186 patients (41.6%) were told they just needed to relax more, 92 (20.6%) were recommended to drink alcohol, 236 (52.8%) considered ceasing care because their concerns were not addressed, 92 (20.6%) were referred to psychiatry without medical treatment, 72 (16.8%) felt unsafe during a medical encounter, and 176 (39.4%) said they were made to feel crazy, the most distressing surveyed behavior (rated at a mean [SD] of 7.39 [3.06] of 10 on a numerical rating scale of distress). A total of 1150 quotations were analyzed qualitatively; common themes included lack of clinician knowledge (247 quotations) and dismissive behaviors (211 quotations).

Conclusions and Relevance

In this cross-sectional study, a patient-centered measure of adverse experiences in vulvovaginal care was developed. Participants reported common past experiences with gaslighting and substantial distress; they frequently considered ceasing care. There is an urgent need for education supporting a biopsychosocial, trauma-informed approach to vulvovaginal pain and continued development of validated instruments to quantify patient experiences.

Investigating brain activity at rest in patients with persistent genital arousal disorder (PGAD) using functional magnetic resonance imaging

Persistent genital arousal disorder (PGAD) is a rare disease causing high emotional distress eminently impacting the individual's quality of life. Experts in this field assume that the disease is caused by a multifaceted interplay of different etiologies which may share a common neurobiological basis. However, only one functional neuroimaging investigation exist, and a more in-depth comprehension of the neurobiological foundation is required. Therefore, this study aims to provide new insights into how the functional integration of brain regions may relate to PGAD. By using the functional magnetic resonance imaging (fMRI) technique, functional connectivity at rest (rs-FC) was compared between patients suffering PGAD (n = 26) and healthy controls (n = 26). Patients with PGAD showed different pattern in connectivity within brain structures putatively associated with the psychological and somatic dimensions of the disease including the right amygdala, left anterior cingulate cortex, right insula cortex, thalamic nuclei and prefrontal regions as seeds. The majority of these showed differences in brain connectivity pattern to the precuneus and prefrontal regions. The study offers preliminary insights into the characteristics and relevant neural mechanisms of PGAD. Nevertheless, since this study did not identify any peripheral correlates that would corroborate the interpretation of these findings, they were interpreted from a more theoretical perspective, thereby offering potential areas of focus for future research.

Application of International Society for the Study of Women's Sexual Health consensus algorithm for persistent genital arousal disorder/genito-pelvic dysesthesia to 10 cases and use of epidural spinal injections as long term management

Introduction

Persistent genital arousal disorder/genito-pelvic dysesthesia (PGAD/GPD) is a debilitating, but poorly understood disorder. To address the lack of knowledge regarding mechanism and treatments, the International Society for the Study of Women's Sexual Health (ISSWSH) consensus statement proposed a region-based approach for management of PGAD/GPD, including possible etiologies. Annular tears of the lumbar intervertebral disc are a recently acknowledged etiology of PGAD/GPD, and current evidence suggests that management of symptomatic tears resistant to non-invasive treatment may require lumbar endoscopic spinal surgery.

Aim

This case series offers 10 cases of PGAD/GPD symptoms, in order to describe resource efficient management, including use of epidural spinal injections to reduce barriers to care for this debilitating condition.

Methods

Individuals were identified by investigators in clinical practice. Electronic medical record notes and relevant imaging from the past 3 years were reviewed.

Results

Half of the patients tried three or more treatments before finding any symptomatic relief. Two patients, with annular tears evident on magnetic resonance imaging (MRI), found complete relief with epidural spinal injections. A patient with hypertonic pelvic floor found total relief with pelvic floor physical therapy. Two patients found alleviation of symptoms with discontinuation of triggering medications, and four patients had palliation of symptoms with gabapentin and/or pregabalin.

Conclusion

These cases demonstrate the utility of the ISSWSH consensus algorithm in guiding initial diagnosis and treatment of PGAD/GPD. However, flexibility is important in management to choose the appropriate treatment pathway to provide the most effective symptom management. Current evidence suggests the use of epidural spinal injections for temporary symptom relief, however, this case series suggests its use for long term management.

Persistent Genital Arousal Disorder/Genito-Pelvic Dysesthesia (PGAD/GPD): From Diagnostic Approach to Treatment - A Narrative Review

Persistent Genital Arousal Disorder/Genito-Pelvic Dysesthesia (PGAD/GPD) is characterized by persistent or recurrent unwanted genital arousal, causing significant distress to the affected individual. Classified as a sexual dysfunction, PGAD/GPD is predominantly described in women and severely affect their quality of life with psychological repercussions. Despite its morbidity, PGAD/GPD remains unfamiliar to healthcare professionals. This article provides a narrative review of the disorder, addressing current literature on its pathophysiology, diagnosis, and treatment approaches from a biopsychosocial perspective. The aim is to increase awareness among healthcare providers, enabling appropriate management strategies for PGAD/GPD and improving patient overall well-being.

Examining the Psychometric Properties of the HBI-19 Scale in a Sample of Women with Persistent Genital Arousal Symptoms

Persistent Genital Arousal Disorder/Genito-Pelvic Dysesthesia (PGAD/GPD) is a highly distressing, yet poorly understood health concern characterized by persistent, unwanted, and unpleasant genital arousal sensations in the absence of psychological arousal and desire. PGAD/GPD symptoms can be reduced by engaging in frequent sexual behaviors, meaning that hypersexual behavior may be present as a feature of PGAD/GPD in some cases. Given this association and the current lack of measures designed for assessment of PGAD/GPD specifically, the present study aimed to investigate the psychometric properties of the Hypersexual Behavior Inventory (HBI-19) in a sample of women with PGAD/GPD symptoms. Specifically, the factor structure of the HBI-19 was explored via Exploratory Factor Analysis (EFA) as well as evaluation of model fit indices and reliability indices (Cronbach's alpha). EFA revealed a two-factor structure for the HBI-19 in the sample of women with PGAD/GPD symptoms, differing from the originally validated three-factor structure. RMSEA as well as TLI values suggested poor fit for all three models examined, including the two-factor model, while SRMR suggested good fit for the two-factor and three-factor model and suggested poor fit for the one-factor models. These findings suggest measurement non-invariance at the configural level and indicate that hypersexual behavior is best understood as a possible feature of PGAD/GPD as opposed to a core element of PGAD/GPD.

Interpersonal Experiences with Persistent Genital Arousal: Connections between Symptom Disclosure, Partner Responses, and Catastrophizing on Relationship Adjustment and Symptom Severity

Increased research attention to interpersonal factors in genitopelvic pain conditions, such as vulvodynia, have led to more comprehensive understanding of couple dynamics in pain, sexual, and relationship outcomes. There has been very little examination of interpersonal factors in Persistent Genital Arousal Disorder/Genitopelvic Dysesthesia (PGAD/GPD), a distressing condition involving persistent sensations of arousal and often pain. The aims of the present study were to examine whether individuals disclose their symptoms to intimate partners and whether interpersonal variables (e.g., partner responses, symptom disclosure, and catastrophizing) are related to relationship adjustment and symptom severity. Seventy-six individuals with symptoms of PGAD/GPD participated in a one-time anonymous online survey. Over three-quarters (85.5%) of the sample disclosed their symptoms to their partners in some way. Greater supportive partner responses and lower symptom catastrophizing were related to better relationship adjustment among participants with PGAD/GPD symptoms. Greater symptom catastrophizing also predicted greater PGAD/GPD symptom severity. Partner responses were not related to PGAD/GPD symptom severity. Although interpersonal factors have been linked to symptom severity in chronic pain and genitopelvic pain conditions, the results of the current study suggest that interpersonal factors may play a slightly different role in PGAD/GPD symptom experiences and in the conceptualization of PGAD/GPD more broadly.

Lumbar endoscopic spine surgery for persistent genital arousal disorder/genitopelvic dysesthesia resulting from lumbosacral annular tear-induced sacral radiculopathy

BACKGROUND

Persistent genital arousal disorder/genitopelvic dysesthesia (PGAD/GPD) is characterized by distressing, abnormal genitopelvic sensations, especially unwanted arousal. In a subgroup of patients with PGAD/GPD, cauda equina Tarlov cyst-induced sacral radiculopathy has been reported to trigger the disorder. In our evaluation of lumbosacral magnetic resonance images in patients with PGAD/GPD and suspected sacral radiculopathy, some had no Tarlov cysts but showed lumbosacral disc annular tear pathology.

AIM

The aims were 2-fold: (1) to utilize a novel multidisciplinary step-care management algorithm designed to identify a subgroup of patients with PGAD/GPD and lumbosacral annular tear-induced sacral radiculopathy who could benefit from lumbar endoscopic spine surgery (LESS) and (2) to evaluate long-term safety and efficacy of LESS.

METHODS

Clinical data were collected on patients with PGAD/GPD who underwent LESS between 2016 and 2020 with at least 1-year follow-up. LESS was indicated because all had lumbosacral annular tear-induced sacral radiculopathy confirmed by our multidisciplinary management algorithm that included the following: step A, a detailed psychosocial and medical history; step B, noninvasive assessments for sacral radiculopathy; step C, targeted diagnostic transforaminal epidural spinal injections resulting in a temporary, clinically significant reduction of PGAD/GPD symptoms; and step D, surgical intervention with LESS and postoperative follow-up.

OUTCOMES

Treatment outcome was based on the validated Patient Global Impression of Improvement, measured at postoperative intervals.

RESULTS

Our cohort included 15 cisgendered women and 5 cisgendered men (mean ± SD age, 40.3 ± 16.8 years) with PGAD/GPD who fulfilled the criteria of lumbosacral annular tear-induced sacral radiculopathy based on our multidisciplinary management algorithm. Patients were followed for an average of 20 months (range, 12-37) post-LESS. Lumbosacral annular tear pathology was identified at multiple levels, the most common being L4-L5 and L5-S1. Twenty-two LESS procedures were performed in 20 patients. Overall, 80% (16/20) reported improvement on the Patient Global Impression of Improvement; 65% (13/20) reported improvement as much better or very much better. All patients were discharged the same day. There were no surgical complications.

CLINICAL IMPLICATIONS

Among the many recognized triggers for PGAD/GPD, this subgroup exhibited lumbosacral annular tear-induced sacral radiculopathy and experienced long-term alleviation of symptoms by LESS.

STRENGTHS AND LIMITATIONS

Strengths include long-term post-surgical follow-up and demonstration that LESS effectively treats patients with PGAD/GPD who have lumbosacral annular tear-induced sacral radiculopathy, as established by a multidisciplinary step-care management algorithm. Limitations include the small study cohort and the unavailability of a clinical measure specific for PGAD/GPD.

CONCLUSION

LESS is safe and effective in treating patients with PGAD/GPD who are diagnosed with lumbosacral annular tear-induced sacral radiculopathy.

International Society for the Study of Women's Sexual Health (ISSWSH) Review of Epidemiology and Pathophysiology, and a Consensus Nomenclature and Process of Care for the Management of Persistent Genital Arousal Disorder/Genito-Pelvic Dysesthesia (PGAD/GPD)

BACKGROUND

Persistent genital arousal disorder (PGAD), a condition of unwanted, unremitting sensations of genital arousal, is associated with a significant, negative psychosocial impact that may include emotional lability, catastrophization, and suicidal ideation. Despite being first reported in 2001, PGAD remains poorly understood.

AIM

To characterize this complex condition more accurately, review the epidemiology and pathophysiology, and provide new nomenclature and guidance for evidence-based management.

METHODS

A panel of experts reviewed pertinent literature, discussed research and clinical experience, and used a modified Delphi method to reach consensus concerning nomenclature, etiology, and associated factors. Levels of evidence and grades of recommendation were assigned for diagnosis and treatment.

OUTCOMES

The nomenclature of PGAD was broadened to include genito-pelvic dysesthesia (GPD), and a new biopsychosocial diagnostic and treatment algorithm for PGAD/GPD was developed.

RESULTS

The panel recognized that the term PGAD does not fully characterize the constellation of GPD symptoms experienced by patients. Therefore, the more inclusive term PGAD/GPD was adopted, which maintains the primacy of the distressing arousal symptoms and acknowledges associated bothersome GPD. While there are diverse biopsychosocial contributors, there is a common underlying neurologic basis attributable to spontaneous intense activity of the genito-pelvic region represented in the somatosensory cortex and its projections. A process of care diagnostic and treatment strategy was developed to guide the clinician, whenever possible, by localizing the symptoms as originating in any of five regions: (i) end organ, (ii) pelvis/perineum, (iii) cauda equina, (iv) spinal cord, and (v) brain. Psychological treatment strategies were considered critical and should be performed in conjunction with medical strategies. Pharmaceutical interventions may be used based on their site and mechanism of action to reduce patients' symptoms and the associated bother and distress.

CLINICAL IMPLICATIONS

The process of care for PGAD/GPD uses a personalized, biopsychosocial approach for diagnosis and treatment.

STRENGTHS AND LIMITATIONS

Strengths and Limitations: Strengths include characterization of the condition by consensus, analysis, and recommendation of a new nomenclature and a rational basis for diagnosis and treatment. Future investigations into etiology and treatment outcomes are recommended. The main limitations are the dearth of knowledge concerning this condition and that the current literature consists primarily of case reports and expert opinion.

CONCLUSION

We provide, for the first time, an expert consensus review of the epidemiology and pathophysiology and the development of a new nomenclature and rational algorithm for management of this extremely distressing sexual health condition that may be more prevalent than previously recognized. Goldstein I, Komisaruk BR, Pukall CF, et al. International Society for the Study of Women's Sexual Health (ISSWSH) Review of Epidemiology and Pathophysiology, and a Consensus Nomenclature and Process of Care for the Management of Persistent Genital Arousal Disorder/Genito-Pelvic Dysesthesia (PGAD/GPD). J Sex Med 2021;18:665-697.