Persistent genital arousal and restless genitalia: sexual dysfunction or subtype of vulvodynia?

Predictors of Psychosocial and Functional Outcomes in Persistent Genital Arousal Disorder/Genito-Pelvic Dysesthesia: Application of the Fear-Avoidance Model

Persistent Genital Arousal Disorder/Genito-Pelvic Dysesthesia (PGAD/GPD), which affects up to 4.3% of individuals, is a distressing and poorly understood condition characterized by persistent, unwanted, and often painful sensations of genito-pelvic arousal (eg, throbbing) in the absence of sexual desire. PGAD/GPD is associated with significant negative impacts on psychosocial well-being and daily functioning. Recent research has indicated that PGAD/GPD shares many similarities with other forms of chronic genito-pelvic pain. This study applied the fear-avoidance model of chronic pain to PGAD/GPD to identify cognitive and behavioral factors associated with psychosocial and functional outcomes. A total of 263 individuals with PGAD/GPD symptoms completed a cross-sectional online survey of symptom intensity, cognitive and behavioral predictors (symptom catastrophizing, hypervigilance to symptoms, symptom fear and avoidance, self-efficacy), depression symptoms, and role functioning. Symptom catastrophizing, fear of symptoms, avoidance of symptoms, and hypervigilance to PGAD/GPD symptoms were significantly correlated with poorer psychosocial and functional outcomes, whereas higher self-efficacy was significantly associated with lower depression and better role functioning. Two serial parallel mediation models examined the fear-avoidance pathway from PGAD/GPD symptom intensity to depression symptoms and role functioning. In both models, the pathway through symptom catastrophizing, fear of symptoms, and symptom avoidance was significant, but the pathway through symptom catastrophizing, fear of symptoms, and symptom hypervigilance was not. The results of this study provide support for the applicability of the fear-avoidance model to PGAD/GPD. Interventions targeting fear-avoidance factors may help to reduce PGAD/GPD symptom intensity, distress, and increase psychological well-being and daily functioning. PERSPECTIVE: This article provides support for the applicability of the fear-avoidance model of chronic pain to Persistent Genital Arousal Disorder/Genito-Pelvic Dysesthesia (PGAD/GPD). These results suggest that interventions targeting fear-avoidance cognitions and behaviors (catastrophizing, fear, avoidance, hypervigilance) may help to reduce PGAD/GPD symptom intensity and improve psychological well-being and daily functioning.

Current state of the red scrotum syndrome

Red scrotum syndrome is a chronic, difficult-to-recognize dermatosis affecting middle-aged and elderly people. It is manifested by erythema of the scrotum with clear boundaries, without neck. The etiology and pathogenesis of the disease have not been established. Hypotheses about the causes of dermatosis as a consequence of uncontrolled use of topical steroids, neurological inflammation, formation of microbial biofilm are based on anamnestic data and the results of trial treatments. Etiologically and pathogenetically justified therapy has not been proposed. Therapy with the use of doxycycline, gabapentin, pregabalin, indomethacin, tacrolimus was carried out in small groups of patients. The lack of clarity in the etiology and understanding of the mechanism of development of the disease explains the lack of a unified focus of the proposed therapies based on isolated clinical cases. In general, the problem of diagnosis and treatment rests on the absence of major clinical, epidemiological and laboratory studies that allowed to establish the pathophysiology and assess the true prevalence of red scrotum syndrome.

Sexual dysfunction due to pudendal neuralgia: a systematic review

Background

The pudendal nerve is considered as the main nerve of sexuality. Pudendal neuralgia is an underdiagnosed disease in clinical practice. The aim of this systematic review is to highlight the role of pudendal neuralgia on sexual dysfunction in both sexes.

Methods

A PubMed search was performed using the following keywords: “Pudendal” AND “Sexual dysfunction” or “Erectile dysfunction” or “Ejaculation” or “Persistent sexual arousal” or “Dyspareunia” or “Vulvodynia”. The search involved patients having sexual dysfunction due to pudendal neuralgia. Treatment received was also reported.

Results

Five case series, seven cohort studies, two pilot studies, and three randomized clinical trials were included in this systematic review. Pudendal nerve and/or artery entrapment, or pudendal neuralgia, is a reversible cause of multiple sexual dysfunctions. Interventions such as anesthetic injections, neurolysis, and decompression are reported as potential treatment modalities. There are no studies describing the role of pudendal canal syndrome in the pathophysiology or treatment of delayed ejaculation or penile shortening.

Discussion

Pudendal neuralgia is an underestimated yet important cause of persistent genital arousal, erectile dysfunction (ED), premature ejaculation (PE), ejaculation pain, and vulvodynia. Physicians should be aware of this entity and examine the pudendal canal in such patients before concluding an idiopathic cause of sexual dysfunction.

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

Introduction

Persistent genital arousal disorder/genito-pelvic dysesthesia (PGAD/GPD) is a distressing condition characterized by persistent, unwanted sensations of genital arousal (eg, feelings of being on the verge of orgasm, and of lubrication, swelling, tingling, throbbing) that occur in the absence of sexual desire. Although PGAD/GPD is associated with significant impairments in psychosocial functioning, the healthcare (HC) experiences of affected individuals are not well understood.

Aim

The aims of this study were to examine the barriers to HC, the costs of HC, and the associations among HC experiences, symptoms, and psychosocial outcomes in those with PGAD/GPD symptoms.

Methods

One hundred and thirteen individuals with PGAD/GPD symptoms completed an online, cross-sectional self-report questionnaire about their HC history and experiences.

Main Outcome Measures

Self-reported HC barriers, and financial costs associated with PGAD/GPD HC. Validated measures of HC experiences (eg, comfort communicating with HC practitioners [HCPs]), and psychosocial (eg, depression, anxiety) and PGAD/GPD symptom outcomes.

Results

The majority of participants (56.6%) reported waiting at least 6 months to seek HC for PGAD/GPD symptoms. Those who sought HC approached many HCPs (46.0% approached 6+ HCPs). Several barriers to HC were identified (eg, lack of HCP knowledge of PGAD/GPD), and high costs were reported. A series of multiple linear regression analyses found an association between HC experiences, psychosocial, and symptom outcomes. Specifically, decreased comfort communicating with one's HCP was associated with greater depressive and anxiety symptoms.

Conclusion

High costs and numerous barriers to seeking HC for PGAD/GPD symptoms were identified, and discomfort communicating with an HCP about PGAD/GPD was associated with increased symptoms of depression and anxiety. These results highlight the need for more awareness of this condition in order to improve care for this population. Jackowich RA, Boyer SC, Bienias S, et al. Healthcare Experiences of Individuals With Persistent Genital Arousal Disorder/Genito-Pelvic Dysesthesia. J Sex Med 2021;9:100335.

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.

Persistent Genital Arousal Disorder: a Biopsychosocial Framework

Purpose of Review

Persistent genital arousal disorder (also referred to as genitopelvic dysesthesia or PGAD/GD) is a distressing and largely underrecognized condition characterized by persistent, unwanted genital arousal (sensations, sensitivity, vasocongestion) in the absence of subjective/cognitive arousal and sexual desire. The purpose of this review is to summarize recent findings on biological and psychosocial factors in PGAD/GD as they pertain to the assessment and treatment of this condition. These findings will be considered within a biopsychosocial framework, for the purposes of considering next steps for clinical and research efforts.

Recent Findings

A small number of studies have recently examined potential biological aetiologies for PGAD/GD: pharmacological agents, spinal pathology and peripheral nerve involvement. Recent studies have also found that PGAD/GD is associated with a significant negative impact on psychosocial wellbeing and daily functioning as compared to symptom-free individuals. In addition, these results highlight cognitive/affective responses to symptoms (e.g. catastrophizing of symptoms) that may influence outcomes. However, biological and psychological research are rarely integrated in these studies, despite the interrelationship between these factors.

Summary

Although PGAD/GD was first described in the scientific literature almost two decades ago, most research on PGAD/GD is presented in the form of case studies. Prospective treatment trials that integrate biopsychosocial factors are needed in order to provide effective and efficient care to this population. This research would be facilitated by the development of a patient-reported outcome measure, as well as greater education/awareness among healthcare providers and the public about this distressing condition.

Is it Really Rare? Restless Genital Syndrome

Restless genital syndrome (RGS) is a new definition in which awareness has begun to emerge in recent years. RGS is described as complex sensations of discomfort in the genital area, as itching, contraction, pain, and swelling in the absence of sexual stimulation. This condition, which may be quite uncomfortable for the patient, is hidden due to shame and not brought to the attention of physicians. Other problems that patients may encounter are that many physicians are inexperienced regarding such symptoms, that the family physician or the first physician does not know to which specialty they should refer patients with these symptoms, and that there is no clear consensus on treatment. Numerous etiologies, pharmacologic and non-pharmacologic treatment options have been discussed in the literature. We discussed two female patients who were diagnosed as having RGS and benefited from treatment.

Persistent Genital Arousal Disorder: Review of Pertinent Peripheral Nerves

INTRODUCTION

Persistent genital arousal disorder (PGAD) is a condition that is still poorly understood. Etiologies reported for PGAD are vascular, neurological, pharmacological, and psychological. Determining the neurophysiological etiology of PGAD began with developing an understanding of the underlying biomechanics of the pudendal nerve and the female sexual response.

AIM

To summarize the anatomy, physiology, etiologies, diagnostics, and treatments of the pertinent peripheral nerves involved in the pathology of PGAD.

METHODS

We performed a PubMed, Cochrane, Embase, Web of Science, and Google Scholar search for English-language articles in peer-reviewed journals with no predefined time period for inclusion. Terms included "humans"[All Fields] AND "persistent"[All Fields] AND/OR ("genitalia"[All Fields] OR "genital"[All Fields]) AND/OR "arousal"[All Fields] AND/OR ("disease"[All Fields] OR "disorder"[All Fields]) AND/OR "nerve"[All Fields]. The main outcomes of the papers were reviewed.

MAIN OUTCOME MEASURE

The main outcome measures were the anatomy and physiology, etiologies, history and physical examination, diagnostic imaging, and current evidence for the treatment of PGAD related to the peripheral nervous system.

RESULTS

Most of the literature for PGAD originates from case studies. The diagnosis of PGAD itself is still a debated topic of discussion. More recent data published indicate that this disease affects males, as well.

CONCLUSION

Nerve entrapment may be a source of continuous arousal. Associated PGAD symptoms would depend on the segment of the nerve involved. Unwelcomed or unwanted arousal has been observed as the most common detrimental symptom. Pelvic 3-tesla magnetic resonance imaging is recommended in all patients with suspected nerve entrapment. Lumbosacral 3-tesla magnetic resonance imaging is recommended if a Tarlov cyst or a herniated intervertebral disc is suspected. If the peripheral nerve is the source of the pathology, surgical intervention may be curative. A multidisciplinary team approach consisting of a medical provider, pelvic floor physical therapist, and sex therapist has demonstrated benefits. There are currently no Food and Drug Administration-approved evidenced-based treatments for PGAD. Klifto KM, Dellon AL. Persistent Genital Arousal Disorder: Review of Pertinent Peripheral Nerves. Sex Med Rev 2020;8:265-273.

Persistent genital arousal disorder: Treatment by neurolysis of dorsal branch of pudendal nerve

BACKGROUND

Persistent genital arousal disorder (PGAD) is a woman's perception that she is in a state of sexual arousal, without the ability of arousal to be satisfied by orgasm. It is the hypothesis of this study that PGAD results from a minimal degree of nerve compression of the dorsal branch of the pudendal nerve. If this is true, PGAD could be treated by neurolysis of the dorsal branch of the pudendal nerve.

METHODS

A retrospective chart review from 2010 through 2018, of those women having neurolysis of the dorsal branch of the pudendal nerve for PGAD. The main outcome measures were the pre-operative and post-operative changes in clitoral symptoms (arousal, numbness, pain).

RESULTS

Eight women included in this study were followed more than 26 weeks since surgery (mean = 65, range = 26-144 weeks). Seven of these women had the surgery bilaterally, and each of these had an excellent result, meaning elimination of the arousal symptoms, and the ability to resume normal sexual intercourse. The patient with unilateral decompression of the dorsal branch of the pudendal nerve was the only patient who had some, versus complete improvement in arousal symptoms. Of the seven women that had pain, six had complete relief and one had partial relief. No major surgical complications were observed.

CONCLUSION

The relief of arousal symptoms by neurolysis of the dorsal nerve to the clitoris supports the hypothesis that PGAD is due to a minimal degree of compression of the dorsal branch of the pudendal nerve.

Case Report: Persistent Genital Arousal Disorder in an Adolescent Woman

BACKGROUND

After several visits with unrelated complaints, a 16-year-old female patient disclosed symptoms of unwanted genital arousal and was diagnosed with persistent genital arousal disorder (PGAD).

CASE

A 16-year-old female patient with history of depression, sexual abuse, and dysmenorrhea insistently requested etonogestrel rod removal. At 2 visits after implant removal, the patient disclosed the reason for her insistence: PGAD symptoms developed after implant insertion, although they worsened with removal. Chart review revealed selective serotonin reuptake inhibitor discontinuation before symptom onset. Normalization of sexual arousal occurred with counseling, selective serotonin reuptake inhibitor treatment, and hormonal contraception.

SUMMARY AND CONCLUSION

This case highlights the importance of clinician recognition of PGAD symptoms, which adolescents might not openly disclose. Clinicians must nonjudgmentally collect medication history and sexual history, including sexual arousal and satisfaction, to make this diagnosis.

Neuropelveology: An Emerging Discipline for the Management of Chronic Pelvic Pain

Chronic pelvic pain (CPP) is a common condition involving multiple, organ-specific medical specialties, each with its own approach to diagnosis and treatment. Management requires knowledge of the interplay between pelvic organ function and neuro-functional anatomy, and of the neurologic and psychological aspects of CPP, but no current specialty fully encompasses this approach. Neuropelveology is an emerging discipline focusing on pathologies of the pelvic nervous system on a cross-disciplinary basis. It involves a neurological/neurosurgical approach, combining the knowledge required for a proper neurologic diagnosis, confirmation by transvaginal/transrectal examination of the pelvic nerves, and advanced laparoscopic surgery in selected cases of CPP. The management of CPP requires multidisciplinary contributions, and neuropelveology may offer an educational framework for the interdisciplinary exchange of knowledge between clinical physicians and basic researchers.

Not only limbs in atypical restless legs syndrome

Restless legs syndrome (RLS) typically affects the limbs, but the involvement of other body parts has also been reported. In this essay, we critically review all literature reports of atypical RLS cases with unusual localizations. Applying the updated diagnostic criteria of the International restless legs syndrome study group (IRLSSG), which also consider symptoms localized outside of the lower limbs, a few of these atypical cases reported in the previous literature resulted in a definitive diagnosis of RLS. We also discuss the relationship between RLS and burning mouth syndrome (BMS) or restless genital syndrome (RGS). We conclude clinical sleep specialists should be aware of unusual RLS localizations because they respond to the usual treatment for RLS. All the IRLSSG diagnostic criteria should be applied in every suspected case, in order to establish a correct diagnosis of this disabling but treatable condition.