Persistent Genital Arousal Disorder in Women (PGAD)

Content written by Irwin Goldstein MD

OVERVIEW:

Persistent genital arousal disorder (PGAD) 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.

Persistent genital arousal disorder (PGAD) 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 are oftenashamed for having inappropriate genital feelings. Women with PGAD are often having suicidal thoughts.

Persistent genital arousal disorder may be classified into primary, lifelong if the PGAD is present throughout the person’s life or into secondary, acquired if the PGAD 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 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 are beginning to be understood. PGAD may be associated with psychological-related pathophysiologies. Women with PGAD have described that stress worsens PGAD symptoms, whereas distraction and relaxation strategies lessens PGAD symptoms.

PGAD 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 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 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 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 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.

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. 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 secondary to arterial-venous malformation may be cured by selective embolization. Women with PGAD secondary to pelvic venous incompetence might benefit from embolization of the incompetent ovarian vein. Some severely depressed women with PGAD may benefit using repeated electroconvulsive therapy. Surgical release of pudendal nerve entrapment has resulted in PGAD 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 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, minially invasive spine surgery may cure PGAD 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 from radiculopathy of the sacral spinal nerve roots.

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