Case Report: Persistent Genital Arousal Disorder in an Adolescent Woman

Selective serotonin reuptake inhibitors, post-treatment sexual dysfunction and persistent genital arousal disorder: A systematic review

PURPOSE

Adverse effects of selective serotonin reuptake inhibitors (SSRIs) on sexual function have been an important area of research for many years. However, the duration of SSRI-associated sexual adverse effects, and their possible persistence after treatment discontinuation, is still uncertain. The aims of the current systematic review were first to identify existing evidence of sexual dysfunction following SSRI discontinuation, and to provide an account of reported symptoms and proposed treatment options; and second, to establish whether current literature allows accurate estimates of the prevalence of such sexual dysfunction.

METHODS

A systematic review was conducted on PubMed, Embase, and Google Scholar; papers with clinical data regarding patients with persistent sexual dysfunction after SSRI treatment suspension were included.

RESULTS

Overall, two retrospective interventional studies, six observational studies and 11 case reports were judged eligible for inclusion. It was not possible to determine reliable estimates of prevalence. Similarly, a cause-effect relationship between SSRI exposure and persistent sexual impairment could not be ascertained. Nonetheless, the potential for continued sexual disturbances despite discontinuation could not be entirely ruled out.

CONCLUSIONS

There is a need to investigate a possible dose-response relationship between SSRI exposure and persistent sexual adverse effects. Treatment options for persistent dysfunctions remain limited, but novel therapeutic approaches may be required in order to address an otherwise neglected need for sexual well-being.

Psychological Treatment of Persistent Genital Arousal Disorder/Genitopelvic Dysesthesia Using an Integrative Approach

Persistent genital arousal disorder/genitopelvic dysesthesia (PGAD/GPD) is characterized by persistent, unwanted physiological genital arousal (i.e., sensitivity, fullness, and/or swelling) in the absence of sexual excitement or desire which can persist for hours to days and causes significant impairment in psychosocial well-being (e.g., distress) and daily functioning. The etiology and course of PGAD/GPD is still relatively unknown and, unsurprisingly, there are not yet clear evidence-based treatment recommendations for those suffering from PGAD/GPD. We present the case of a 58-year-old woman with acquired persistent genital arousal disorder, which began in March 2020; she believed she developed PGAD/GPD due to a period of significant distress and anxiety related to the COVID-19 pandemic. After seeking medical diagnosis and treatment from multiple healthcare providers and trying a combination of pharmacological and medical treatment modalities, she presented for psychological treatment. An integrative therapy approach (3 assessment sessions, 11 treatment sessions), which included cognitive behavior therapy, distress tolerance and emotion regulation skills from dialectical behavior therapy, and mindfulness practice, was utilized. The patient reported improvements anecdotally (e.g., decreased impact on occupational and social functioning, greater self-compassion, less frequent and shorter duration of PGAD/GPD flare-ups, improved ability to cope with PGAD/GPD symptoms, and decreased need for sleeping medication) and on self-report measures (e.g., lower PGAD/GPD catastrophizing, lower anxiety and depression, and greater overall quality of life).We report the use of an integrative (i.e., psychoeducational, cognitive behavioral, dialectical behavioral, and mindfulness-based) intervention, which may be an effective psychological treatment for PGAD/GPD.

Exploring the link between eating disorders and persistent genital arousal disorder/genito-pelvic dysesthesia: first description and a systematic review of the literature

BACKGROUND

Persistent Genital Arousal Disorder/Genito-Pelvic Dysesthesia (PGAD/GPD) characterized by recurrent physiological genital without corresponding psychological arousal is a poorly understood and researched condition. Based on the first two case descriptions of eating disorders directly linked to PGAD/GPD the aim of this paper was to systematically review the literature on possible associations between eating disorders and PGAD/GPD.

METHOD

A systematic literature search on eating disorders and PGAD/GPD was conducted in PubMed, PsycINFO, and Scopus, complemented by Google Scholar. We included case reports, case series, cross-sectional studies and review articles published in peer-reviewed journals written in English or German-language.

RESULTS

The included original papers described a total of 2078 cases with PGAD/GPD symptomatology. Of these, 892 participants fulfilled all five PGAD/GPD core criteria. The aetiology of PGAD/GPD is unknown. Multifactorial genesis of PGAD/GPD is presumed including neurological, pharmacological, hormonal, vascular and psychological causes. A high degree of psychological comorbidity is reported. No study was found that drew a direct link between eating disorders and PGAD/GPD. Although PGAD/GPD symptoms also occur in adolescents, there are no findings in this regard. However, we found a gap in data collection: eating disorders as potential psychiatric comorbidities were systematically recorded in only a few studies.

CONCLUSION

The existing literature have not yet considered a possible link between eating disorders and PGAD/GPD so far. According to the authors' knowledge, this work is the first review to systematically explore the associations. We suspect underreporting of PGAD/GPD cases in eating disorders and particularly during adolescence. We argue that there are several common factors that appear to be important in the etiology, course, and treatment of both disorders (e.g. hormonal dysregulation or sensory sensitivity and avoidance), warranting future research on the possible comorbidity of these disorders.

Treatments for Persistent Genital Arousal Disorder in Women: A Scoping Review

BACKGROUND

Persistent genital arousal disorder (PGAD) is characterized by elevated discomfort associated with persistent genital arousal in the absence of sexual desire.

AIM

To perform a scoping review of the proposed treatments for PGAD and their efficacy.

METHODS

A scoping review was carried out (PRISMA-Scr) that included articles on PGAD as the main disorder, only in women, which explained, in detail, the treatment and its efficacy, was empirical, was written in English and Spanish. No prior filtering by years was performed.

OUTCOMES

Three different effective treatments were found (Physical therapies, pharmacological therapies, and psychotherapeutics in combination with other therapies).

RESULTS

Thirty-eight articles were selected. From physical therapies, treatments using neuromodulation, transcutaneous electrical stimulation, Botox, surgery, electroconvulsive therapy, manual therapy, pelvic floor therapy, dietary changes, and transcranial magnetic stimulation showed effectiveness. Using the pharmacological approach, paroxetine, duloxetine, pramipexole, ropinirole, and clonazepam treatments were effective. Psychotherapy treatments showed effectiveness only in combination with other types of treatments, specifically a combination of cognitive-behavioral strategies with pharmacological treatment.

CLINICAL IMPLICATIONS

Pharmacological treatment, specifically SSRIs, have proven to be the therapy of choice for different subtypes of patients.

STRENGTHS AND LIMITATIONS

This study analyzed treatment effectiveness with different approaches and took into consideration those articles where psychotherapy was used as a combination treatment with pharmacological and physical therapy. The main limitation is that it was focused exclusively on women, and the results cannot be generalized to include men.

CONCLUSIONS

To date, a combination of pharmacological interventions with physical therapy and, in some occasions, with psychological therapy is main strategy followed to accomplish effective treatment of PGAD. Martín-Vivar M, Villena-Moya A, Mestre-Bach G, et al. Treatments for Persistent Genital Arousal Disorder in Women: A Scoping Review. J Sex Med 2022;19:961-974.

Persistent Genital Arousal Disorder (PGAD): A Clinical Review and Case Series in Support of Multidisciplinary Management

INTRODUCTION

Persistent genital arousal disorder (PGAD) is an uncommon condition resulting in intrusive, unwanted and distressing symptoms of genital arousal. Presentation can vary and most cases do not have an immediately identifiable etiology.

OBJECTIVES

To present evaluation and treatment recommendations for PGAD from a multidisciplinary perspective and provide case examples.

METHODS

A focused review of the literature on diagnosis, workup, and treatment of PGAD was completed. A case series of 3 varying presentations of PGAD is offered.

RESULTS

PGAD results in high levels of patient distress and is best managed with a multidisciplinary treatment approach. Identification and management of co-occurring symptoms or disease states is imperative, particularly psychologic and psychiatric comorbidities. With appropriate intervention, patients may achieve improvement of their physical symptoms and a decrease in associated psychological distress.

CONCLUSION

PGAD is an uncommon and highly distressing condition that requires thoughtful evaluation for appropriate diagnosis and treatment. Multidisciplinary treatment approaches provide the best opportunity to address the needs of patients and optimizing treatment response. Pease ER, Ziegelmann M, Vencill JA, et al. Persistent Genital Arousal Disorder (PGAD): A Clinical Review and Case Series in Support of Multidisciplinary Management. Sex Med Rev 2021;XX:XXX-XXX.

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 After Motor Vehicle Accident: A Case Report

Persistent genital arousal disorder (PGAD) is a clinical syndrome characterized by persistent unwanted feelings of sexual arousal that are not associated with any specific sexual arousal or stimulus. The severity of symptoms range from mild to severe distress that interrupts daily life for patients. We present a 44-year-old previously healthy woman who developed PGAD after involvement in a motor vehicle accident in 2018. After sustaining lower spinal trauma, 3 months later, she began to experience intermittent tingling feelings in her clitoris. She noticed that exacerbations in back pain were also associated with PGAD symptoms. These symptoms progressively worsened to which she was constantly feeling as if she was on the verge of an orgasm. Her quality of life was severely diminished for 3 months, after which she presented to gynecology. Treatment of lidocaine patches applied to the sacrum were found to completely eliminate the feelings of clitoral stimulation. She also began physical therapy for the residual back pain. One year after initiation of treatment, she has experienced significant improvement in both the back pain and PGAD symptoms. Her quality of life is much improved and plans on continuing a treatment plan of lidocaine patches and physical therapy. Recognition of PGAD in women is important for clinicians as that it can go undiagnosed for long periods of time and can interfere with quality of life for patients.

The Pharmacotherapy of Persistent Genital Arousal Disorder

Purpose of Review

Persistent genital arousal disorder (PGAD) is a rare, yet debilitating, disease, which was first described at the beginning of this century and has not yet been considered by the ICD-10 or DSM-5. Since affected subjects usually suffer tremendously, this review aims at offering an overview of pharmacological approaches to treat this disorder.

Recent Findings

Until now, no randomised placebo-controlled clinical trials have been conducted on PGAD, and the international registries have not recorded any ongoing trials. Current knowledge on pharmacological options for the treatment of PGAD relies mainly on case reports/case series. Most importantly, there is evidence that some drugs such as SSRIs and SNRIs might induce or worsen PGAD.

Summary

Knowledge on pharmacological treatment options for PGAD is not yet evidence-based, while some reports even assume an induction of PGAD by serotonergic antidepressants. Nevertheless, practitioners should be aware of PGAD and carefully discuss with the patient an individual treatment trial by considering the experience up to now.