A new medical treatment with botulinum toxin in persistent genital arousal disorder: successful treatment of two cases

A clinical guide to rare male sexual disorders

Conditions referred to as 'male sexual dysfunctions' usually include erectile dysfunction, ejaculatory disorders and male hypogonadism. However, some less common male sexual disorders exist, which are under-recognized and under-treated, leading to considerable morbidity, with adverse effects on individuals' sexual health and relationships. Such conditions include post-finasteride syndrome, restless genital syndrome, post-orgasmic illness syndrome, post-selective serotonin reuptake inhibitor (SSRI) sexual dysfunction, hard-flaccid syndrome, sleep-related painful erections and post-retinoid sexual dysfunction. Information about these disorders usually originates from case-control trials or small case series; thus, the published literature is scarce. As the aetiology of these diseases has not been fully elucidated, the optimal investigational work-up and therapy are not well defined, and the available options cannot, therefore, adequately address patients' sexual problems and implement appropriate treatment. Thus, larger-scale studies - including prospective trials and comprehensive case registries - are crucial to better understand the aetiology, prevalence and clinical characteristics of these conditions. Furthermore, collaborative efforts among researchers, health-care professionals and patient advocacy groups will be essential in order to develop evidence-based guidelines and novel therapeutic approaches that can effectively address these disorders. By advancing our understanding and refining treatment strategies, we can strive towards improving the quality of life and fostering healthier sexual relationships for individuals suffering from these rare sexual 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.

Application of Botulinum Neurotoxin in Female Sexual and Genitourinary Dysfunction: A Review of Current Practices

INTRODUCTION

The past 2 decades have witnessed an increased amount of research into botulinum neurotoxin (BoNT) as a treatment for various forms of sexual dysfunction and pain syndromes refractory to other medical therapy. BoNT is postulated to reduce pain sensation by inhibiting neuropeptide release in the presynaptic neuron. Dyspareunia, vaginismus, vestibulodynia, and persistent genital arousal disorder are female sexual dysfunctions with cryptic pathophysiology and limited treatment options. BoNT has emerged as a potential treatment for many of these afflictions in women.

OBJECTIVES

To review the literature regarding BoNT as a treatment for female sexual and genitourinary dysfunction.

METHODS

A PubMed search for English-language articles was performed using the following terms: "Botox," "botulinum toxin," "botulinum toxin A," "Onabotulinum A," "Abobutlinum A," "BoNT," and "BoNT-A." The main outcomes measured by each study were resolution of dysfunction. This entailed reduction of pain with intercourse for dyspareunia, reduction of pain for vestibulodynia, decreased arousal for persistent genital arousal disorder, and ability to tolerate penetration for vaginismus.

RESULTS

A total of 12 human studies that evaluated BoNT as a treatment for female sexual disorders were included. Study types included prospective, retrospective, cohort, pilot, and open-label.

CONCLUSION

There is growing evidence suggesting that BoNT is a safe and efficacious treatment option for female patients suffering from various sexual and genitourinary disorders. However, more research is needed to develop a better understanding of the mechanisms through which BoNT treats these disorders. Dick B, Natale C, Reddy A, et al. Application of Botulinum Neurotoxin in Female Sexual and Genitourinary Dysfunction: A Review of Current Practices. Sex Med 2021;9:57-63.

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.

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.