Persistent genital arousal disorder (PGAD) is marked by spontaneous, unwanted genital arousal (fullness, swelling, increased sensitivity) in the absence of subjective sexual desire and fantasies that is not relieved with orgasm.
PGAD is rare and is mainly described in women. It is included in the International Classification of Diseases (ICD-11), but it is not characterized in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, 5th edition, Text Revision (DSM-5-TR) (1, 2).
General references
1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 5th ed, Text Revision. American Psychiatric Association Publishing; 2022
2. 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(4):665-697. doi:10.1016/j.jsxm.2021.01.172
Etiology of Persistent Genital Arousal Disorder
Most cases of PGAD occur without clear etiology. However, multiple factors have been identified as possible contributing factors that include vascular malformations, neurologic conditions (eg, Tarlov cysts), pharmacologic issues (initiation or abrupt discontinuation of SSRIs and SNRIs) and other physiologic and psychological factors (1, 2). PGAD can be associated with other conditions like overactive bladder and restless leg syndrome (3).
Etiology references
1. Pease ER, Ziegelmann M, Vencill JA, Kok SN, Collins CS, Betcher HK. Persistent Genital Arousal Disorder (PGAD): A Clinical Review and Case Series in Support of Multidisciplinary Management. Sex Med Rev. 2022;10(1):53-70. doi:10.1016/j.sxmr.2021.05.001
2. Goldstein I, Elise JB, Johnson JA. Persistent sexual arousal syndrome and clitorial priapism. In: Goldstein I, Meston CM, Davis S, Traish A, eds. Women's Sexual Function and Dysfunction: Study, Diagnosis and Treatment. Routledge, Taylor & Francis Group; 2006:674-685 (Taylor & Francis, 2006).
3. Waldinger MD, Schweitzer DH. Persistent genital arousal disorder in 18 Dutch women: Part II. A syndrome clustered with restless legs and overactive bladder. J Sex Med. 2009;6(2):482-497. doi:10.1111/j.1743-6109.2008.01114.x
Symptoms and Signs of Persistent Genital Arousal Disorder
Symptoms of PGAD include persistent genital arousal, fullness, swelling, and heightened sensitivity for extended period of time that is not relieved with orgasm. Symptoms of arousal are not associated with subjective sexual excitement or desire and are often intrusive, unwanted, and distressing. Arousal may be triggered by sexual stimuli, nonsexual stimuli, or occur spontaneously without any trigger.
Diagnosis of Persistent Genital Arousal Disorder
Medical and sexual history
There are no standardized recommendations for evaluating PGAD. Guidelines recommend a multidisciplinary approach to include a medical provider, pelvic floor physical therapist, and a sex therapist (1).
A thorough evaluation of PGAD should begin with a clinical interview that focuses on sexual history, medical history, history of psychological trauma, mental health issues, and relationship issues. (See table .)
The physical exam should include a thorough assessment of the clitoris, labia, vulvar vestibule, urethra, periurethral glands and vagina paying close attention to pelvic floor musculature (2). PGAD is often associated with areas of hypertonicity, uncontrolled muscular contractions, and overt pain. Urinalysis and culture may be warranted, along with laboratory testing including liver, thyroid, and renal function, and follicle stimulating hormone, prolactin, and estradiol levels. Pelvic ultrasound with Doppler, CT, or MRI, may be helpful if a pelvic or abdominal mass is suspected. Dedicated imaging of the lumbosacral spine to assess nerve pathology due may be considered if PGAD is associated with bladder, bowel, extremity or back pain.
Diagnosis references
1. Pukall CR, Goldmeier D. Persistent genital arousal disorder. In: Hall KSK, Binik YM, eds. Principles and Practice of Sex Therapy. 6th ed. The Guilford Press; 2020:488-503.
2. Pease ER, Ziegelmann M, Vencill JA, Kok SN, Collins CS, Betcher HK. Persistent Genital Arousal Disorder (PGAD): A Clinical Review and Case Series in Support of Multidisciplinary Management. Sex Med Rev. 2022;10(1):53-70. doi:10.1016/j.sxmr.2021.05.001
Treatment of Persistent Genital Arousal Disorder
Treatment of cause, if identified
Medications
Psychiatric therapies
For Tarlov cysts, surgery is an option
Treatment for PGAD is dependent on whether an identifiable underlying cause can be determined. The main goal of treatment is to reduce identifiable factors contributing to symptoms. Treatment options range from medical to behavioral interventions and, rarely, surgical procedures (eg, if Tarlov cysts are identified as likely contributing factors).
Pharmacologic treatment options include topical and systemic analgesics, nerve-stabilizing medications (eg, topiramate) (1), and injection of botulinum toxin (2).
Behavioral health interventions may involve cognitive behavioral therapy, mindfulness, sex therapy, and psychotropic medication. Additional treatments that have shown benefit in some cases have included hypnotherapy (3), transcranial magnetic stimulation (TMS) (4), and electroconvulsive therapy (ECT) (5).
Treatment references
1. Goldstein I, Elise JB, Johnson JA. Persistent sexual arousal syndrome and clitorial priapism. In: Goldstein I, Meston CM, Davis S, Traish A, eds. Women's Sexual Function and Dysfunction: Study, Diagnosis and Treatment. Routledge, Taylor & Francis Group; 2006:674-685 .
2. Nazik H, Api M, Aytan H, Narin R. A new medical treatment with botulinum toxin in persistent genital arousal disorder: successful treatment of two cases. J Sex Marital Ther. 2014;40(3):170-174. doi:10.1080/0092623X.2013.788109
3. Elkins GR, Ramsey D, Yu Y. Hypnotherapy for persistent genital arousal disorder: a case study. Int J Clin Exp Hypn. 2014;62(2):215-223. doi:10.1080/00207144.2014.869136
4. McMullen R, Agarwal S. Persistent Genital Arousal Disorder-Case Report of Symptomatic Relief of Symptoms With Transcranial Magnetic Stimulation. J ECT. 2016;32(3):e9-e10. doi:10.1097/YCT.0000000000000299
5. Korda JB, Pfaus JG, Kellner CH, Goldstein I. Persistent genital arousal disorder (PGAD): case report of long-term symptomatic management with electroconvulsive therapy. J Sex Med. 2009;6(10):2901-2909. doi:10.1111/j.1743-6109.2009.01421.x
Key Points
Persistent genital arousal disorder (PGAD) is characterized by spontaneous, unwanted genital arousal without sexual desire and not relieved by orgasm; it is rare and usually occurs in women.
Causes are often unclear but may include neurologic, vascular, or pharmacologic factors, and it may be associated with conditions such as overactive bladder or restless legs syndrome.
Symptoms include persistent, intrusive genital arousal unrelated to sexual interest, which may be triggered by sexual or nonsexual stimuli or occur spontaneously and is often distressing.
Diagnosis is based on medical, sexual, and psychosocial history.
Treatment focuses on underlying causes and may include medications, behavioral therapies, and, rarely, surgical or neuromodulation interventions.
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