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

Abstract

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.

Persistent Genital Arousal Disorder After Motor Vehicle Accident: A Case Report

“…11 Innervation to the clitoris is provided by the dorsal branch of the pudendal nerve. 12 In a study done by Klifto and Dellon on patients with PGAD, the most common location of nerve entrapment observed in their cohort of 34 patients was distal to the exit of the canal of Alcock, where the dorsal branch of the pudendal nerve exits the inferior pubic ramus canal, located where the inferior pubic ramus joins the pubic symphysis, and not at the exit of the canal of Alcock. 12 In their experience, MRI studies have not been helpful in documenting the site of compression.…”

“…12 In a study done by Klifto and Dellon on patients with PGAD, the most common location of nerve entrapment observed in their cohort of 34 patients was distal to the exit of the canal of Alcock, where the dorsal branch of the pudendal nerve exits the inferior pubic ramus canal, located where the inferior pubic ramus joins the pubic symphysis, and not at the exit of the canal of Alcock. 12 In their experience, MRI studies have not been helpful in documenting the site of compression. 12 In the case of our patient, it is likely that the nerve entrapment is due to the herniated intervertebral disks, but peripheral entrapment cannot be ruled out.…”

“…12 In their experience, MRI studies have not been helpful in documenting the site of compression. 12 In the case of our patient, it is likely that the nerve entrapment is due to the herniated intervertebral disks, but peripheral entrapment cannot be ruled out. The patient's lumbar MRI demonstrated multilevel disk pathology, including disk herniation and impingement on the lateral recesses.…”

The Pharmacotherapy of Persistent Genital Arousal Disorder

“…Various factors have been associated with the occurrence of PGAD, including Tarlov cysts, pelvic congestion and varices, pelvic injuries or injuries of neural structures, nerve compression, tumours, pudendal neuralgia or other rare peripheral neuropathies (e.g. ilioinguinalis/iliohypogastricus syndrome and spermaticus neuralgia) and restless legs syndrome (see [10••] for review and [12]). Per differential diagnoses, the practitioner should screen for genitopelvic pain disorders, bladder disorders, vulvodynia and somatoform disorders.…”

“…With regard to non-pharmacological treatment options, dietary modification and counselling (n = 1, soy-based diet); pelvic floor physiotherapy (n = 1); transcutaneous electrical nerve stimulation (TENS, n = 4, one of them without response); transcranial magnetic stimulation (TMS, n = 2); pudendal or sacral neuromodulation (n = 2); electroconvulsive therapy (ECT, n = 3); surgical procedures, such as removal of periclitoral mass, clitoridectomy or neurolysis of the dorsal branch of the pudendal nerve (n = 8); coil embolisation of a dilated ovarian vein (n = 3) and wearing a V-brace (n = 1) have been reported as successful in the respective cases (for an overview, see [10••], as well as [12][13][14]). From a psychotherapeutic perspective, success with couple therapy and hypnotherapy have been described in one case, respectively [10••].…”