Understanding Persistent Genital Arousal Disorder

Persistent genital arousal disorder (PGAD) is a condition of sexual dysfunction whereby the genitals experience unprovoked arousal, quite outside of the person’s wishes. The term genito-pelvic dysesthesia (GPD) was added in 2021, to encompass the variety of symptoms of this condition more broadly.

The causes of PGAD/GPD are unknown.

Symptoms of PGAD/GPD

Symptoms are mostly experienced in the clitoris but can occur in the mons pubis, vulva, vestibule, vagina, urethra, perineum, bladder and/or rectum, and for diagnosis of PGAD/GPD, must be experienced for three months or longer.

Spontaneous genital arousal (tingling or throbbing)
Not experienced during any sexual desire or subjective sexual arousal (i.e. nothing is sexually exciting at all)
May persist for hours or days
Causes high levels of distress and embarrassment
Feeling of being on the verge or orgasm
Uncontrollable orgasms without sexual interest, thoughts or fantasies
Lubrication
Swelling
Tingling
Throbbing
Contractions
Buzzing
Burning
Twitching
Itching
Pain

Theoretical causes of PGAD/GPD

Reported, suspected causes of PGAD include vascular, neurological, pharmacological and psychological. Understanding the neurophysiology of this condition starts with an understanding of the biomechanics of the pudendal nerve and female sexual response.

If a nerve is trapped, it can result in the nerve constantly firing, resulting in continuous arousal. But, this doesn’t explain why this occurs in people who have been assessed for pelvic floor dysfunction with no findings.

Possible factors contributing to PGAD/GPD¹

Psychosocial
Symptom distress
Anxiety symptoms/panic
Depressive symptoms/suicidality
Obsessive-compulsive symptoms
Catastrophisation/hypervigilance
Sexual/emotional/other trauma
Other psychiatric comorbidities
Sexual functioning
Relationship adjustment
Other medical comorbidities
Overactive/hypertonic pelvic floor muscle dysfunction
Pudendal neuropathy
Sacral Tarlov cyst
Lumbar disc disease
Annular tear
Medications
Trazodone
Use of or discontinuation of SSRIs/SNRIs

Treatment of PGAD/GPD

Osteopathy/chiropractic and musculoskeletal treatments
Sex therapy (adjunct)
Anti-androgen therapy²
Hormone therapy
Psychotherapy and other psychological strategies (eg, CBT [including decatastrophizing], mindfulness, breathwork, self-compassion, etc.)
Pelvic floor: sacral/pudendal neuromodulation
Tarlov cyst surgery or aspiration (with or without fibrin glue)
Lumbar disc disease surgery (eg, laminectomy, discectomy, annuloplasty)
Dose adjustment of SSRI/SNRIs
Electroconvulsive therapy (ECT)
Holistic assessment by a qualified, experienced naturopath or functional medicine doctor (nutrition, subclinical signs and symptoms)
Biofeedback has been suggested as a treatment option, targeting the pelvic muscles/nerves
High-dose SSRI antidepressants may help
Reassurance that this condition actually exists and is likely to spontaneously disappear can be very soothing and in fact, in some cases, has relieved the patient of the condition spontaneously
Stimulation to orgasm can provide relief, at least at first, but this ‘treatment’ ceases to be effective over time. Masturbating to orgasm can be really distressing.

Diagnosing PGAD/GPD – ISSWSH guidelines¹

Diagnostic criteria include:

Persistent or recurrent, unwanted or intrusive, distressing sensations of genital arousal
Duration of ≥3 months
May include other types of genito-pelvic dysesthesia (eg, buzzing, tingling, burning, twitching, itch, pain)
Most commonly experienced in the clitoris but also in other genito-pelvic regions (eg, mons pubis, vulva, vestibule, vagina, urethra, perineal region, bladder, and/or rectum)
May include being on the verge of orgasm, experiencing uncontrollable orgasms, and/or having an excessive number of orgasms
Not associated with concomitant sexual interest, thoughts, or fantasies

PGAD/GPD is associated with:

When examined, there isn’t overt evidence of genital arousal e.g. genital lubrication, swelling of clitioris or labia
Limited resolution, no resolution, or aggravation of symptoms by sexual activity
Compromised orgasm quality (eg, aversive, impaired, altered frequency, intensity, timing, and/or pleasure)
Aggravation of genito-pelvic dysesthesia by certain circumstances (eg, sitting, car driving, music or sounds, general anxiety, stress, or nervousness)
Despair, emotional lability, catastrophisation, and/or suicidality
On physical examination, absent evidence of genital arousal (genital lubrication, swelling of clitoris or labia)

ISSWSH PGAD/GPD diagnostic algorithm

References^1,3

1.
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). The Journal of Sexual Medicine. Published online April 2021:665-697. doi:10.1016/j.jsxm.2021.01.172
2.
Deka K, Dua N, Kakoty M, Ahmed R. Persistent genital arousal disorder: Successful treatment with leuprolide (antiandrogen). Indian J Psychiatry. Published online 2015:326. doi:10.4103/0019-5545.166633
3.
Klifto KM, Dellon AL. Persistent Genital Arousal Disorder: Review of Pertinent Peripheral Nerves. Sexual Medicine Reviews. Published online April 2020:265-273. doi:10.1016/j.sxmr.2019.10.001