Overview
Persistent genital arousal disorder/genito-pelvic dysesthesia (PGAD/GPD), originally described as persistent sexual arousal syndrome (PSAS), is a disorder that causes people to have unwanted or disruptive feelings of genital arousal (swelling, tingling, throbbing in their genitals) or to be on the verge of orgasm for long stretches of time when they are not sexually excited or feeling desire. The International Society for the Study of Women’s Sexual Health (ISSWSH) further describes PGAD/GPD as a disorder that may include other types of sensations such as buzzing, burning, twitching, itching, or pain that may occur in the genitals or other parts of the body. Often, it is tough to find the cause of PGAD/GPD symptoms, which makes it difficult to treat and poorly understood, even among doctors.
For PGAD/GPD patients, having sex or experiencing an orgasm usually does not help these feelings go away and, in fact, may make matters worse. Such constant, unrelenting feelings of genital arousal are extremely bothersome for those with PGAD/GPD, often leading to despair, emotional distress, and even suicidal thoughts or attempts at suicide.
Although PGAD/GPD can occur in both men and women, it is more common in women. To be considered PGAD/GPD, symptoms must be bothersome to the patient and last for at least three months.
Symptoms
PGAD/GPD symptoms may be constant (always present) or intermittent (they come and go). Some people with PGAD/GPD have periods of time without symptoms, but later experience flare-ups of their symptoms again. If a person has had PGAD/GPD since their earliest childhood recollection, it is called a lifelong condition. Usually, this is not the case, and PGAD/GPD symptoms develop later in a person’s life, making it an acquired condition.
Since it has only recently been defined by the sexual medicine community, many providers know less about PGAD/GPD than other sexual dysfunctions. As experts continue to study it, we will begin to know more about the condition and its symptoms. However, the following is a list of the most commonly reported PGAD/GPD symptoms to date:
- Persistent genital arousal that is:
- Involuntary (out of your control)
- Unwanted, intrusive, and bothersome
- Unrelated to sexual interest, thoughts, or fantasies
- Unresolved or aggravated by sexual activity or orgasm
- The feeling of constantly being on the verge of orgasm
- Continuous tingling, pulsating, or throbbing of genitals
- Genital pain, pressure, or discomfort
- Underlying stress, shame, or anxiety about the condition that may lead to despair, emotional distress, or even suicidal thoughts or attempts at suicide
Causes
Like most sexual disorders, researchers believe that PGAD/GPD symptoms are caused by a combination of factors, meaning that there is no one, single cause of PGAD/GPD. In fact, there are several things that could cause or contribute to PGAD/GPD that may be related to a person’s biology, psychology, social or cultural background, and/or medication history.
PGAD/GPD symptoms may stem from a problem in the central nervous system (CNS). Sometimes, a nerve root (part of the nerve that enters or exits the spine) becomes irritated due to a lower back injury. This irritated nerve root fires without the patient’s permission, sending sensory information to the spinal cord from the genital region of the body. When this happens, the brain thinks that this sensory information coming from the genital region is arousal. Therefore, the patient may have ongoing feelings of genital arousal even when their genitals are normal and he or she is not mentally turned on. The neurochemicals in the brain can play a role in causing PGAD/GPD as well.
Research shows that suddenly stopping or starting selective serotonin reuptake inhibitor (SSRI) antidepressants may contribute to PGAD/GPD. Psychological factors like catastrophizing (responding more intensely to a situation or assuming the worst) and social factors like a patient’s shame and embarrassment about symptoms may make them even worse. Finally, the general lack of awareness about the condition (even among providers) and the fact that there are few accessible treatment options may lead to even more emotional distress for PGAD/GPD patients and possibly a worsening of symptoms.
Diagnosis
PGAD/GPD can be diagnosed by an experienced sexual medicine provider through a complete patient history, a physical exam, and any necessary laboratory tests.
It is very important that providers take the time to do a thorough patient history with each person who may be experiencing PGAD/GPD. Often, PGAD/GPD patients have had negative medical experiences regarding their symptoms, and they may feel that providers lack the knowledge or resources to help them with their condition, or worse, that their story is being dismissed. A full patient history is key to supporting the patient as he or she deals with this distressing condition, but it is helpful in other ways as well. It provides background information that is necessary for understanding the onset of the disorder and may even point to possible causes. Therefore, before doing anything else, a provider should get a comprehensive history from the patient that includes the patient’s description of symptoms and his or her medical, surgical, social, and medication history.
Next, the provider should physically examine the genitals. If the patient is female, the provider should perform a vulvoscopy (an examination of the vulva using a special microscope), use a wet mount (a test for infection), and measure the pH of the vagina. A cotton-tipped swab can be used to identify possible areas of pain or heightened symptoms (such as feelings of genital arousal) in the patient. Additionally, a pelvic floor assessment may be helpful for determining if a pelvic floor disorder is contributing to PGAD/GPD symptoms.
After getting the results of the physical exam, the provider may recommend follow-up laboratory tests like thyroid and sex hormone testing, vascular testing, and/or neuro-genital testing or magnetic resonance imaging (MRI) of the spine. Neuro-genital testing and MRI assessment can help a medical provider determine if a patient’s PGAD/GPD symptoms are related to the sacral and lumbar section of the spinal cord.
Treatment
A customized approach is best when it comes to treating PGAD/GPD. Logically, the treatment plan should be focused on addressing what is thought to be the underlying cause of the symptoms, which differs from patient to patient.
Since PGAD/GPD is believed to be caused by the combination of excess sensory information from irritated nerve sources and an imbalance of excitatory and inhibitory neurochemicals in the brain, treatment should be aimed at correcting both situations. If MRI assessment shows a treatable spinal problem may be causing PGAD/GPD symptoms, a knowledgeable spine surgeon can determine if a minimally invasive spinal surgery would be a possible treatment option for the patient. A provider might recommend medications to help with any pain symptoms or the imbalance of neurochemicals in the brain.
Pelvic floor therapy is a good option for those patients who have a pelvic floor disorder. Providers may look into adjusting medications if the patient’s PGAD/GPD is thought to have been influenced by them. Finally, counselling, cognitive behavioral therapy (CBT), sensate focus therapy (a technique to help individuals refocus on their sensory perceptions and sensuality), mindfulness, and yoga may be beneficial treatment options for patients who are suffering psychological distress due to their PGAD/GPD symptoms.
Resources:
Felman, A. Medically reviewed by University of Illinois. (2017, May 9). What is persistent genital arousal disorder (PGAD)? Medical News Today. https://www.medicalnewstoday.com/articles/249594.
Goldstein, I., Clayton, A.H., Goldstein, A.T., Kim, N.N., & Kingsberg, S.A. (2018). The International Society for the Study of Women’s Sexual Health Textbook of Female Sexual Function and Dysfunction Diagnosis and Treatment. Wiley Blackwell.
Goldstein, I., Komisaruk, B.R., Pukall, C.F., Kim, N.N., Goldstein, A.T., Goldstein, S.W., Hartzell-Cushanick, R., Kellogg-Spadt, S., Kim, C.W., Jackowich, R.A., Parish, S.J., Patterson, A., Peters, K.M., & Pfaus, J.G. (2021). 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, 18(4), 665-697. https://www.jsm.jsexmed.org/article/S1743-6095(21)00175-2/fulltext.
Management of Persistent Genital Arousal Disorder [Video]. (2019). Produced by the International Society for the Study of Women’s Sexual Health, presented by Rachel Rubin, MD.
Management of Persistent Genital Arousal Disorder (PGAD): Central Causes [Video]. (2019). Produced by the International Society for the Study of Women’s Sexual Health, presented by Irwin Goldstein, MD.
Peripheral and Central Mechanisms of Persistent Genital Arousal Disorder [Video]. (2019). Produced by the International Society for the Study of Women’s Sexual Health, presented by James G. Pfaus, PhD.
Persistent Genital Arousal Disorder: Definition [Video]. (2019). Produced by the International Society for the Study of Women’s Sexual Health, presented by Rachel Rubin, MD.
SX21: Sex in the 21st Century. (2010, February 24). Persistent Genital Arousal Disorder in Women (PGAD). https://sexualmed.org/known-issues/female-persistent-genital-arousal-disorder.
Weintraub, K. Medically reviewed by Arefa Cassoobhoy, MD, MPH. (2020, January 10). Arousal Syndrome No Cause for Shame, Doctors Say. WebMD. https://www.webmd.com/brain/news/20200110/arousal-syndrome-no-cause-for-shame-doctors-say.
