Persistent Genital Arousal Disorder (PGAD): What to Know

Persistent Genital Arousal Disorder (PGAD): What to Know

Persistent Genital Arousal Disorder (PGAD): What to Know – Persistent genital arousal disorder (PGAD) is a rare condition that causes spontaneous, persistent, and unwanted genital arousal in the absence of sexual desire. PGAD is not relieved by orgasm and may require multiple orgasms over hours or days for the aroused state to subside.1

Although males can be affected, PGAD is more common in females who experience increased blood flow and heightened sensations in the clitoris, vulva, and anus.2

Deka K, Dua N, Nakoty M, Ahmed R. Persistent genital arousal disorder: successful treatment with leuprolide (antiandrogen). Indian J Psychiatry. 2015;57(3):326–328. doi:10.4103/0019-5545.166633

It is not entirely clear what causes PGAD, making the diagnosis and treatment complex. A case-by-case approach is needed.

This article explains what persistent genital arousal syndrome is, including what it feels like and its possible causes. It also describes how PGAD is diagnosed and treated and what to expect if you develop signs and symptoms of PGAD.

What Is Persistent Genital Arousal Disorder (PGAD)?

Persistent genital arousal disorder is a relatively new condition that was only officially included in the International Consultation on Sexual Medicine, Third Edition (ICSM-3) in 2009.3 In the 2022, International Classification of Diseases, 11th Edition (ICD-11), it is categorized under “Other Specified Sexual Arousal Dysfunction.”1

According to the International Society for the Study of Women’s Sexual Health (ISSWSH), PGAD is the unwanted, unrelenting sensation of genital arousal that has negative effects both psychological and social. This includes having mood swings, catastrophizing (believing a situation is worse than it is), or even having suicidal thoughts or feelings.4

Although there are psychological components to PGAD, it is not regarded as a psychological disorder and is not included in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) issued by the American Psychiatric Association.

PGAD is thought to affect between 1% and 4% of adults to varying degrees.5

Characteristics of PGAD

Broadly, PGAD is the sudden, unwanted, and uncontrollable arousal of the genitals. The arousal is marked by increased blood flow to the genitals with or without engorgement.

The tingling, pulsing, or throbbing sensations are unwanted and not relieved by masturbation (stimulation of the genitals) or orgasm (climax).1 PGAD can persist for hours or days and is recurrent.6

PGAD may be triggered by sexual stimuli, nonsexual stimuli (such as the rubbing of clothes against the genitals), or in the absence of any stimuli.

Unique to PGAD is the persistence of genital arousal in the absence of any sexual desire.1 Over time, this can take its toll on a person’s mental health, leading to depression, anxiety, self-consciousness, and panic attacks.7

The symptoms can be lifelong (referred to as primary PGAD) or occur later in life as a result of another condition (secondary PGAD).8

It is not clear why females appear to be affected by PGAD more than males. On the one hand, women appear more vulnerable to arousal disorders than men.9 On the other hand, it may simply be that the condition is underreported in males.

Priapism, PSAS, and PGAD: What Is the Difference?

PGAD was previously referred to as persistent sexual arousal syndrome (PSAS). The term has since been abandoned given that sexual arousal by definition involves a physiological and psychological response to sexual thoughts or stimuli. PGAD occurs in the absence of a psychological response.6

Another term less commonly used is “restless genital syndrome.” The term was proposed when PGAD was linked to restless legs syndrome (RLS), another condition characterized by an uncontrollable physiological response.11 Although there is evidence that PGAD and RLS have similar disease pathways, a link has not yet been definitively established.

Some experts also compare PGAD to penile priapism (a painful and persistent erection that lasts more than six hours without stimulation) and clitoral priapism (a rare condition in which the clitoris is painfully engorged, usually due to medications).12

Yafi FA, April D, Power MK, Sangkum P, Hellstrom WJG. Penile priapism, clitoral priapism, and persistent genital arousal disorder: a contemporary review. Sex Med Rev. 2015;3(3):145-159. doi:10.1002/smrj.51

While PGAD can occur with or without engorgement,2 abnormally increased blood flow to the genitals suggests that some of the same mechanisms may be involved.

What Does PGAD Feel Like?

As per its name, PGAD symptoms are characterized by persistence. Symptoms of PGAD can last for hours to days or be constant for certain individuals with primary PGAD.14

The symptoms can vary between females and males but often include:1

  • Throbbing, pulsing, aching, tingling, or pounding sensations in the
  • genitals, perineum, or anus1
  • Sensitivity to touch or pressure1
  • Clitoral or penile fullness or erection12
  • Vaginal contractions2

Deka K, Dua N, Nakoty M, Ahmed R. Persistent genital arousal disorder: successful treatment with leuprolide (antiandrogen). Indian J Psychiatry. 2015;57(3):326–328. doi:10.4103/0019-5545.166633

Penile spasms12

Feeling as if you are near orgasm (“cumming”)15
Only temporary relief with orgasm, or no relief from orgasm1

If symptoms like these develop spontaneously, are unwanted and uncontrollable, and persist in the absence of sexual stimulation or desire, you may have PGAD.

What Causes PGAD?

PGAD is poorly understood but is thought to involve neurological (related to nerves), vascular (related to blood circulation), pharmaceutical (related to medications), or psychological (related to emotions) factors, either alone or in combination.

The symptoms are believed to originate in one or more of the following five regions of the body:4

Among some of the possible explanations for PGAD symptoms are the following.

Tarlov Cysts

Genital arousal in females and males is directed by nerves that originate in the lower thoracic spine and upper lumbar spine (specifically the T11 to L2 vertebra). PGAD is thought to be caused, at least in some people, by the compression of the pudendal nerve, which is located near the base of the spine. This is the nerve that provides sensations to the genitals.16

Studies have found that females with PGAD often have fluid-filled sacs called Tarlov cysts on nerve roots of the lower spine.16 Some research even suggests they are the main cause of PGAD in females.17

Tarlov cysts are relatively common, but ones large enough to compress nerves are not. Females tend to have Tarlov cysts more often than males, often as a result of spinal trauma or surgery.18

Other spine-related causes of PGAD include disk herniation (the bulging of the soft cushion between spinal bones) and spinal stenosis (the narrowing of the central column of the spinal cord).16

Arteriovenous Malformations

Abnormalities in blood flow can also cause or contribute to PGAD. Arteriovenous malformation (AVM) is one such example.

An AVM occurs when arteries (vessels that carry blood from the heart) and veins (vessels that carry blood back to the heart) are abnormally connected. An AVM in the pelvis can lead to a condition called venous insufficiency in which blood can’t get back to the heart, causing it to pool in the genitals.19

AVM is one of the contributing factors to pelvic congestion syndrome (PCS), a medical condition that causes chronic pelvic pain in females.20 PCS, in turn, can cause the formation of varicose veins in and around the genitals, leading to PGAD.21

Stress and Other Psychological Factors

Psychological issues may not “cause” PGAD, but they can contribute to and even perpetuate PGAD symptoms.

A 2020 review from the ISSWSH suggested that personality traits like neuroticism paired with a sexually conservative upbringing can make a person more emotionally reactive to abnormal sensations in their genitals.4

This can lead to a hypervigilant state in which a person is constantly assessing symptoms to see if they are changing or getting worse. Hypervigilance, in turn, fuels high levels of stress and anxiety that can lead to the “catastrophizing” of symptoms.4

There is evidence that stress and anxiety not only increase the perception of pain and discomfort but may also trigger PGAD episodes in some people.22

Antidepressants

PGAD has been linked to certain classes of antidepressants. These include selective serotonin reuptake inhibitors (SSRIs) like Lexapro (escitalopram) or Zoloft (sertraline) or serotonin-norepinephrine reuptake inhibitors (SNRIs) like  Effexor (venlafaxine) or Cymbalta (duloxetine).23

While the association between PGAD and antidepressants remains unclear, some researchers suggest that it may be due to RLS, a common side effect of both SSRIs and SNRIs.24

RLS is caused by dysfunction of the part of the brain called the basal ganglia, which regulates smooth body movements. The basal ganglia are additionally tasked with translating sexual urges into a physiological response.25

It is possible that the mechanisms that trigger RLS might also trigger PGAD. The same might occur if SSRIs or SNRIs are suddenly stopped, triggering RLS in people with antidepressant withdrawal.4

How Is PGAD Diagnosed?

PGAD was first described in 2001 by researchers Sandra Leiblum and Sharon Nathan, who established criteria by which PGAD is definitively diagnosed.4

In 2021, the ISSWSH updated the criteria so that PGAD can now be diagnosed based on the following characteristics and conditions:4

You have persistent or recurring, unwanted or intrusive, distressing sensations of genital arousal.
These sensations are present for three months or more.
There may be other sensations in the genitals or pelvic region, such as buzzing, tingling, burning, twitching, itching, or pain.
While the sensations are most often experienced in the clitoris, other nearby regions may be affected, such as the vulva, vagina, perineum, bladder, anus, or urethra (the tube through which urine exits the body).
You may experience uncontrollable orgasms, have an excessive number of orgasms, or feel as if you are on the verge of orgasm.
These sensations occur in the absence of sexual thoughts, fantasies, or interests.

As part of the diagnosis, the healthcare provider will review your medical history (including any medications you take) and perform a physical exam to check for any abnormalities in or around the genitals.

Other tests may be ordered to narrow the possible causes, including:4

Blood hormone tests: These check for hormonal imbalances like hyperthyroidism (overactive thyroid) that are often seen in people with PGAD.
Anesthesia testing: This is when a topical or local anesthetic is applied to your genitals to see if symptoms persist. If they do, your symptoms could be due to a spinal nerve problem.

Neurological testing: This includes an in-office test called electromyography (EMG) that measures involuntary muscle responses to a low-voltage electrical current.
Doppler ultrasound: This noninvasive imaging test can detect AVM using sound waves as well as anatomical signs of pelvic floor dysfunction.
Arteriograms: This is a type of X-ray that can spot AVM and other blood vessel problems using a special dye injected into the bloodstream.
Magnetic resonance imaging (MRI): This nonradioactive imaging test can help detect soft tissue problems like Tarlov cysts and disk herniation.
How Is PGAD Treated?

Based on the findings of your tests, your healthcare provider may recommend one or more treatments. Because there are no standard treatments for PGAD, treatment is dispensed on a case-by-case basis, often with multiple providers.

Psychological Treatment

Though the cause of PGAD may be physical, psychological treatment is often recommended to help you better cope with stress, anxiety, or other emotional issues surrounding PGAD.

Cognitive behavioral therapy (CBT) is one such approach that has been shown to reduce pain intensity and distress in women with PGAD.4 CBT is a form of talk therapy that allows you to identify inaccurate or negative thoughts so that you can respond to them in a more effective way.

Sex therapy may also be recommended to overcome anxiety and discomfort centered around your genitals or to adjust sexual practices to accommodate PGAD symptoms.17 Relaxation techniques like deep breathing and progressive muscle relaxation can also help.4

Physical Therapy

Strengthening and stabilizing pelvic floor muscles has been shown to improve daily function in women with PGAD.4 Pelvic floor physical therapy involves a variety of modalities, some of which are performed at home and others of which are delivered by a physical therapist.

These include:4

Myofascial release: This a form of massage used to release tightness and pain around the fibrous tissues surrounding muscles.
Transcutaneous electrical nerve stimulation (TENS): This involves a small device that delivers a gentle electrical current near nerves to block or change your perception of pain.
Lymphatic drainage: This form of massage may ease swelling and pain by dispersing accumulated fluid around the pelvis.

Steps should be taken to identify and avoid any movements, such as stretching and squatting, that may cause PGAD flares.

Medications

Many different medications are used off-label for the treatment of PGAD. Off-label means the drug has not been approved by the Food and Drug Administration (FDA) for the treatment of the condition, but healthcare providers may prescribe the drug if they think it could be beneficial.

The drugs are chosen based not only on the presumed cause but also on the types of symptoms you are experiencing. These include anticonvulsant drugs, tricyclic antidepressants, opioid painkillers, antipsychotics, different types of nerve pain medications:4

PGAD Outlook: What to Expect

PGAD is a rare condition that generally responds well to treatments, although it can take time to find the right combination of treatments.4

Whether PGAD can be “cured” depends on the situation. While it may be possible for PGAD to go away on its own, cases often recur in episodic flares or persist continuously for a long time.

The causes of PGAD are diverse, and no single treatment works for everyone. Treatment focuses on minimizing symptoms to improve a person’s quality of life, functional abilities, and emotional well-being.4

New treatments are being explored every year as awareness of this once-unknown condition increases among healthcare providers and affected people.

Summary

Persistent genital arousal disorder is a rare and poorly understood condition in which genital arousal occurs spontaneously without sexual stimulation. It is an unwanted and typically recurrent condition that can persist for hours or days and undermine a person’s quality of life. PGAD is not relieved by orgasm.

PGAD is more common in females than males. Possible causes include Tarlov cysts, arteriovenous malformations, stress, and certain antidepressants. As there is no standard treatment plan, treatment is individualized and may involve psychotherapy, physical therapy, medications, and surgery.

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