By Tiffaney Marlow, Reg. PT

Persistent genital arousal disorder (PGAD) is an under-researched and poorly understood condition affecting men and women. PGAD is described as spontaneous, unwanted genital arousal in the absence of any subjective perception of sexual interest or desire, occurring for a period of 6 months or more (1,2,3). Those affected by PGAD describe states of physiological arousal lasting for hours or days, which are unaffected by orgasm or medication (1,2,4). Patient’s describe these symptoms as unrelenting, unpleasant and sometimes even painful (1,2). What triggers these symptoms seems to vary between individuals but may include; sexual stimulation, masturbation, stress and anxiety (4).

As these symptoms of arousal occur without warning, they are intrusive, occurring when patients are at school, at work or in social settings (4). Not surprisingly, 75% of women who were surveyed about living with PGAD reported moderate to high levels of distress about their condition (4). They described feelings of embarrassment, anxiety and depression often resulting in social withdrawal (4).

Unfortunately, the cause of PGAD is unknown. There are a number of theories but, most research to date has been on a case by case basis with no clear pattern. Some current theories include:

• PGAD may be part of a cluster called Restless Gential Syndrome – it has been highly associated with overactive bladder (67%) and restless leg syndrome (67%) (3,4,6)

• PGAD may be caused by central dopaminergic dysfunction as it has been associated with OCD, depression and anxiety (3,7)

• PGAD may also be linked to pelvic floor dysfunction where increased myofascial and connective tissue tension may cause increased sensitivity of nerves in the pelvis, restricted blood flow and abnormal genital sensations (3, 8).

It is suspected that there is no specific cause of PGAD but rather it is a combination of factors including psychological, physiological and social elements.

How can Pelvic Physiotherapy help patients suffering from PGAD?

Although PGAD has not been extensively researched, the presentation and nature of symptoms associated with the disorder are similar to that of chronic pelvic pain. Symptoms must persist for greater than 6 months, they are often triggered by stress or anxiety and have a significant impact on patients’ lives leading to high levels of distress and social isolation. Chronic pain has been thoroughly researched and we know effective treatment is often multi-disciplinary, multi-modal and addresses both the peripheral tissues and the affected nervous system (9,10).

We know that pain is an output of our brain in response to an actual or perceived threat of danger (9,10). Nerves within our body act as an alarm system, sending messages to our brain about changes in temperature, movement/pressure, blood flow and stress (9). It is the brain that  then determines whether these messages should be perceived as pain (9).

In the case of chronic pelvic pain, the threshold required to sound our alarm system is much lower. The nervous system becomes ‘sensitized’ and the brain may perceive pain in the absence of injury or disease (9). As pain is multi-factorial there are many contributing factors to chronic pelvic pain including muscles and connective tissue tension, a patient’s preconceived thoughts about their pain as well as other life stressors causing stress and anxiety (9,10).

Pelvic physiotherapists are well equipped to help patients address their pelvic pain and symptoms of PGAD using a multimodal approach which may include (9,10):

• Pain Education: understanding the neuroscience behind pain, the plasticity of one’s nervous system, understanding our body’s threat response and how to manage those threats are the first steps to managing pelvic pain.

• Manual Therapy: assessing and treating the tissues of the pelvic floor and surrounding musculature. Using manual therapy (massage and trigger point release) to release tight muscles, address tension in the connective tissue and improve vascular flow.

• Exercise: to improve body awareness and loosen joints and muscles around the pelvis. Movement can improve one’s body awareness of painful pelvis, improve joint mobility, increase blood flow and release endorphins which are our body’s natural pain killers.

• Graded Motor Imagery/Visualization: visualization exercises with the focus on the pelvis can improve body awareness and reduce pain.

• Mindfulness and Stress Management: pelvic pain and PGAD symptoms are aggravated by stress and anxiety. Using tools such as mindfulness and meditation can help to manage psychological triggers of symptoms.

If you suffer from PGAD consider speaking to a Pelvic Physiotherapist to help with managing your symptoms.

References:

1. Jackowich RA, Pink L, Gordon A, Pukall CF. Persistent Genital Arousal Disorder: A Review of Its Conceptualizations, Potential Origins, Impact, and Treatment. Sexual Medicine Review. 4(4):329-42

2. Thubert T et al. Persistent genital arousal disorder: A systematic review. Progress in Urology. 2012. 22(17):1043-1050

3. Rosenbaum Physical Therapy Treatment of Persistent Genital Arousal Disorder During Pregnancy: A Case Report. 2010. International Society for Sexual Medicine

4. Leiblum S. Persistent Sexual Arousal Syndrome: A Descriptive Study. The Journal of Sexual Medicine. 2005. 2(3):331-337

5. Facelle T et al., Persistent Genital Arousal Disorder: Characterization, Etiology, and Management. The Journal of Sexual Medicine. 2013. 10(2):439-450

6. 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 2009.6:482–97

7. 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;6:2901–9

8. Rosenbaum TY. Pelvic floor involvement in male and female sexual dysfunction and the role of pelvic floor rehabilitation in treatment: A literature review. J Sex Med 2007;4:4–13

9. Adriaan L, Hilton S, Vandyken C. Why Pelvic Pain Hurts Neuroscience Education for Patients with Pelvic Pain. 2014

10. Hilton S. Persistent Pelvic Pain. The Pain Practitioner Vol 22(2)