Irwin Goldstein1, Barry R Komisaruk2, Caroline F Pukall3, Noel N Kim4, Andrew T Goldstein5, Sue W Goldstein6, Rose Hartzell-Cushanick6, Susan Kellogg-Spadt7, Choll W Kim8, Robyn A Jackowich3, Sharon J Parish9, April Patterson10, Kenneth M Peters11, James G Pfaus12. 1. Alvarado Hospital, San Diego, CA, USA; San Diego Sexual Medicine, San Diego, CA, USA. Electronic address: dr.irwingoldstein@gmail.com. 2. Department of Psychology, Rutgers University, Newark, NJ, USA. 3. Department of Psychology, Queen's University, Kingston, ON, Canada. 4. Institute for Sexual Medicine, San Diego, CA, USA. 5. Centers for Vulvovaginal Disorders, Washington, DC, USA. 6. San Diego Sexual Medicine, San Diego, CA, USA. 7. Center for Pelvic Medicine, Bryn Mawr, PA, USA; Drexel University College of Medicine, Philadelphia, PA, USA. 8. Center for Minimally Invasive Spine Surgery, San Diego, CA, USA. 9. Departments of Psychiatry and Medicine, Weill Cornell Medical College, New York, NY, USA. 10. Whole Body Physical Therapy, Los Angeles, CA, USA. 11. Oakland University William Beaumont School of Medicine, Royal Oak, MI, USA. 12. Centro de Investigaciones Cerebrales, Universidad Veracruzana, Xalapa, VER, Mexico.
Abstract
BACKGROUND: Persistent genital arousal disorder (PGAD), a condition of unwanted, unremitting sensations of genital arousal, is associated with a significant, negative psychosocial impact that may include emotional lability, catastrophization, and suicidal ideation. Despite being first reported in 2001, PGAD remains poorly understood. AIM: To characterize this complex condition more accurately, review the epidemiology and pathophysiology, and provide new nomenclature and guidance for evidence-based management. METHODS: A panel of experts reviewed pertinent literature, discussed research and clinical experience, and used a modified Delphi method to reach consensus concerning nomenclature, etiology, and associated factors. Levels of evidence and grades of recommendation were assigned for diagnosis and treatment. OUTCOMES: The nomenclature of PGAD was broadened to include genito-pelvic dysesthesia (GPD), and a new biopsychosocial diagnostic and treatment algorithm for PGAD/GPD was developed. RESULTS: The panel recognized that the term PGAD does not fully characterize the constellation of GPD symptoms experienced by patients. Therefore, the more inclusive term PGAD/GPD was adopted, which maintains the primacy of the distressing arousal symptoms and acknowledges associated bothersome GPD. While there are diverse biopsychosocial contributors, there is a common underlying neurologic basis attributable to spontaneous intense activity of the genito-pelvic region represented in the somatosensory cortex and its projections. A process of care diagnostic and treatment strategy was developed to guide the clinician, whenever possible, by localizing the symptoms as originating in any of five regions: (i) end organ, (ii) pelvis/perineum, (iii) cauda equina, (iv) spinal cord, and (v) brain. Psychological treatment strategies were considered critical and should be performed in conjunction with medical strategies. Pharmaceutical interventions may be used based on their site and mechanism of action to reduce patients' symptoms and the associated bother and distress. CLINICAL IMPLICATIONS: The process of care for PGAD/GPD uses a personalized, biopsychosocial approach for diagnosis and treatment. STRENGTHS AND LIMITATIONS: Strengths and Limitations: Strengths include characterization of the condition by consensus, analysis, and recommendation of a new nomenclature and a rational basis for diagnosis and treatment. Future investigations into etiology and treatment outcomes are recommended. The main limitations are the dearth of knowledge concerning this condition and that the current literature consists primarily of case reports and expert opinion. CONCLUSION: We provide, for the first time, an expert consensus review of the epidemiology and pathophysiology and the development of a new nomenclature and rational algorithm for management of this extremely distressing sexual health condition that may be more prevalent than previously recognized. 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). J Sex Med 2021;18:665-697.
BACKGROUND: Persistent genital arousal disorder (PGAD), a condition of unwanted, unremitting sensations of genital arousal, is associated with a significant, negative psychosocial impact that may include emotional lability, catastrophization, and suicidal ideation. Despite being first reported in 2001, PGAD remains poorly understood. AIM: To characterize this complex condition more accurately, review the epidemiology and pathophysiology, and provide new nomenclature and guidance for evidence-based management. METHODS: A panel of experts reviewed pertinent literature, discussed research and clinical experience, and used a modified Delphi method to reach consensus concerning nomenclature, etiology, and associated factors. Levels of evidence and grades of recommendation were assigned for diagnosis and treatment. OUTCOMES: The nomenclature of PGAD was broadened to include genito-pelvic dysesthesia (GPD), and a new biopsychosocial diagnostic and treatment algorithm for PGAD/GPD was developed. RESULTS: The panel recognized that the term PGAD does not fully characterize the constellation of GPD symptoms experienced by patients. Therefore, the more inclusive term PGAD/GPD was adopted, which maintains the primacy of the distressing arousal symptoms and acknowledges associated bothersome GPD. While there are diverse biopsychosocial contributors, there is a common underlying neurologic basis attributable to spontaneous intense activity of the genito-pelvic region represented in the somatosensory cortex and its projections. A process of care diagnostic and treatment strategy was developed to guide the clinician, whenever possible, by localizing the symptoms as originating in any of five regions: (i) end organ, (ii) pelvis/perineum, (iii) cauda equina, (iv) spinal cord, and (v) brain. Psychological treatment strategies were considered critical and should be performed in conjunction with medical strategies. Pharmaceutical interventions may be used based on their site and mechanism of action to reduce patients' symptoms and the associated bother and distress. CLINICAL IMPLICATIONS: The process of care for PGAD/GPD uses a personalized, biopsychosocial approach for diagnosis and treatment. STRENGTHS AND LIMITATIONS: Strengths and Limitations: Strengths include characterization of the condition by consensus, analysis, and recommendation of a new nomenclature and a rational basis for diagnosis and treatment. Future investigations into etiology and treatment outcomes are recommended. The main limitations are the dearth of knowledge concerning this condition and that the current literature consists primarily of case reports and expert opinion. CONCLUSION: We provide, for the first time, an expert consensus review of the epidemiology and pathophysiology and the development of a new nomenclature and rational algorithm for management of this extremely distressing sexual health condition that may be more prevalent than previously recognized. 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). J Sex Med 2021;18:665-697.
Authors: David Healy; Audrey Bahrick; Maarten Bak; Angelo Barbato; Rocco Salvatore Calabrò; Barbara M Chubak; Fiammetta Cosci; Antonei B Csoka; Barbara D'Avanzo; Silvia Diviccaro; Silvia Giatti; Irwin Goldstein; Heiko Graf; Wayne J G Hellstrom; Michael S Irwig; Emmanuele A Jannini; Paddy K C Janssen; Mohit Khera; Manoj Therayil Kumar; Joanna Le Noury; Michał Lew-Starowicz; David E J Linden; Celine Lüning; Dee Mangin; Roberto Cosimo Melcangi; Omar Walid Muquebil Ali Al Shaban Rodríguez; Jalesh N Panicker; Arianna Patacchini; Amy M Pearlman; Caroline F Pukall; Sanjana Raj; Yacov Reisman; Rachel S Rubin; Rudy Schreiber; Stuart Shipko; Barbora Vašečková; Ahad Waraich Journal: Int J Risk Saf Med Date: 2022