By Stephanie Prendergast, MPT, Cofounder, PHRC Los Angeles
In 2021, a panel of experts published a consensus and management of care paper on Persistent Genital Arousal Disorder/Genito-Pelvic Dysesthesia (PGAD/GPD) in the Journal of Sexual Medicine. The paper describes a treatment algorithm involving five different therapeutic targets for PGAD/PGD! The paper describes how clinicians newer to treating this diagnosis can conduct a history, examination, lab work and imaging to help guide effective treatment combinations based on a person’s underlying factors.
Region 1: End Organ In this care, the term ‘end organ’ refers to visceral structures such as the clitoris, vestibule, urethra/bladder, vulva or vagina. Repetitive infections, hormone deficiencies, vulvar disease and clinical clitoral pathology can cause or contribute to PGAD symptoms. All of these situations are treatable with appropriate medical management which in turn can help alleviate or completely resolve symptoms.
Region 2: Pelvis/Perineum Pelvic floor dysfunction, pudendal neuralgia (compression, tension, entrapment, neuroma), and vascular pelvic pathologies (pelvic congestion syndrome, arteriovenous malformation) also can cause PGAD/GPD. Pelvic floor dysfunction and pudendal neuralgia are effectively managed with pelvic floor physical therapy and medical management. Vascular pathologies can effectively be treated with medical management and may involve surgery. Treating the underlying pathology will result in symptom improvement!
Below, we will explain the central nervous system impairments that can be factors to consider.
Region 3: Cauda Equina
The Cauda Equina is the bundle of lumbar and sacral nerve roots located at the lower end of the spinal cord. These nerve roots innervate the pelvic floor and the genitals. If the nerve roots become inflamed they can cause a host of symptoms, including PGAD/GPD. Examples of dysfunction include Tarlov or other cysts and lumbar spine or disc pathology. Imaging such as a lumbar MRI and /or CT scan may aid in the diagnosis. Symptoms and impairments can be treated with a combination of physical therapy, neuromodulation, cauda equina injections, pharmaceuticals, and in some cases, surgery.
Region 4: Spinal Cord
The spinal cord plays a role in sensory, motor, and autonomic pelvic function. If there is an injury anywhere in the cervical, thoracic or lumbar spine PGAD/GPD may result. Withdrawal symptoms from SSRIs and/or trazodone can impact spinal cord function and should be considered when taking a patient’s history. Neurologic and Imaging studies and physical examination can be helpful for the diagnosis. Treatment involves treating the underlying impairment with a combination of pharmaceuticals, physical therapy, and surgery.
Region 5: Brain
Functional MRI (fMRI) studies of the brain have confirmed that some people with PGAD/GPD demonstrate alterations in certain parts of their brain associated with sensation, motor function, and autonomic function of structures in the genital region. Withdrawal from SSRIs and/or can be a contributing factor to these changes. Most people with anytype of persistent pain will have changes in their brain and spinal cord, but the good news is our nervous system can change and change back. Treatment for fMRI brain changes involve treating all the underlying factors causing symptoms and they can be helped with certain neuromodulating pharmaceutics. A promising new technology called Transcranial Magnetic Stimulation (TMS) is effectively used for refractory cases of anxiety and depression and is being studied with promising results for chronic overlapping pain conditions.
We understand that many people may not have access to experts to help them with their diagnosis. The article we reference in these posts is an excellent tool for clinicians wanting to learn more. We commend the authors of this paper for their work. If you are a medical professional wanting to learn more, consider joining ISSWSH and attending virtual and in-person conferences on numerous sexual health topics!
Reference: International Society for the Study ofWomen’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) published in The Journal of Sexual Medicine in 2021
Are you unable to come see us in person in the Bay Area, Southern California or New England? We offer virtual physical therapy appointments too!
Virtual sessions are available with PHRC pelvic floor physical therapists via our video platform, Zoom, or via phone. For more information and to schedule, please visit our digital healthcare page.
In addition to virtual consultation with our physical therapists, we also offer integrative health services with Jandra Mueller, DPT, MS. Jandra is a pelvic floor physical therapist who also has her Master’s degree in Integrative Health and Nutrition. She offers services such as hormone testing via the DUTCH test, comprehensive stool testing for gastrointestinal health concerns, and integrative health coaching and meal planning. For more information about her services and to schedule, please visit our Integrative Health website page.
Melissa Patrick is a certified yoga instructor and meditation teacher and is also available virtually to help, for more information please visit our therapeutic yoga page.
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