Suppose you had unrelenting, unwanted, persistent genital sensations—meaning symptoms like multiple orgasms, genital pressure, genital discomfort, engorgement, throbbing, or pulsation in tissues like the clitoris, vagina, perineum, or anus.  Suppose these symptoms were spontaneous, without any sexual interest or activity.  Suppose they were persistent without times of relief, occurring spontaneously and lasting for minutes or even hours at a time without warning. (Goldstein, 2019) Suppose these symptoms could be present even when you aren’t sexually aroused and in the absence of sexual stimulation or activity.  (Hecht, 2016)

Your first reaction to this might be, “how is this possible?”  How can a person experience spontaneous arousal or multiple orgasms daily for hours at a time?  

The symptoms listed above are signs of something called persistent genital arousal disorder or PGAD.  Individuals with this condition become sexually aroused without sexual stimulation or sexual activity. They may feel like they are having orgasms constantly and symptoms may last hours, days, or weeks at a time. These symptoms, when left untreated, can cause personal distress, significantly disrupt daily life, and may even cause suicidal thoughts. Even when not sexually aroused, PGAD may cause arousal-like erection or swelling in the vagina/clitoris, and individuals with PGAD are often ashamed of having inappropriate genital feelings. Unfortunately, there are few medications and treatments for the symptoms of PGAD.

The first documented case of PGAD was in 2001 by Leiblum and Nathan, reported as PSAS or persistent sexual arousal syndrome. PGAD is associated with spontaneous orgasms or feelings that orgasm is imminent.  The individual may feel that they need to reach a point of orgasmic release to alleviate the symptoms of persistent arousal but symptoms may not be relieved with orgasm. That is the frustrating part for these individuals—the lack of relief despite the occurrence of orgasm. PGAD is most common in women but it also has been reported in men.  In men, the condition is often referred to as priapism. Priapism is an erection that lasts several hours or more even without anything sexually stimulating or arousing to cause the erection.  

In 2009,  Waldinger termed the combination of PGAD, which may also include restless leg syndrome, overactive bladder syndrome, and urethral hypersensitivity as Restless Genital Syndrome.  Symptoms, in this case, may include unpleasant sensations like burning, wetness, itching, pressure, pins/needles, and feelings of imminent orgasm in the absence of sexual desire or fantasies.  

There are two classifications of PGAD: primary-lifelong, which is present throughout the person’s life, and secondary, which is acquired and develops later in life.  

PGAD symptoms may include what is listed above and the following:

• flushed or redness in the face and neck
• abnormally high blood pressure
• shallow breathing
• muscle spasms throughout the body
• blurred vision
• pain in the genital area, especially the clitoris or penis
• worry, depression, distraction, poor concentration, difficulty making decisions, irritability, agitation, and depressed mood 

Possible Causes of PGAD:

1. 1. Pinching or compressing of the pudendal nerve
2. 2. improper blood flow in /out of the penis/clitoris 
3. 3. artery or venous malformations due to pelvic congestion
4. 4. central nervous system causes (note that anxiety, depression, bipolar disorder, OCD can be comorbidities): stroke, post-op brain surgery, neurologic diagnoses like Tourette’s Syndrome, epilepsy, blunt CNS trauma/surgery, cervical or lumbosacral interventions/surgery, and cysts or tears in the nerve tissue of the sacral spinal nerve roots, 
5. 5. other medical considerations: discontinuation of cholesterol medication, discontinuation of estrogen therapy, use or discontinuation of anti-depressants such as Trazadone, initiation/use of or withdrawal of SSRI’s, initiation or discontinuing hormone therapy, and excessive use of herbal estrogens
6. 6. hormonal causes
7. 7. complications of vasectomy, UTI

It’s vital that you find the right team of providers to help you manage PGAD:

Physician/CRNP/PA: can use trigger point therapy, treat superficial nerve blocks, and apply botox to alleviate the hyperactivity of nerves

Pelvic Physical Therapist: can use manual techniques and exercise therapy to address pelvic floor dysfunction. Can use biofeedback techniques to refine pelvic floor activation. Can mobilize viscera, pelvic organs, and tissue.

Psychotherapist: to address trauma or abuse that may exist in about 50% of the cases and cognitive behavioral therapy

Acupuncturist: to soothe the nervous system stuck in a constant fight or flight pattern

Additional treatments:

1. 1.  Meditation and mindfulness training
2. 2.  Relaxation techniques for your muscles in your pelvic floor and surrounding tissue in the pelvis, back, hips, and legs
3. 3.  Manual therapy to relax muscle tissue to help alleviate pressure on the nerves 
4. 3.  Desensitization of the skin and local tissue
5. 4.  Home exercises and self-care strategies determined by a pelvic floor physical therapist
6. 5.  Physical agents: transcutaneous electrical nerve stimulation (TENS), low-level laser, and vaginal dilators

It can feel overwhelming, frustrating, and hopeless when suffering from PGAD. Fortunately, there are ways to manage PGAD that can help you lead a more normal life. Contact us to learn how the pelvic floor specialists at Rebalance Physical Therapy can help you manage your PGAD symptoms.

References:

Case Study from 2010. Rosenbaum TY. Sexual Medicine.  Physical therapy treatment of persistent genital arousal disorder during pregnancy; a case report.  2010.

Hecht, Evelyn 2016.  A Pelvic Physical Therapist’s Approach to PGAD: Persistent Genital Arousal Disorder.  Retrieved from emhphysicaltherapy.com

Goldstein I.  Persistent genital arousal disorder update on the monster of sexual dysfunction.  J Sex Med 2013: 10;2357-2358.

Jackowich R, Pink L, Gordon A, Pukall C. Persistent Genital Arousal Disorder: A Review of Its Conceptualizations, Potential Orgins, Impact and Treatment. Sex Med Review 2016; 1-14.

Leiblum S, Brown C, Wan J et al.  Persistent sexual arousal syndrome; a descriptive study.  J Sex Med 2005; 2: 331-337.  

Butler D, Moseley L.  Explain Pain.  Noigroup Publications Adelaide, Australia 2013.