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Global Translational Medicine Persistent genital arousal disorder

posterolateral sidewalls, with 10 mL of 1% lidocaine which should be conducted depending on the PGAD
without vasoconstrictor on each side, using the bilateral condition.
pudendal nerve block technique described previously . Upon returning to the AESH on May 8, 2023, she
[17]
The patient reported improvement 15 minutes after the reported excellent adaptation to the use of paroxetine
procedure. Concomitantly, the dose of pregabalin was 15 mg, with the only adverse effect being drowsiness. The
increased to 75 mg in the morning and 150 mg at night, patient also reported having orgasms only when seated or
fluoxetine was replaced with paroxetine 20 mg, and the when the coccygeal region was stimulated. According to her,
patient was referred for mental health assessment in the during penetrative sexual intercourse, she noticed a slight
Psychiatry Department and to Neurology Department for reduction in sensitivity, as well as a decrease in the number
further evaluation of her neurological condition. of orgasms; however, she was satisfied with the result and
The patient returned after 2 weeks for follow-up, was not bothered by this change in the response pattern
complaining of adverse gastrointestinal effects due to during intercourse with her partner. As for autoerotism,
pregabalin. She reported an improvement in symptoms after sympathetic block, she described difficulty in locating
after the pudendal nerve block, with an approximate the area of greatest pleasurable sensitivity in the genitalia
80% reduction in the frequency of orgasms, i.e., around and the need for more stimuli to reach orgasm. Since the
3 orgasms/day. In the return visit, the patient expressed patient no longer reported distress nor complained of
intense fear of the recurrence of the symptoms. Again, intrusive arousal and orgasm, we decided to maintain the
transcutaneous blockage guided by digital vaginal palpation prescribed medication and instructed the patient to return
was performed, as described above, unilaterally on the right for a safety follow-up visit at the AESH together with the
side with 1% lidocaine without vasoconstrictor. Pregabalin mental health and neurology teams.
was administered. During the same visit, the patient stated
that she had not engaged in sexual intercourse since the 3. Discussion
first transcutaneous blockage was performed, due to the This case report sought to demonstrate the clinical
lack of sexual desire. management of PGAD in a woman. It is challenging to
In the third follow-up after the second pudendal nerve define the appropriate strategy to control this condition
blockage on March 27, 2023, the patient reported having since the laboratory and imaging test results do not
[9]
performed sexual intercourse with normal sexual response, always directly lead to the diagnosis , complicating
exhibited sexual desire and arousal, and achieved orgasm. the identification of an appropriate treatment regimen.
She was then referred to psychological monitoring and However, it is known that peripheral neurological processes
physiotherapy. The patient had a consultation session with such as congenital anomalies or pudendal nerve injuries
a psychiatrist on March 31, 2023, when she was switched can result in the spontaneous activation of sympathetic C
[18]
from fluoxetine 60 mg/day to paroxetine 15 mg/day. sensory fibers related to sexual arousal , which could, in
part, explain the patient’s condition.
The evaluation by the neurology team was carried out
on April 6, 2023, when the patient presented with “pulling/ After the first pudendal nerve blockage with 1%
pressure-type” pain that originated from the lumbar region lidocaine, the patient experienced an immediate reduction
to the buttocks, bilaterally, without irradiation to the legs, in 80% of the referred symptoms, convincing evidence
with an intensity of 7/10, and with pain in the coccygeal that the same treatment methodology already described
region with 10/10 intensity that worsened with movement. in another case report could lead to a rapid improvement
[19]
Sensitivity examination showed tactile hypoesthesia of the condition . It is worth mentioning that the patient
in the territories of L5-L4-L3 and S1, with some sites had undergone an unsuccessful medullary blockage
of allodynia. The muscle strength assessment revealed and was also using several pain medications, including
strength grade 4 upon bilateral hip flexion + hip extension centrally-acting neuromodulators. Since she had pelvic
+ hip abduction and adduction; strength grade 5 in the pain due to radicular compression radiating to the perineal
distal portion of the leg upon bilateral plantar and dorsal region, we decided to perform pudendal nerve blockage
[20]
flexion, inversion, and eversion; and torque grade 2 upon since PGAD may be associated with pudendal neuralgia .
bilateral abduction and adduction in the two lower limbs. This technique has been reported in a case of PGAD and
An MRI scan of the lumbosacral spine and bilateral hip, as proved to be effective for the immediate improvement of
[19]
well as electroneuromyography, was requested. The dose of symptoms .
pregabalin was adjusted to 150 mg per 12 h while the doses Since the etiology of PGAD is not yet well defined,
of other medications were maintained. Neurosurgical there is no established protocol for the management of
evaluation pointed to the necessity of pudendal block, this condition. However, several interventions have been

Volume 2 Issue 4 (2023) 3 https://doi.org/10.36922/gtm.2341