Introduction 

Overview of PGAD

Persistent genital arousal disorder (PGAD) is a rare and sensitive condition that is described by a person feeling too much and continuous genital arousal (pulsation, swelling, tingling) even when they are not aware of having a sexual desire and are not being stimulated through sexual intercourse.¹ This means having unwanted “turn-ons” that you cannot control. The arousal doesn't go away during a normal sexual experience or orgasm. 

PGAD was earlier thought to be a disorder for only females, but it can affect both males (presentation is different and pathology is unknown) and females. Although it has been more studied and noted in females, it is believed to affect about 1% of females in the population.^2,3 Many affected individuals find it very upsetting, annoying, uncomfortable, and even painful in some cases. When it gets very bad, it can even cause a lot of suicidal thoughts, feelings of shame, isolation, and in severe instances, lead to suicide.^1,4 This can result in psychological and social distress. 

The disease can be referred to as new; it was first described in 2001. In 2010, some diagnostic criteria were established, which included:² 

• Physical signs of sexual arousal lasting for hours, days, or months, like swelling, tingling, throbbing, or heightened sensitivity to touch in the genital area
• Genital arousal  not relieved with an orgasm
• Genital arousal without sexual interest and desire
• Arousal was unwanted and bothersome
• Arousal caused anxiety

There have been several explanations about the cause or causes of PGAD, but the basis of the condition is still very unclear.⁵ Hence, it is essential to be aware of the issue. Many people suffer silently and are left undiagnosed/untreated due to limited awareness and understanding of this condition. 

This article will discuss the neurological, vascular, and hormonal factors that contribute to PGAD, to provide a better understanding of its aetiology.

Neurological causes of PGAD 

What is the role of the nervous system in normal genital arousal?

For both sexes, genital arousal is a dynamic process that involves a complex interaction between the central and peripheral neural pathways that will cause the final event of penile erection and clitoral tumescence.⁶ 

These include the nervous system's central (CNS) and peripheral (PNS) components. Different parts of the brain (i.e. amygdala, hypothalamus, insula) are responsible for the thought process of sexual arousal and excitement; they then send signals to the PNS. The PNS, through the somatic nervous system and sacral/thoracolumbar components of the parasympathetic and sympathetic nervous systems, is crucial for the arousal process. This is done with the help of neurotransmitters and nerves.⁶ If the nerves or associated structures relating to the genitals are altered or faulty, it may cause PGAD.² 

There are certain neurologic disorders or malfunctions that can cause PGAD, some of which are discussed below.

Nerve dysfunction/neuropathy 

The pudendal nerve is one of the nerves important for regulating erectile and ejaculatory functions of the arousal process. Its dorsal part transmits perception of stimulation to the skin over the sides and tissues of the penis/clitoris; this is what the body translates and essentially what you feel when you are aroused.⁸
The compression, entrapment, irritation, inflammation, or damage to this nerve can lead to PGAD symptoms.⁷

A number of studies in women support the claim that a damaged pudendal nerve contributes to the aetiology of PGAD, with most patients experiencing hyperesthesia.^2,9 You feel a heightened sensation to little or no touch on your genitals.

This damage could be caused by:^2,8,10

• Spinal cord injury
• Herniated discs 
• Pelvic surgery, pelvic trauma, birth injury, falls, bicycle riding
• Surgical (sling procedures for stress urinary incontinence) or diagnostic procedures (colonoscopies) 
• Clitoral adhesions
• Papillary hidradenomas or periclitoral masses 

What brain deficits can cause PGAD?

Some parts of the brain, like the amygdala, hypothalamus, and insula, are involved in different aspects of sexual function. While the exact processes are still not fully known, studies show that problems in these parts of the brain may cause PGAD.¹¹  

Tarlov’s cysts, a fluid-filled ball of isolated or multiple nerve roots in the spine, and restless legs syndrome have been found to be a consistent cause of PGAD in females.² These may co-occur with other disorders like irritable bowel syndrome and an overactive bladder. Individuals with Tarlov's cysts have their nerves in the sacrum compressed or entrapped, which can be very painful and restrictive; however, many studies show that surgical removal of the cysts can relieve PGAD symptoms.¹

Other neurological conditions that may contribute to PGAD are multiple sclerosis and epilepsy.¹¹

Vascular causes of PGAD

Blood flow (circulation) issues can also cause PGAD since healthy sexual stimulation depends on good blood flow. Any problem with blood flow, whether it's in the veins or the arteries, can cause persistent congestion, hypersensitivity, and involuntary arousal.

A vascular issue that has been shown to be part of the cause of PGAD in women is pelvic congestion syndrome (PCS).¹² In PCS, veins in the ovary and pelvis are weak, so they bulge, twist, and turn (varicose), causing the woman to have chronic pain that can worsen with activities like walking, lifting, and even standing for a long time.¹³

A study showed that steroids and cardiac shunts may, in individuals with heart defects, also cause PGAD symptoms by increasing vascular permeability.¹²

Hormonal causes of PGAD 

Our hormones are also involved and very important in the control and regulation of sexual desire, genital sensitivity, and vascular function. An imbalance in hormones like oestrogen, progesterone, testosterone, and cortisol, for example, can cause persistent genital arousal disorder (PGAD) by impacting nerve sensitivity, blood flow, and neurotransmitter activity.¹⁴ 

Here are some of the hormones and how PGAD may occur due to their fluctuations:

Oestrogen and PGAD

Oestrogen is a female gonad hormone; it is responsible for maintaining blood flow, feelings of sensation, and lubrication of the female genitals. When you have too little oestrogen, it can cause problems like PGAD.

In menopausal and perimenopausal women whose oestrogen levels decline with age, they are commonly affected by genitourinary syndrome of menopause (GSM). In these individuals, the cells and tissues of the vagina, labia and surrounding genital structures start to dry, wear off, and waste (atrophy).¹⁵ 

This causes a sort of overreaction, widening and swelling of the blood vessels in the pubic area that then causes PGAD symptoms.

Testosterone and hypersensitivity

Abnormal testosterone levels can also increase how sensitive your genitals will be. These abnormal levels of testosterone can occur when one uses hormone therapy medications.

Transgender and postmenopausal women using testosterone supplements can develop symptoms of PGAD.¹⁶

Cortisol and stress-related hormonal dysregulation

The body controls reactions to stress by releasing the stress hormones in line with our fight-or-flight response. 

Studies have discovered that chronic stress, anxiety, and obsessive-compulsive behaviours (OCD) cause/co-occur with PGAD.¹⁷ This is because the sequence of stress hormones released by the hypothalamic-pituitary-adrenal (HPA) axis is damaged.

Summary 

PGAD is a complicated and sensitive disease that affects the nervous, vascular, and hormonal systems, among others. In summary: 

• Neurological causes include the nerve, brain, and neurotransmitter dysfunction or imbalances, while
• Vascular causes, like pelvic congestion syndrome and problems with how blood flows through the vessels supplying the genitals, will cause a PGAD
• Low oestrogen, an increase in testosterone, or hormone changes caused by stress can also cause PGAD
• People need to be aware of PGAD, as it will help further studies, identification, and better treatment options

FAQs

Is PGAD the same as hypersexuality?

PGAD is not the same as hypersexuality. In contrast, PGAD does not involve unwanted and frequent sexual thoughts and desires.¹⁸ The feeling of genital arousal happens even though there is no sexual desire. People with PGAD may seek relief from sexual activity and masturbation to get rid of tension, not for joy and a pleasurable experience.

Does PGAD affect sexual life?

Most people affected by PGAD explain that they can no longer enjoy their sexual lives. For some, they have had to increase their sexual activity to relieve symptoms, while others say that they avoid having sex. Some comments made by affected persons in a particular study include:⁵

• “I cannot engage in sexual activity without suffering serious effects”
• “PGAD has made me not want sex because it makes my symptoms worse”
• “I’m scared of sex”
• “My partner felt guilty”

Can PGAD be treated?

There is no specific treatment or cure for PGAD because the disorder is not fully understood yet. Efforts to treat PGAD involve treating the underlying cause. 

Some examples of specific treatments for neurovascular and hormonal causes of PGAD are: topical anesthetics, pelvic floor therapy, nerve decompression, botulinum injections, pharmacological therapies (SNRIs), and venous embolization.²