Introduction

Persistent Genital Arousal Disorder (PGAD) is a rare, unpleasant syndrome that those who are assigned female at birth go through. It was first reported in 2001 by Leiblum and Nathan; however, it is still poorly understood.¹ 

The patient endures genital arousal even though the sexual desire has nothing to do with the arousal.² The symptoms can be triggered at random times without the presence of genital stimulation (masturbation) or sexual ideas; however, because it is poorly understood, it is difficult to diagnose. This is why it is essential to understand the clinical criteria as well as the differential diagnostic methods of PGAD so that patients are also comfortable while talking about their concerns. 

Symptoms of PGAD

The main symptom of PGAD is the feeling of unwanted genital arousal without sexual desire. To be specific, the sensations in the genitals include;

• Tingling
• Pulsing 
• Throbbing
• Swelling 
• Heightened sensitivity 

PGAD is particularly challenging as the standard method of arousal relief, such as causing orgasms, doesn’t typically work to help with the uncomfortable state patients go through. In reality, it might give temporary relief or worsen the symptoms. Day-to-day activities are significantly impacted by PGAD, which can result in physical discomfort, mental stress, such as anxiety, loneliness, depression, guilt, and/or embarrassment, so it is important to remove the stigma surrounding the condition to allow people to seek the correct support.

Physical discomfort consists of;

• Increased sensitivity to vibrations, such as travelling on a bus
• Pain in the pelvic region
• Discomfort when wearing tight clothes 
• Discomfort whilst sitting 
• Pain on the bottom²

Diagnostic criteria for PGAD

At the moment, there are no universal diagnostic guidelines to follow for PGAD; however, with clinical case studies and expert consensus, an unofficial guide is available for healthcare professionals to help identify the condition created by Leiblum and Nathan. The criteria are heavily dependent on patient-reported symptoms, which means that it is important to be thorough with open clinician-patient communication as well as a look at the patient's history.

1. Uncontrollable genital arousal sensations

The hallmark feature of PGAD is the experience of ongoing physical sensations such as genital throbbing, tingling, swelling, pulsation, or heightened sensitivity. Unlike physiological sexual arousal, these sensations arise spontaneously and are not linked to sexual desire or stimulation. The arousal can be caused by activities such as sitting, walking, or exposure to vibrations.

2. No sexual desire

A defining element that differentiates PGAD from hypersexuality or typical sexual arousal disorders is the clear disconnect between physical arousal and sexual interest. Patients consistently report that the physical symptoms occur without any conscious sexual thoughts or fantasies, and they often find these feelings deeply distressing rather than pleasurable.

3. Distress 

PGAD has a social and physiological impact. Some patients would describe their experience as having made a disruption in their intimate relationships, daily activities and overall mental health due to feelings of shame and anxiety. 

4. Temporary relief 

Symptoms can temporarily be subdued after an orgasm; however, the relief is only for a short time. This highlights the odd symptom of PGAD, as sexual arousal would no longer be present after an orgasm for a while.

5. Extended duration of symptoms

PGAD symptoms last for a long time and their intensity fluctuates; however, the symptoms do not resolve by themselves, so they need the appropriate intervention to aid with symptoms. 

PGAD is also primarily diagnosed using patient narratives, which would only work when the experts create a safe space for patients by creating a non-judgmental space so the patients can freely talk about their symptoms. 

An expert had 10 female participants with PGAD syndrome aged between 11 -70 years. With the observations, two patterns were found 

1. 80% had daily out-of-context sexual arousal episodes (≤30/day), which usually resulted in an orgasm 
2. 40% had lesser but longer-lasting nonorgasmic arousals ²

Studies have also shown that patients with PGAD suffer from higher rates of sexual dysfunction, swelling of the genitals, and a lot of lubricants as well as a detrimental effect on their mental health, which points towards depression, fearing and avoiding places that might cause panic and feeling helpless or embarrassed.³ 

Associated symptoms frequently include neurological factors such as restless leg syndrome and nerve damage, which can cause pain and weakness in the pelvic region. Sacral dorsal-root Tarlov cysts are also common, which are fluid-filled sacs on sacral nerve roots (nerves located in the pelvis).⁴

Clinical examination

Clinicians need to ask about past trauma which involves the genital region, lumbar spine and pelvis. If there was any history of childbirth complications, sexual abuse, injuries or surgical procedures, it should be documented. History of medication such as antidepressants, particularly SSRIs and SNRIs, should be considered as their withdrawal symptoms can be linked to PGAD-like symptoms. 

A mental health assessment is also a vital tool for diagnosis, considering the relationship between PGAD symptoms and psychological distress. Physical examinations should solely focus on pelvic examination as well as neurological examination. 

Although there is no definitive physical test for PGAD, signs of pelvic nerve entrapment and signs of nerve hypersensitivity can be a diagnostic clue. Finally, a gynecologic examination is also vital as it can show vascular congestion of signs of pelvic floor dysfunction, whilst neurological evaluation would show areas that have nerve damage or irritations.²

Differential diagnosis

Many conditions share the same symptoms as PGAD so it is vital to rule out other potential causes before officially making a diagnosis, which is why several healthcare providers step in, as mentioned above. 

1. Neurological assessment

Doctors may do tests to examine pelvic nerve function because PGAD may be associated with nerve discomfort. Imaging such as MRI scans may be advised if nerve damage is suspected in order to check for conditions such as spinal nerve compression or Tarlov cysts.

2. Pelvic examination

A pelvic exam can help rule out problems like pelvic congestion, swelling of the clitoris, infections, or masses that might be pressing on nerves which can affect movement and sensations in the genital and anus which also controls defecation and urination.^5,6Clitoral priapism can be ruled out through vaginal inspection.

3. Hormonal testing

The symptoms of PGAD may be influenced by hormonal abnormalities, particularly following menopause. Hormone levels can be checked using blood testing.

4. Medication review

Healthcare professionals will examine any past or present medication use to determine whether these could be contributing factors because certain medications (such as hormone therapy or antidepressants) can alter blood flow or the neurological system.

5. Psychological assessment

A mental health evaluation can assist in determining whether the symptoms are being exacerbated by stress, worry, or a traumatic experience. This is not to suggest that PGAD is "all in the mind," but controlling the illness requires an awareness of emotional wellness.

6. Imaging tests

To look for structural issues in the spine, pelvis, or pelvic nerves that could be causing symptoms, MRI or ultrasound scans may be performed.

Through these methods, doctors can exclude other conditions like:

• Urinary tract infections (UTIs): ruled out through dipstick test
• Vulvodynia (chronic vulval pain): ruled out through pelvic examination
• Pelvic floor dysfunction: ruled out through pelvic examination
• Spinal disorders: ruled out through imaging tests
• Clitoral priapism: ruled out through vaginal inspection 

FAQs

Is PGAD a psychological or physical condition?

Both are neurological and psychological components. While physical nerve issues are often involved, psychological factors like anxiety or trauma can also play a role. 

Can PGAD go away on its own?

It is very rare for PGAD to go away by itself, and it often needs assistance with appropriate intervention

What is the cure for PGAD?

Although there is no known cure for PGAD, there are treatments that can help with its symptoms, including physical therapy, psychological support, and medications that block nerves.

Summary

In summary, PGAD results in involuntary genital sensations, such as tingling or swelling, particularly on the clitoris, without any trigger or sexual desire. The sufferers' daily lives are impacted by this uncommon and upsetting illness. Since there are no recognised tests for PGAD, the diagnosis is made based on the patient's description of symptoms, ruling out other illnesses such as infections and nerve problems as well as emotional factors. A considerate and comprehensive approach is necessary to guarantee the accuracy of the diagnosis and the patient's support.