Introduction 

Persistent genital arousal disorder (PGAD) is random and unwanted genital arousal without sexual stimulation. It is a rare disorder which is still largely misunderstood. Approximately 1-6% of people are reported to be diagnosed with PGAD.¹ With the absence of desire and its persistent nature, this disorder can be debilitating, having life-changing effects on mental health. 

Although the exact causes of PGAD remain unknown, certain medications can induce this disorder. Where hormones like serotonin levels in the body are altered, symptoms of unwanted genital arousal can arise. Serotonin levels can be particularly affected by antidepressants like serotonin reuptake inhibitors (SSRIs), making these a common culprit. Interestingly, research has suggested that both the discontinuation and use of these medications can trigger PGAD. In this article, we will discuss the role of these medications in PGAD and help you to understand your symptoms, while bringing awareness to this disorder. 

Understanding persistent genital arousal disorder 

PGAD is the spontaneous and unwanted arousal of the genitals with the absence of sexual desire. This can present at times when you normally would not expect to be aroused. Symptoms include unwanted erections or vaginal swelling which can be uncomfortable.⁴ The amount of time the symptoms last may vary, with reports of it even persisting for weeks. Due to its persistent nature, daily activities like work and school can be interrupted. 

Often this disorder can be confused with hypersexuality. Hypersexuality can be characterised as compulsive sexual desire or sex addiction. In PGAD, there is no desire involved and only physical symptoms of arousal are experienced. You can think of this as an irregularity between the mental state and the body. Due to the lack of understanding surrounding this disorder, often symptoms and experiences may be dismissed.

Let's explore the symptoms of PGAD in depth. There are many physical and psychological symptoms which can be experienced.²

• Constant genital arousal - you may experience pain and feel like you are constantly on the verge of sexual climax
• Pelvic pain with radiation down to the legs, lower back and/or buttocks
• Urological issues. Increase in urgency and frequency of emptying the bladder
• Restless leg syndrome - an urge to move the lower limbs constantly while resting
• Anxiety and depression
• Sexual dysfunction. Arousal can become associated with PGAD rather than sexual desire. Intimacy and relationships can become difficult

Due to the stigma, a lot of sufferers of PGAD do not seek medical help. At this current time, there are more reports of PGAD being diagnosed in women. However, the accuracy of this can be questioned due to the expected underreporting.

Antidepressants and sexual function 

Depression is the constant feeling of sadness and loss of interest in normal daily activities.⁵ Depression and other mood disorders are commonly treated by antidepressants, with SSRIs being amongst the most common ones. While known to be extremely effective in treating these mood disorders, the side effects are known to be difficult for the user. The sexual side effects of these medications are some of the most reported. These can include the inability or delay of reaching sexual climax and reduced libido. 

As mentioned previously, the main cause of these side effects is the effects of these medications on the hormone serotonin. Serotonin is a neurotransmitter which is involved in the regulation of mood, sleep and appetite. While SSRI increases the effect of serotonin, the effects of dopamine can be decreased. This is an important factor to take note of because dopamine is involved in the regulation of sexual pleasure. 

However, the effect these SSRIs have on the body can vary from person to person. The above mechanism is what is expected but the existence of PGAD shows that it does not always work the same way for everyone. The processes by which sexual pleasure and mood are regulated are extremely delicate and interruptions by the use of SSRIs can cause adverse effects. More research needs to be done to understand why some individuals experience contradicting side effects. 

The link between SSRIs and PGAD 

Many hypotheses have been proposed to understand the link between the onset of PGAD and SSRIs. Although none of them have been fully proven, some do present sensible mechanisms. 

Some of the theories proposed suggest that when SSRIs are used, receptor sensitivity in the brain is altered, which then has effects on the peripheral nervous system. When usage is chronic, the brain compensates for the high levels of serotonin caused by the SSRIs by decreasing the effect of other receptors. As a result, some of these receptors that control the pathways involved in genital arousal may become interrupted and unregulated too.³ 

Other theories suggest that the constant suppression of dopamine caused by SSRIs can overstimulate the pathways involved in genital arousal, causing the debilitating symptoms of PGAD.³

However, the most common theory surrounds the onset of PGAD due to SSRI withdrawal. Abrupt discontinuation of SSRIs is known to be extremely symptomatic with experiences such as insomnia and dizziness. Sometimes, one of these symptoms of withdrawal can be PGAD.7 Agai,n the mechanism of action of this is not well known. 

Chronic use of SSRIs hypersensitise serotonin receptors in the brain. Abrupt discontinuation disrupts the balance between the important neurotransmitters which may cause the spontaneous genital symptoms seen in PGAD.³ These symptoms are less common when SSRIs are titrated off.

Other causes of PGAD

While antidepressants and SSRIs are often seen as a more common cause of PGAD, having pre-existing comorbidities may make you more susceptible.⁸

Examples of these pre-existing conditions include:

• Pelvic floor dysfunction. This can increase symptoms of PGAD. Irritation of the pelvic floor muscles can activate the sensory nerves involved in PGAD causing unwanted and continuous genital arousal
• Obsessive-compulsive disorder (OCD)
• Post-traumatic stress disorder (PTSD)
• Menopause

Managing and treating symptoms 

Due to the lack of understanding surrounding the mechanism of PGAD, treatment and management are difficult. However, many methods have been trialled and shown to be effective. Whether a single method or multiple approaches are used, PGAD symptoms can be made more manageable.

These management methods may include pharmacological interventions like dopamine agonists and benzodiazepines, cognitive behavioural therapy and mindfulness activities.⁶ Where it is thought that the pelvic floor is involved in the onset, pelvic floor therapies can be recommended to relieve irritation and tension in the muscles and nerves. It is important to address the stigmatisation surrounding PGAD and to ensure that support groups are made available. 

FAQs

Is PGAD genetic?

There is no known gene linked to PGAD. However, if heightened nerve sensitivity which can be genetic persists, you may have an increased risk of PGAD.

Is PGAD permanent?

Not necessarily. Sometimes PGAD symptoms can be temporary and recovery can depend on the causes and how your body responds to stopping the antidepressants.

Summary 

Persistent genital arousal disorder can be extremely debilitating, with a lot of stigma surrounding it. More awareness around it must be created so that the many people using SSRIs and antidepressants know that a side effect can be PGAD. The way SSRIs work in the brain can be complex but if you are aware of the risks associated with the way these medications work, you can understand why conditions like PGAD may arise. 

The exact link between these antidepressants and PGAD needs better understanding but PGAD symptoms need to be taken seriously. Although there is no definitive cure or treatment, symptoms can be managed and these should be widely accessible for those experiencing PGAD.