Introduction

Persistent genital arousal disorder (PGAD) is a condition that causes you to experience the sensations of arousal, specifically genital arousal, in the absence of sexual stimulation or thoughts.^1,2 These sensations may include throbbing, tingling and pressure, which are often not relieved by orgasm, and can persist for hours or days.¹ Whilst its precise prevalence is not known, we know that PGAD predominantly affects cisgender women,² and that it is highly likely to be underdiagnosed.³ The causes of PGAD are still being investigated by scientists, although emerging research^3,4,5 has suggested that your nervous system, particularly the nerves that supply your genital region with sensation, has a possible role in the onset of symptoms.

In this article, we’ll explore the anatomy and function of your nervous system, focusing on the nerves that supply your pelvic and genital region with sensation and movement, and how the entrapment of these nerves can lead to symptom onset.

Anatomy and function of the pudendal nerve

Your peripheral nervous system (PNS) comprises your entire nervous system excluding your brain and spinal cord, and is itself a network of nerves that provide sensation (innervation) to different areas of your body.

One of the major nerves that supplies sensation to your pelvic region and genitalia is the pudendal nerve, which comes from your lower spine region called the sacrum (S2-S4).⁴ The pudendal nerve exits your pelvis through the greater sciatic foramen, curves around a bone called the ischial spine, re-enters your pelvis through the lesser sciatic foramen, and travels through Alcock’s canal (a tunnel-like structure formed by surrounding tissue).⁴ This complex nerve pathway is important in controlling your pelvic floor muscles (muscles that support pelvic organs, e.g. bladder and uterus) and functions such as sexual sensation, urination, and defecation.

The pudendal nerve separates into three main branches:

• The Dorsal nerve of the clitoris is responsible for providing sensation to your clitoris and is important in sexual sensations⁴
• The Perineal nerve controls the movement of your perineal muscles, and provides sensation to your labia⁶
• The Inferior rectal nerve controls your muscles and skin around your anus⁶

Understanding nerve entrapment

Your nerves can become irritated through direct injury, being stretched, compressed, or entrapment.^8,9 Since your nerves are highly sensitive and don’t like to get trapped, this can cause unpleasant or painful sensations in the affected area. Sometimes the cause of an irritated nerve is unknown, but common causes may include an unusual anatomy, childbirth (vaginal delivery), pelvic injuries, surgeries in your pelvic region, sitting on hard surfaces for prolonged periods, or excessive cycling.^8,9

Beyond causing unpleasant sensations, trapped nerves can trigger:

• Neurogenic inflammation: This is a special type of inflammation where your nerves release chemicals that trigger inflammation. Now the inflamed area has become even more sensitive, creating a vicious cycle where more sensitivity leads to sensations feeling more intense, which leads to more discomfort¹⁰
• Ectopic discharge: This is the abnormal, or spontaneous firing of your nerves, which can cause unusual sensations like tingling or burning. For instance, your nerves may send a signal to your brain without them even being stimulated¹¹
• Central sensitisation: this is when your brain becomes overly sensitive to incoming sensory signals. Sensations you may have previously considered to be minor are amplified and perceived as more intense. You can think of this like a car alarm sounding at the slightest breeze^10,12

Pudendal nerve compression and PGAD

Researchers have found that when your pudendal nerve, especially the branch that connects to your clitoris (dorsal nerve), becomes irritated or trapped, it may directly contribute to the onset of PGAD symptoms.^2,4,5 This compression may happen due to the previously mentioned causes, but also if your pelvic muscles are too tight and press on your pudendal nerve. Additionally, nerves passing through narrow spaces like Alcock’s canal (Pudendal canal) can be enough to trigger irritation.^4,5

Like we discussed previously, our nerves don’t like to be trapped; This is also true for the pudendal nerve, only now the irritated nerve is causing you to experience heightened sensitivity and abnormal sensations in your genital region. This usually manifests as an intensified or continuous sense of arousal, even when nothing sexual is happening. You can think of it like a faulty wire that keeps sending electrical signals despite the switch being turned off. The sensations you experience may include:

• Tingling, throbbing, and pressure in your genitals
• Engorgement of your clitoris
• Vaginal contractions
• Vaginal lubrication
• Pain or discomfort in your genital area
• Unprovoked orgasm/s

The symptoms of PGAD can last hours, days, or persist over longer periods of time, with orgasms often not sufficient to provide reprieve.^1,2 Symptoms may also become worse when sitting or from wearing tight-fitting clothing on your lower body, which further suggests the mechanical influence of nerve compression.

It is important to be aware that not all cases of PGAD are related to the irritation of your pudendal nerve. However, if you happen to note that your symptoms are linked to certain positions, or began after any pelvic-related injury, or surgery, etc, it may explain and help guide you to receiving effective treatment.

Summary

PGAD is a complex condition that is still poorly understood. Whilst researchers are still investigating the different causes of PGAD, emerging evidence has revealed that the nervous system has a role in symptom onset. The pudendal nerve has important functions in movement and sexual sensation, and when irritated, can cause you to experience genital arousal without sexual stimulation or desire. Understanding how your nervous system may play a role in PGAD symptom onset is important to help reduce the stigma surrounding the condition and help you receive effective treatment.

FAQs

How is pudendal nerve compression diagnosed?

Diagnosis often involves pelvic exams and magnetic resonance imaging (MRI)⁴, which can identify if a nerve is compressed or if there are any abnormalities around the nerve. A review of your symptom history will likely be explored, especially if your symptoms appear linked to your positioning, posture, or previous injuries to the pelvic area.

How is pudendal nerve compression treated?

The treatment for pudendal nerve compression will depend on what is causing irritation of the nerve, e.g., if it is caused by tight pelvic floor muscles or by a cyst nearby that is applying pressure on the nerve. Once the cause has been established, your medical provider will determine the best treatment for you. This may include physical therapy (to release tight pelvic floor muscles), medication to reduce or block nerve signalling (nerve blocks), or in some cases, surgery (e.g., cyst removal).⁹