Surgical Outcomes of PGAD/GPD Patients with Sacral Radiculopathy Associated with Tarlov Cyst

Introduction In 2012, Komisaruk and Lee introduced the concept that a bothersome women's sexual health issue associated with catastrophization and suicidal ideation, currently defined as Persistent Genital Arousal Disorder/Genito-Pelvic Dysesthesia (PGAD/GPD), could be mediated by sacral radiculopathy from Tarlov cysts in the cauda equina. To more safely and effectively manage PGAD/GPD patients in our facility with such suspected cauda equina pathology, a robust collaboration was developed in 2016 among specialists in sexual medicine, spine surgery and neurophysiology. A management algorithm was developed to select appropriate patients for surgical treatment. Objective The aim of this study is to review the treatment outcome of PGAD/GPD patients with sacral radiculopathy associated with Tarlov cysts in the cauda equina selected by our collaborative management algorithm. Methods Charts from 2015 to 2021 of PGAD/GPD patients presenting to our sexual medicine facility were reviewed. Patients who met the definition of PGAD/GPD in the broadest sense were included. They all experienced unwanted, unrelenting, distressing dysesthesia symptoms (e.g. arousal, pain and/or itching) in the genito-pelvic region lasting >3 months. The management algorithm was used to identify those PGAD/GPD patients with sacral radiculopathy from a surgically treatable sacral Tarlov cyst. The algorithm included: i) ruling out triggers in the end organ and pelvic/perineum regions; ii) performing neurogenital testing to identify patients with test results consistent with sacral radiculopathy; iii) reading sacral MRIs during regular collaborative meetings to identify patients with a surgically treatable sacral Tarlov cyst; and iv) performing a caudal block with an anesthetic agent to assess for temporary clinically significant PGAD/GPD symptom reduction. Those patients who met these selection criteria and underwent an imbricating Tarlov cyst procedure using minimally invasive spine surgery techniques were followed for at least 6 months. Results Ten patients (8 women, 2 men), mean age 40 years (range 19 - 66), met inclusion criteria. Patients were discharged the same day or the next morning post-operatively. There were no serious complications. Follow-up was > 6 months (range 6 - 16 months). A total of 7 (70%) patients reported post-operative clinical improvement on PGI-I at last follow up. Two patients reported “very much better”, three patients reported “much better” and two patients reported “little better”. Two patients had no improvement. One patient was much worse; it is believed that the PGI-I score of 6 reflects the worsening of the PGAD/GPD condition and not a specific result of the surgical procedure. Conclusions Cauda equina pathology from Tarlov cysts can cause distressing PGAD/GPD from sacral radiculopathy. Collaboration among sexual medicine, spine surgery and neurophysiology specialists enabled an effective management algorithm to identify and treat appropriate PGAD/GPD patients with sacral radiculopathy having a surgically treatable sacral Tarlov cyst. Imbricating the Tarlov cyst using minimally invasive spine surgery techniques is associated with a 70% clinical improvement in these select patients. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Elliquence and Lumenis