A case report of persistent genital arousal disorder/genito-pelvic dysesthesia secondary to lumbar facet cyst-induced sacral radiculopathy treated by lumbar endoscopic spine surgery

Abstract Introduction Persistent genital arousal disorder/genito-pelvic dysesthesia (PGAD/GPD), characterized by distressing, abnormal genito-pelvic sensations, especially unwanted genital arousal, may be triggered by pathology in Region 3, the cauda equina. Sacral radiculopathy is an inflammatory irritation of the S2-S3 nerve roots in the cauda equina, formed by convergence of pelvic, pudendal, and sciatic nerves and clinical symptoms that involve the sensory fields of these nerves. In a subgroup of patients, both cauda equina Tarlov cyst-induced sacral radiculopathy and lumbosacral annular tear-induced sacral radiculopathy have been reported to trigger PGAD/GPD, and in both conditions, endoscopic spine surgery has been shown safe and effective. Lumbar facet cysts, most common at the L4-L5 level, arise from lumbar zygapophyseal joints and can cause sacral radiculopathy. Thus, it is possible that lumbar facet cyst-induced sacral radiculopathy may be a trigger for PGAD/GPD. Objective To report one case of PGAD/GPD secondary to lumbar facet cyst-induced sacral radiculopathy, successfully treated with lumbar endoscopic spine surgery (LESS). Methods A 55-year old woman with a long history of PGAD/GPD presented to our spine-sexual medicine program for biopsychosocial assessment and treatment using our multidisciplinary management algorithm: Step A) detailed psychosocial and medical history; Step B) non-invasive assessments for sacral radiculopathy; Step C) targeted diagnostic transforaminal epidural spinal injection (TFESI) resulting in temporary clinically significant reduction of PGAD/GPD symptoms; Step D) surgical intervention with LESS and post-operative multidisciplinary follow-up. The patient was diagnosed with PGAD/GPD from lumbar facet cyst-induced sacral radiculopathy and underwent LESS for an L4-5 facet cyst. Results This 55 year old cisgendered woman had multiple painful spontaneous orgasms, shooting sharp pains that felt “like a bruise” going up the inside of her vagina, hypersensitivity of her vulva, clitoris, vagina, urethra and anus, along with constant symptoms of arousal and urinary urgency. These began in 2008 after her second childbirth. Her PGAD symptoms worsened over the last 2 years. She experienced sensations of pins and needles in her right buttocks, front of her left thigh, and down both legs into feet and toes. She also had severe constipation and restless leg syndrome. Neurogenital testing, including quantitative sensory testing, sacral dermatome testing and bulbocavernosus reflex latency testing, were all abnormal consistent with sacral radiculopathy. Region 1 anesthesia testing for vestibular pain showed persistent PGAD/GPD symptoms despite numbness on vestibular cotton swab testing. Pudendal nerve testing was negative. It was thus hypothesized that her PGAD/GPD trigger was closer to the central nervous system. Her MRI showed an L4-5 facet cyst. A TFESI with anesthetic was positive with temporary symptom reduction. She underwent LESS to excise the facet cyst and was discharged the same day. At early post-operative follow-up, she is PGAD-free. She no longer has irritative bladder symptoms, sciatica, restless leg syndrome, or pins and needles, and her constipation symptoms have improved. Conclusions Of the many recognized triggers for PGAD/GPD, we report for the first time a patient diagnosed with lumbar facet cyst-induced sacral radiculopathy after a multidisciplinary step-care management algorithm evaluation. She experienced marked improvement with lumbar endoscopic spine surgery. Disclosure No