Workup for Persistent Genital Arousal Disorder (PGAD)
The diagnostic workup for PGAD should include a comprehensive neurological evaluation, focusing on potential sacral neuropathy, as neurological causes are frequently identified in patients with this distressing condition. 1
Initial Assessment
Medical History
- Detailed characterization of arousal symptoms:
- Onset and duration of symptoms
- Frequency and intensity of arousal episodes
- Presence or absence of orgasm during episodes
- Triggers (sexual or non-sexual)
- Response to orgasm (whether symptoms resolve temporarily)
- Associated distress and impact on quality of life
Key Associated Symptoms to Evaluate
- Urologic complaints (present in 70% of patients) 1
- Neuropathic perineal or buttock pain (present in 60% of patients) 1
- Symptoms of overactive bladder 2
- Symptoms of restless leg syndrome 2
- Psychiatric symptoms (anxiety, depression, relationship difficulties) 3
Medication Review
- Complete medication history to identify potential pharmacologic causes 2
- Special attention to:
- Recent medication discontinuation (particularly antidepressants)
- Medications affecting serotonin levels
Physical Examination
- Focused neurological examination of lower extremities
- Pelvic examination to rule out local pathology
- Assessment for signs of neuropathy
Diagnostic Testing
First-Line Testing
- MRI of lumbosacral spine with focus on:
- Tarlov cysts (most common neurological finding in 40% of cases) 1
- Spinal disc herniation
- Spina bifida occulta
- Other structural abnormalities
Additional Testing Based on Clinical Suspicion
Electromyography and nerve conduction studies to evaluate for:
- Sensory polyneuropathy (found in 20% of patients) 1
- Pudendal neuropathy
Laboratory testing:
- Thyroid function tests
- Blood glucose/HbA1c
- Serum testosterone levels (as recommended for other sexual disorders) 4
Urodynamic testing if urologic symptoms are present
Psychological Assessment
- Evaluation for:
- Anxiety disorders
- Depression
- History of sexual trauma
- Relationship difficulties
- Impact on quality of life
Multidisciplinary Approach
Given the complex nature of PGAD, a multidisciplinary approach involving neurology, urology, gynecology, and mental health professionals is essential for proper diagnosis and management 5. The workup should be tailored based on the predominant symptoms and suspected etiology.
Common Pitfalls to Avoid
- Attributing symptoms solely to psychological causes without thorough neurological evaluation
- Failing to identify potentially treatable neurological lesions
- Overlooking medication-related causes
- Not addressing the significant psychological distress associated with the condition
The evidence strongly suggests that PGAD is often a neurological condition with identifiable causes in up to 90% of cases when properly evaluated 1. Appropriate neurological treatment resulted in significant improvement or cure in 80% of treated patients in one case series, highlighting the importance of thorough neurological workup rather than assuming a purely psychological etiology.