What is the recommended treatment for persistent genital arousal disorder?

Treatment of Persistent Genital Arousal Disorder

The recommended first-line treatment for persistent genital arousal disorder (PGAD) is selective serotonin reuptake inhibitors (SSRIs) such as paroxetine, sertraline, fluoxetine, or citalopram, combined with psychological interventions targeting the underlying causes of the condition. 1

Understanding PGAD

PGAD is characterized by:

• Persistent sensations of genital arousal in the absence of sexual stimulation or emotion
• Unwanted arousal that causes moderate to severe distress
• Symptoms that can be spontaneous and unrelenting
• Arousal that does not typically remit after orgasm(s)
• Symptoms that can last hours, days, or occur constantly 2

Treatment Algorithm

First-Line Approaches:

1. Pharmacological Treatment:

   • SSRIs: Paroxetine, sertraline, fluoxetine, or citalopram 1, 3
   • Anticonvulsants: Pregabalin or gabapentin for modulating sensory perception 4, 5
   • SNRIs: Duloxetine has shown effectiveness in some cases 3, 5

2. Psychological Interventions:

   • Cognitive-behavioral therapy
   • Mindfulness meditation and acceptance therapy
   • Psychosexual therapy
   • Therapy to improve communication with partners 1, 2

Second-Line Approaches:

1. Physical Therapies:

   • Pelvic floor physical therapy
   • Transcutaneous electrical nerve stimulation
   • Manual therapy 3

2. Neuromodulation Techniques:

   • Transcranial magnetic stimulation
   • Electroconvulsive therapy (for severe cases) 3, 6

3. Additional Pharmacological Options:

   • Clonazepam for anxiety-related symptoms (use with caution due to addiction potential) 3
   • For restless leg syndrome-associated PGAD: Pramipexole or ropinirole 3
   • Cannabinoids (limited evidence) 5

Important Considerations

Medication Cautions

• SSRIs paradoxical effect: While SSRIs are first-line treatment, they can also induce or worsen PGAD in approximately 28% of cases, particularly during administration or discontinuation 5
• Monitor closely for symptom changes when starting or stopping serotonergic medications

Evaluation for Underlying Causes

• Assess for potential neurological conditions (e.g., Tarlov cysts, spinal lesions)
• Screen for vascular abnormalities
• Evaluate for pelvic floor dysfunction
• Consider association with overactive bladder and restless leg syndrome 2

Treatment Monitoring

• Regular assessment of symptom improvement
• Monitoring for medication side effects
• Evaluation of relationship functioning and quality of life
• Adjustment of treatment approach based on response 1

Multidisciplinary Approach

PGAD likely represents a range of conditions manifesting in unwanted genital sensations. Successful treatment requires:

• Consideration of all reversible physiological or pharmacological causes
• Combination of pharmacological interventions with physical therapy
• Addition of psychological therapy when indicated
• Referral to specialists (urology, neurology, sexual health) for complex cases 2, 3

Prognosis

The prognosis for PGAD varies based on the underlying etiology and treatment response. Many patients require ongoing management with a combination of approaches to achieve symptom control and improved quality of life 2, 6.