Can masturbation as a coping mechanism for a male patient with significant Restless Legs Syndrome (RLS) symptoms increase the risk of augmentation?

Masturbation and RLS Augmentation Risk

Masturbation as a coping mechanism does not increase the risk of augmentation in RLS—augmentation is a medication-induced phenomenon specifically caused by dopaminergic agents, not by behavioral activities.

Understanding Augmentation

Augmentation is a well-defined iatrogenic complication characterized by:

• Progressive worsening of RLS symptoms with earlier onset during the day, increased intensity, and anatomic spread to upper extremities or trunk 1, 2
• This phenomenon occurs specifically with dopamine agonists (pramipexole, ropinirole, rotigotine) and levodopa, not from behavioral interventions 1, 2
• The American Academy of Sleep Medicine now recommends against standard use of dopaminergic agents precisely because of this augmentation risk 1

Behavioral vs. Pharmacological Mechanisms

• Augmentation is a pharmacological phenomenon resulting from chronic dopamine receptor stimulation, leading to paradoxical worsening despite dose increases 2, 3
• Masturbation or sexual activity is a behavioral coping strategy that some patients use for temporary symptom relief, similar to walking, stretching, or massage 1
• One case report documented a patient with "restless genital syndrome" (a variant presentation) who experienced genital symptoms associated with RLS that responded to pramipexole, but this represents a symptom manifestation rather than a causative behavior 4

Evidence-Based Risk Factors for Augmentation

The actual risk factors for developing or worsening RLS include:

• Dopaminergic medications: The primary cause of augmentation, with pramipexole, ropinirole, and rotigotine carrying the highest risk 1, 2
• Iron deficiency: Ferritin ≤75 ng/mL or transferrin saturation <20% can worsen symptoms and increase augmentation risk 1, 3
• Exacerbating medications: Antidepressants (SSRIs, tricyclics), antihistamines, antipsychotics, and lithium can trigger or worsen RLS 1, 5
• Untreated sleep apnea: Can exacerbate RLS symptoms 1

Appropriate Management Strategy

For a patient using masturbation as a coping mechanism:

• Do not discourage this behavioral strategy—it represents a non-pharmacological approach to symptom management similar to other movement-based relief strategies 1
• Focus on evidence-based treatment: Check morning fasting ferritin and transferrin saturation, supplementing if ferritin ≤75 ng/mL or transferrin saturation <20% 1
• Initiate alpha-2-delta ligands (gabapentin, gabapentin enacarbil, or pregabalin) as first-line pharmacological therapy, which carry no augmentation risk 1, 2
• Avoid dopamine agonists as standard treatment given their high augmentation risk 1, 2

Critical Pitfall to Avoid

• Do not conflate behavioral coping mechanisms with medication-induced augmentation—these are entirely separate phenomena with different pathophysiological mechanisms 2, 3
• The concern about masturbation "causing" augmentation has no basis in the RLS literature or treatment guidelines 1, 2, 5, 3, 6