How should I evaluate and manage a patient with an overstretched perineal/genital sensation and reduced inner sexual arousal, worsened by sitting, no nocturnal pain, and a normal sensory exam?

Evaluation and Management of Overstretched Genital Sensation with Reduced Sexual Arousal

This presentation is most consistent with pudendal neuropathy affecting the dorsal branch of the pudendal nerve, and you should pursue electrophysiological testing followed by consideration of pudendal nerve blocks or surgical neurolysis if conservative measures fail. 1, 2

Initial Diagnostic Approach

Key Clinical Features to Assess

• Sensory changes in the genital region: Document the exact distribution of the "overstretched" or numb sensation—whether it affects the clitoris/glans, labia/penile shaft, or perineum, as this maps to specific branches of the pudendal nerve 3

• Pattern of symptoms: The absence of nocturnal pain with worsening on sitting is highly characteristic of pudendal nerve entrapment, distinguishing it from inflammatory or dermatologic conditions 4

• Sexual dysfunction specifics: Quantify the reduction in arousal, ability to achieve orgasm, and any associated pain or dyspareunia, as these reflect the degree of sensory nerve involvement 1, 2

• Trauma history: Specifically ask about pelvic trauma, prolonged cycling, childbirth injuries, or repetitive pelvic strain, as these are the most common causes of pudendal neuropathy 4, 3

Essential Diagnostic Testing

• Electrophysiological studies: Obtain sensory nerve conduction velocity testing of the dorsal nerve of the penis/clitoris, which will show reduced conduction velocity in pudendal neuropathy 3

• 3-Tesla pelvic MRI: This is recommended in all patients with suspected nerve entrapment to identify structural causes of compression 1

• Lumbosacral 3-Tesla MRI: Order this if you suspect Tarlov cysts or herniated discs as potential causes of nerve compression 1

• Screen for diabetes: Measure fasting glucose or HbA1c, as diabetic neuropathy is the most common cause of penile/genital neuropathy and presents with similar sensory changes 5, 6, 3

Differential Diagnosis Considerations

Rule Out Diabetic Autonomic Neuropathy

• If diabetes is present or suspected, assess for other autonomic symptoms including erectile dysfunction, retrograde ejaculation, decreased sexual desire, dyspareunia, inadequate lubrication, and bladder dysfunction (nocturia, urgency, weak stream) 5, 6

• The American Diabetes Association notes that genitourinary disturbances from diabetic autonomic neuropathy present with decreased arousal and altered sensation 5, 6

Distinguish from Persistent Genital Arousal Disorder (PGAD)

• PGAD presents with unwanted arousal sensations rather than reduced arousal, though both can result from pudendal nerve pathology 1, 7, 2

• Your patient's complaint of reduced arousal makes pudendal neuropathy with sensory loss more likely than PGAD 2

Consider Dermatologic Causes

• Examine for lichen sclerosus, which can cause dysesthesia (abnormal burning sensation on the glans or around the urethral meatus in men, or vulvodynia in women) that persists despite resolution of visible skin lesions 5

• However, lichen sclerosus typically causes pain rather than numbness and does not worsen specifically with sitting 5

Management Algorithm

First-Line Conservative Management

• Pressure-relieving measures: Instruct the patient to avoid prolonged sitting, use a donut cushion, and modify activities that compress the pudendal nerve 4

• Pelvic floor physical therapy: Refer to a specialized pelvic floor therapist, as this has demonstrated benefits in pudendal neuralgia and related conditions 5, 1

• Topical anesthetics: Trial of lidocaine 5% ointment can help with dysesthesia, though this addresses symptoms rather than the underlying nerve compression 5

Second-Line Pharmacologic Management

• Neuropathic pain medications: If the patient develops pain or dysesthesia, consider duloxetine (60-120 mg/day) or amitriptyline, which are effective for neuropathic pain 5

• Avoid opioids: The American Diabetes Association explicitly states that opioids should be avoided for chronic neuropathic pain due to addiction risk and modest benefit 5

Interventional Treatments

• Pudendal nerve blocks: If conservative measures fail after 3-6 months, bilateral pudendal nerve blocks with corticosteroid and local anesthetic can provide 2-3 months of relief and serve as both diagnostic and therapeutic interventions 7

• Surgical neurolysis: For refractory cases with confirmed nerve entrapment on imaging and positive response to nerve blocks, neurolysis of the dorsal branch of the pudendal nerve has shown excellent results, with 7 of 8 patients achieving complete elimination of symptoms in one case series 2

• Bilateral approach: When surgery is pursued, bilateral decompression appears superior to unilateral, with all bilaterally treated patients achieving excellent results versus partial improvement with unilateral treatment 2

Psychosexual Support

• Mental health referral: Offer referral to a sex therapist or mental health professional, as chronic genital disorders profoundly affect sexuality and quality of life 5

• Multidisciplinary team: A team approach with a medical provider, pelvic floor physical therapist, and sex therapist has demonstrated benefits for these complex presentations 1

• Erectile dysfunction evaluation (if male): Follow AUA guidelines for comprehensive ED evaluation, including assessment of morning erections, situational factors, and psychogenic components 5

Critical Pitfalls to Avoid

• Don't dismiss normal sensory exam: A normal sensory exam on routine testing does not rule out pudendal neuropathy, as electrophysiological testing is more sensitive for detecting nerve conduction abnormalities 3

• Don't attribute everything to psychological causes: While psychosexual factors are important, the specific pattern of worsening with sitting and absence of nocturnal pain points to a structural nerve problem requiring specific treatment 4, 2

• Don't delay imaging: Waiting too long before obtaining 3-Tesla MRI may miss treatable structural causes of nerve compression 1

• Don't use topical corticosteroids for dysesthesia: If the patient develops neuropathic pain after inflammatory conditions resolve, this represents neuronal sensitization that will not respond to topical steroids and requires neuropathic pain management 5