Persistent genital arousal disorder: Successful treatment with leuprolide (antiandrogen).

Abstract

Byline: Kamala. Deka, Neha. Dua, Monali. Kakoty, Rina. Ahmed Sir, Persistent genital arousal disorder (PGAD) or restless genital syndrome results in spontaneous, persistent and uncontrollable genital arousal, with or without orgasm or genital engorgement, unrelated to any feelings of sexual desire.[sup][1],[2] Here, we present a case of a 53-year-old female, who is a widow for 25 years. She came to us with 21/2 years history of increased sexual sensation in the genital area which she could not control, along with headache, dizziness, low mood, disturbed sleep, and crying spells. She had no desire to have sex, but she used to feel warm inside her vagina with pulsations, lubrication, tingling, throbbing response, and sometimes discharge. Initially, it was 15−20 times a day gradually increased to persist throughout the day. She lied on bed whole day crying, clinging herself or folding her body on herself because of the sensations. To get the relief she used to splash water or sometimes put her fingers inside her vagina following that she felt relief for few minutes but again felt the same sexual sensation. She did not have intercourse, neither did she use any artificial objects for pleasure. Her mood was low throughout the day, sleep disturbed, and appetite decreased. She was a widow for 25 years. No major psychosocial stressor was elicited. There was no history of sexual abuse in childhood. She had attained menopause 4 years back. History of earlier treatment with various such as like conjugated estrogen, cabergoline, alprazolam, vertin, cinnarizine, zolpidem, chlordiazepoxide, escitalopram, clonazepam, clomipramine, and etizolaam in adequate dosages for adequate duration did not have any beneficial effect on her. After being admitted she was investigated for sexual dysfunction. There was no local genital pathology and per vaginum examination was normal. Investigations like blood sugar levels, kidney function test, liver function test, thyroid profile, blood and urine routine and urine culture were within normal limit. Follicle-stimulating hormone (FSH) levels were raised, prolactin and estrogen were within normal range for her age. Total testosterone and free testosterone was normal. Her ultrasonography abdomen, transvaginal ultrasound, magnetic resonance imaging brain, computed tomography scan brain did not reveal any abnormality. Our patient was preoccupied with her increased sexual sensations and had feelings of guilt, shame, hopelessness, worthlessness. After workup, she was diagnosed conceptually to be a case of PGAD with depression. She was started on clomipramine 150 mg/day and clonazepam 1.5 mg/day in divided doses. After 2 weeks as we could not hike the dose of clomipramine due to giddiness, fluoxetine 40 mg/day was added and lignocaine gel local application was made 5−6 times a day along with pelvic floor exercises. She reported a marginal decrease in genital sensations as compared to before but was fluctuating. So after consultation with a gynecologist injection leuprolide3.75 mg (antiandrogen) subcutaneous was added to her treatment and advised to be repeated at 1 month interval for 3 months. Few days after 1[sup]st leuprolide injection, she reported a decrease in sexual sensation. The patient continued to improve and her genital sexual sensation significantly subsided at the time of discharge. She has received the 2[sup]nd and 3[sup]rd dose of injection leuprolide on follow-up and continued other medications as such. The patient is maintaining well for over 1[sup]1/2 years now. A patient of PGAD is generally diagnosed as sexual dysfunction not otherwise specified in the official classificatory system. …