Persistent Arousal Research Articles

Long-term intrathecal infusion of low-dose morphine effectively relieves symptoms of severe restless legs syndrome/Willis-Ekbom disease without inducing opioid tolerance.

Restless legs syndrome/Willis-Ekbom disease (RLS/WED) causes a strong urge to move legs while resting. Restless legs syndrome/WED is an often-inherited disease occurring in 3% to 10% of adult populations, increasing with age. Severity varies from mild disturbance of sleep to painful restless legs and arms, loss of sleep, fatigue, and risk of suicide. Dopaminergic drugs relieve symptoms, but cause augmentation, ie, initially helpful but later increase the burden of symptoms. Oral gabapentinoids and opioids are often added, but opioid tolerance and adverse effects are common. With the high prevalence and incomplete help from oral drugs, significant unmet needs exist for effective therapy for severe RLS/WED. Ongoing spinal intrathecal infusion of low-dose morphine is effective, but not generally recognized, as only 12 cases have been published since 2002. We report 7 patients suffering from severe RLS/WED, who had no relief from oral dopaminergic, gabapentinoid, or opioid drugs; they all had excellent relief during ongoing spinal intrathecal infusion of morphine at only 1 to 5 μg/h, ongoing for 1 to 21 years without need of higher doses of morphine.. We suggest that morphine may be transported with the cerebrospinal fluid reaching and readjusting malfunctioning dopamine neuronal systems in the brain and spinal cord. The effects last only as long as the infusion continues. A patient with RLS/WED and persistent genital arousal disorder (PGAD) was relieved of both RLS/WED and PGAD symptoms. These case reports suggest that intrathecal infusion of low-dose morphine is an effective treatment of severe RLS.

(082) DELAYED ORGASM CAN RESULT FROM LUMBOSACRAL DISC DISEASE DISRUPTING GENITAL SENSORY TRANSMISSION IN THE CAUDA EQUINA: A REVIEW

Abstract Introduction Delayed orgasm may be considered an unwanted, atypically long latency during most genital/sexual activity despite sexual stimulation, causing significant distress to the individual and/or partner, persisting for at least 6 months. Delayed orgasm is reported to affect 6.9% of women. It is associated with negative effects on sexual function, sexual satisfaction, and relationship satisfaction. Pharmacologic, endocrinologic, and neurobiological pathophysiological factors have been identified as possible etiologies of delayed orgasm, but an under-researched etiology is lumbosacral disc disease, specifically lumbosacral annular tear-induced sacral radiculopathy. The pelvic, pudendal, and sciatic nerves all merge at the S2-4 foramina where they coalesce to form the S2-4 nerve roots. These sacral spinal nerve roots (S2-4) ascend to the first synapse in the conus medullaris. During their ascent, they can be irritated mechanically by impingement/compression or chemically by exposure to the extruded nucleus pulposus from lumbosacral annular tears, and thereby disrupt genital sensory transmission with resultant delayed orgasm. The new evidence that delayed orgasm can be successfully treated by endoscopic spine surgery supports the association of delayed orgasm with sacral radiculopathy. There is still a paucity of research regarding delayed orgasm from lumbosacral disc disease. Objective To review the existing literature concerning the contribution of lumbosacral disc disease to delayed orgasm. Methods A literature search on delayed orgasm, its impacts and possible etiologies was performed. The following keywords were searched on Pubmed individually and in combination, related to the association between delayed orgasm and lumbosacral disc disease: delayed orgasm, delayed ejaculation, sexual dysfunction, anorgasmia, and persistent genital arousal disorder. Current definitions were compiled, and overall epidemiology, anatomy, and biopsychosocial factors of delayed orgasm were explored. Results There are a number of publications (n = 19) demonstrating the development of sexual dysfunction after damage to the sacral spinal nerve roots. Furthermore, several studies (n = 4) and case reports (n = 1) have demonstrated that treating lumbosacral disc disease reduces sexual dysfunction including improvement in delayed or reduced ejaculation. While delayed ejaculation encompasses the experience of delayed orgasm for some individuals, the literature fails to address delayed orgasm comprehensively in relation to lumbosacral disc disease, and thus fails to address treatment of lumbosacral disc disease and subsequent resolution of delayed orgasm. People with vulvas are particularly underrepresented in the literature studying the connection between lumbosacral disc disease and delayed orgasm. Conclusions While lumbosacral disc disease has many side effects that may impede daily function, sexual side effects can further detract from one’s personal life and relationship satisfaction. Thus, improving clinician awareness of sexual side effects, particularly delayed orgasm, can help improve treatment for individuals especially as they age. Further research is needed to strengthen the understanding of the effect of sacral radiculopathy on delayed orgasm as well as other sexual dysfunctions. Disclosure No.

(043) INACCURATE AND INADEQUATE ICD-10 CODING RELATED TO FEMALE SEXUAL HEALTH THREATENS PATIENT CARE, RESEARCH AND BILLING

Abstract Introduction The International Classification of Diseases (ICD) is an international health information system for the collection, processing, classification, and presentation of mortality statistics. The ICD 10th Edition (ICD-10) is a tool for physicians and billing professionals to accurately bill for the care provided. However, physicians who treat female sexual health (FSH) disorders report difficulty in finding appropriate codes for diagnoses and clinical syndromes (Parish et al. 2021). These issues impede the process for appropriate treatment and allotting the correct reimbursement to providers. Additionally, quantitative and qualitative research on FSH is limited due to the lack of accurate ICD codes for FSH disorders in this cohort. Objective This study aims to evaluate the ICD-10 coding system to assess the accuracy and quality of codes related to common FSH disorders. Methods A list of 50 most commonly encountered clinical FSH diagnoses was created based on clinical practice findings and ISSWSH guidelines. The list was compared against existing ICD-10 codes to characterize current FSH disorders that are recognized in ICD-10 and determine which FSH disorders are billable (ICD10data.com categorizes codes as “billable” or “non-billable”) or missing entirely. FSH diagnoses explicitly listed as an independent diagnosis or generally listed were considered ICD-10 coded. Diagnoses were considered to not have an existing code if they were not explicitly listed independently or under a more general term. Results 44% (n=22) of the diagnoses did not have existing ICD-10 codes, and 6% (n=3) of the diagnoses had appropriate ICD-10 codes but were not billable (Figure 1, Table 1). FSH diagnoses such as “clitoral adhesions”, “clitorodynia” and “persistent genital arousal disorder” were not coded in ICD-10. Many diagnoses were grouped under general terms - pelvic floor pain disorders were grouped under “R10.2: Pelvic and peroneal pain” which included both male and female diagnoses. Other codes had significant diagnostic overlap - “vulvodynia” was separately cataloged as “N94.810: vulvar vestibulitis”, “N94.818: Other vulvodynia” and “N94.819: vulvodynia, unspecified”. There were numerous common FSH diagnoses with incomplete, inaccurate, or outdated ICD codes. Conclusions These findings highlight the pressing need for an expanded, comprehensive, and precise set of ICD codes dedicated to FSH disorders. Without appropriate coding for 50% of FSH diagnoses, clinical care, research, and healthcare billing are severely impeded. It is much more difficult for physicians to accurately classify and bill for their procedures, which may create problems with clinical documentation leading to delayed treatment and poor clinical outcomes. For example, existing codes for “vulvodynia,” a common disorder affecting 16% of women, are vague and unclear, which lacks practicality for charting and billing purposes. Additionally, the limitations of ICD coding make it nearly impossible to research specific disorders, as they can not be searched in databases like TriNetX. These limitations may explain the large gaps in the literature regarding FSH disorders. Additionally, electronic medical records often have outdated ICD codes, further creating obstacles for clinicians. The current gap in classification, including ICD-10 coding and medical records, must be addressed to advance the understanding and management of FSH disorders. Disclosure No.

Repetitive mild traumatic brain injury impairs norepinephrine system function and psychostimulant responsivity

Traumatic brain injury (TBI) is a complex pathophysiological process that results in a variety of neurotransmitter, behavioral, and cognitive deficits. The locus coeruleus-norepinephrine (LC-NE) system is a critical regulator of arousal levels and higher executive processes affected by TBI including attention, working memory, and decision making. LC-NE axon injury and impaired signaling within the prefrontal cortex (PFC) is a potential contributor to the neuropsychiatric symptoms after single, moderate to severe TBI. The majority of TBIs are mild, yet long-term cognitive deficits and increased susceptibility for further injury can accumulate after each repetitive mild TBI. As a potential treatment for restoring cognitive function and daytime sleepiness after injury psychostimulants, including methylphenidate (MPH) that increase levels of NE within the PFC, are being prescribed “off-label”. The impact of mild and repetitive mild TBI on the LC-NE system remains limited. Therefore, we determined the extent of LC-NE and arousal dysfunction and response to therapeutic doses of MPH in rats following experimentally induced single and repetitive mild TBI. Microdialysis measures of basal NE efflux from the medial PFC and arousal measures were significantly lower after repetitive mild TBI. Females showed higher baseline PFC-NE efflux than males following single and repetitive mild TBI. In response to MPH challenge, males exhibited a blunted PFC-NE response and persistent arousal levels following repetitive mild TBI. These results provide critical insight into the role of catecholamine system dysfunction associated with cognitive deficits following repeated injury, outcome differences between sex/gender, and lack of success of MPH as an adjunctive therapy to improve cognitive function following injury.

A review of persistent genital arousal disorder: Symptoms, diagnosis, and treatment

A medical disease known as persistent genital arousal disorder (PGAD) is the cause of chronic genital arousal. It usually has little to do with sexual desire and can be rather upsetting. The literature on PGAD, emphasizing symptoms, diagnosis, and treatment, is reviewed in this study. PGAD is a condition about which there is still much to understand. However, research has linked it to OAB, restless leg syndrome, certain medications, and problems with the spinal cord. Diagnosis depends on the ability to distinguish between physically exhibited arousal and sexual desire, which is motivated by psychology. Current treatment options include education campaigns, counseling, medication, and potential spinal triggers. Other more invasive therapies have also been used, such as clitoridectomy and pudendal nerve ablation, but their success rates have varied.

(148) “Zebras” in Sexual Medicine from Cauda Equina Pathology

Abstract Introduction Unrelenting, bothersome sexual medicine problems in individuals with a vulva or penis sometimes do not respond to conventional therapies, frustrating both patient and provider. These distressing problems can be categorized as a genito-pelvic dysesthesia (GPD), including genito-pelvic (penile, scrotal, clitoral, vulvar, vestibular, vaginal, bladder, rectal) pain, persistent genital arousal disorder (PGAD), sleep related prolonged erections (SRPE) and hard-flaccid syndrome (HFS), currently considered as “zebras” in sexual medicine. We recently published a study on 20 patients with PGAD/GPD who underwent a multi-disciplinary management algorithm, were determined to have lumbosacral annular tear induced sacral radiculopathy, and with one year follow-up post-spine surgery, 80% revealed improvement in symptoms. Objective To apply our (spine-sexual medicine) multi-disciplinary management algorithm to sexual medicine “zebras”. Methods Patients who presented between July 1, 2021, and June 30, 2023, to our sexual medicine clinic were included in the study cohort. The management algorithm was as follows: biopsychosocial history, multiple validated instruments, physical examination, neurogenital testing, regional anesthesia testing, lumbosacral MRI, and when appropriate, a caudal epidural or transforaminal epidural spinal injection. Those with clinically significant symptom reduction from the spinal injection were offered appropriate spine surgery. Patient Global Impression of Improvement (PGI-I) was assessed post-operatively (1 = very much better, 2 = much better, 3 = better, 4 = no change, 5 = worse, 6 = much worse and 7 = very much worse. Results Our study cohort consisted of 24 patients, 14 with a vulva and 10 with a penis, mean age 42 years (range 25-69) who presented to our clinic over a period of two years. The patients' GPD complaints included genital pain (13), PGAD (6), SRPE (2), HFS (1), bladder pain (1) and rectal pain (1). All patients had results of neurogenital and regional anesthesia tests consistent with sacral radiculopathy, then underwent a diagnostic focal lidocaine spinal injection. Each had a positive response to either a transforaminal epidural spinal injection and underwent lumbar endoscopic spine surgery (n = 21) or a caudal epidural and underwent Tarlov cyst surgery (n = 3). PGI-I scores after surgery indicative of improvement (PGI-I = 1, 2, 3) at one week was 10/22 (45%), at 6 weeks was 9/17 (53%) at 3 months was 9/16 (56%) and at 6 months was 5/6 (83%). Conclusions Patients presenting with sexual medicine complaints not successfully managed by routine treatment strategies often experienced delay in diagnosis and excessive healthcare-seeking behavior resulting in significant distress. In our experience, GPD can result from triggers in the cauda equina, far from the location of the presenting genito-pelvic symptom(s). Our cohort of sexual medicine “zebras” who underwent our multi-disciplinary management algorithm were diagnosed with sacral radiculopathy. These patients opted for spine surgery and reported improvement of symptoms that continued to get better over time. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Eliquence.

(271) Patient with Severe Clitoral Phimosis and Smegmatic Cyst: A Case Report and Review of the Literature

Abstract Introduction Clitoral phimosis describes an attachment of the clitoral prepuce to the glans. This severe form of clitoral adhesions prevents the mobility and retraction of the clitoris and can be accompanied with clitorodynia, persistent arousal, and/or muted or absent orgasm. It often presents with a buildup of smegma and keratin pearls. Previous research suggests that these adhesions are found in up to 22% of women seeking evaluation for sexual dysfunction. Objective To describe a patient with a unique and severe presentation of untreated clitoral adhesions resulting in complete clitoral phimosis and a large pseudocyst, and to share an innovative and minimally invasive procedure option which preserved sexual function. Methods A 60-year old female presented with as a clitoral mass to a urology and sexual medicine practice for consultation regarding surgical excision of the mass with hopes to preserve clitoral sensation. Following an abdominal hysterectomy and bilateral salphingoophrectomy in 2010, the patient of interest presented to her gynecologist for an enlarging clitoris which progressed to form a mass over the course of several years. In 2022 she established care with a new gynecologist who referred her to a gyn-oncologist for concern of the now large mass. She underwent an MRI of the pelvis in September 2022 which revealed a 1.7 x 3.5 x 1.9 cm cystic lesion projecting from the prepuce. This was felt to be an epidermoid cyst or proteinaceous or hemorrhagic cyst arising from the vagina. After speaking to many specialists the plan was to undergo surgical excision, though preservation of sensation could not be guaranteed. The patient canceled surgery to obtain more information as preservation of clitoral sensation was a priority, at which point she presented to our clinic in April of 2023. Results On exam, there were normal labia majora and resorbed labia minora fusing with the clitoral mass. On further examination, complete phimosis with a pinpoint and closed phimotic ring visible and a large smegmatic pseudocyst that was not adherent to the clitoris was appreciated. Clitoral phimosis was discussed at length and as an innovative, yet relatively straightforward solution, our urological surgeon proposed a dorsal slit (in the operating room) procedure for removal of smegma and small excision of excess surrounding tissue. This approach would have little to no known effect on the clitoral nerves as they course dorsally and terminal at the clitoral glans and would allow full retraction of the clitoral prepuce. The procedure was performed in May 2023 under IV sedation. Copious amounts of smegma were irrigated from the cyst and no adhesions were appreciated. After the removal of the smegmatic pseudocyst, our patient reported improved sensation and orgasm without pain or cystic reaccumulation. She was instructed to dilate the opening to avoid re-adherence. Conclusions There is no standardized treatment for clitoral adhesions. This procedure improved our patient’s sexual function and orgasm ability and was spared from a major surgery with significant risks. Equipping physicians with fundamental knowledge about clitoral adhesions would likely result in earlier and more frequent intervention, preventing large and atypical masses like the one observed in this case. Disclosure No.

Differentiation of Restless Genital Syndrome from Persistent Genital Arousal Disorder: A Case Report

Objective: Persistent genital arousal disorder (PGAD) presents with a constant unwelcome sensation of genital arousal. Moreover, restless genital syndrome (RGS) is one of the restless leg syndrome (RLS) variants. Case Representation: We aimed to clarify the differences between clinical diagnoses of these two similar conditions. Assessing the circadian pattern of symptoms, the simultaneous presence of RLS and restless bladder syndrome, exacerbation of symptoms with caffeine use, healing with magnesium use, and familial history of RLS helped us with the differentiation between PGAD and RGS. Conclusion: We propose to rule out the diagnosis of RGS in all patients with PGAD symptoms.

Persistent genital arousal disorder developing secondary to generalized anxiety disorder

Persistent genital arousal disorder developing secondary to generalized anxiety disorder

Management of persistent genital arousal disorder: A case report

Persistent genital arousal disorder (PGAD) is a pathological condition characterized by intrusive, unwanted, and distressing symptoms related to spontaneous and prolonged sensations of genital arousal in the absence of sexual desire or stimulation that may compromise the individual’s quality of life. Here, we report the case of a woman who suffered from PGAD probably associated with multiple alterations in the spinal column and Tarlov cyst, which caused the compression of nerve roots and the abnormal sensitivity of the genital region.

Clinical characterisation of women with persistent genital arousal disorder: the iPGAD-study

Persistent Genital Arousal Disorder (PGAD) is a rare condition—mostly in women—where patients perceive prolonged genital arousal without any sexual desire or stimulation. Etiopathological considerations reach from peripheral to central issues over local disturbance of the pudendal nerve to neuropathy, psychosocial, and pharmacological theories. Since well controlled clinical studies about PGAD in conjunction with a mental and somatic health status are missing, this study is a detailed clinical investigation of PGAD patients compared to healthy controls. 26 women who fulfilled diagnostic criteria for PGAD were compared to 26 age matched healthy controls. Investigations included comparison of vegetative, gynaecological and sexual history, psychiatric features as well as a (neuro-)radiological, neurophysiological and gynaecological examination. Moreover, a detailed clinical characterisation of PGAD symptoms was performed. PGAD symptoms were mostly characterised as tingling or prickling and were permanently present. In over 80%, PGAD symptoms were located in the clitoris. Almost 70% reported radiations to other regions of the body. Most frequent trigger factors were tight clothes, mental stress, driving a car/bus/bicycle and sexual intercourse. Relieving factors were mainly distraction, relaxation, physical exercise, masturbation and swimming. In group comparisons, PGAD presented with significant higher rates of sexual dysfunctions, spontaneous orgasms, swelling of the genitals, extraordinary lubrication as well as higher rates in depression, agoraphobia, generalized anxiety disorder and lifetime panic disorder. Significantly more PGAD patients were diagnosed with restless legs symptoms. In contrast childhood traumatization, somatization disorder, suicidality, gynaecological as well as neurophysiological examination of the pudendal nerve were not different between the groups. MRI of the brain, pelvis and spinal cord was unsuspicious and incidental findings - including Tarlov cysts or pelvic venous congestion - were equally distributed among the groups. In summary, our study provides a careful characterization of women with PGAD highlighting a serious mental burden, most probably as a consequence of PGAD. With the current set of clinical investigations there was no evidence of a clear causal relationship to a specific clinical finding as it has been previously discussed. Future studies and additional techniques will have to further explore where and how in the peripheral or central nervous systems PGAD develops.

The Role of Genetic Mutations on Genes PER2, DEC2, ADRB1 in Bio-Psychological Sex Insomnia Disorder

Sexsomnia, also known as sleep sex, is a type of sleep disorder known as parasomnia. Parasomnias refer to unusual sensations and behaviors, such as sleepwalking, that people may experience during sleep. In the case of sex, people perform sexual behaviors such as masturbation, sexual movements, sexual assault, or initiating sex with another person. Although their eyes may be open and they may make sexual sounds, they are asleep during these activities and are unaware of their behavior upon awakening. Research on the causes of sexual insomnia is limited, but experts have found that it is associated with a wide range of underlying conditions and risk factors, including: other parasomnias, such as sleepwalking and REM behavior disorder, obstructive sleep apnea, seizures sleep disorders, Kline-Lewin syndrome, chronic insomnia, restless legs syndrome, narcolepsy, persistent sexual arousal syndrome, sleep-related disorders, nocturnal psychotic disorders, teeth grinding.

A clinical guide to rare male sexual disorders.

Conditions referred to as 'male sexual dysfunctions' usually include erectile dysfunction, ejaculatory disorders and male hypogonadism. However, some less common male sexual disorders exist, which are under-recognized and under-treated, leading to considerable morbidity, with adverse effects on individuals' sexual health and relationships. Such conditions include post-finasteride syndrome, restless genital syndrome, post-orgasmic illness syndrome, post-selective serotonin reuptake inhibitor (SSRI) sexual dysfunction, hard-flaccid syndrome, sleep-related painful erections and post-retinoid sexual dysfunction. Information about these disorders usually originates from case-control trials or small case series; thus, the published literature is scarce. As the aetiology of these diseases has not been fully elucidated, the optimal investigational work-up and therapy are not well defined, and the available options cannot, therefore, adequately address patients' sexual problems and implement appropriate treatment. Thus, larger-scale studies - including prospective trials and comprehensive case registries - are crucial to better understand the aetiology, prevalence and clinical characteristics of these conditions. Furthermore, collaborative efforts among researchers, health-care professionals and patient advocacy groups will be essential in order to develop evidence-based guidelines and novel therapeutic approaches that can effectively address these disorders. By advancing our understanding and refining treatment strategies, we can strive towards improving the quality of life and fostering healthier sexual relationships for individuals suffering from these rare sexual disorders.

(064) Trigger Point Release of Post Partum Pudendal Compression Relieves Persistent Genital Arousal: Case Report

Abstract Introduction There is very little literature available on Persistent Genital Arousal Disorder (PGAD). Recent consensus definitions have emerged from the ISSWSH working group on PGAD to expel the myth that PGAD is merely in the minds of those who suffer from it. Dr. Goldstein, et al have published research and criteria for diagnosis, and management of this condition which can be a very distressing one. Novel Non-Invasive treatment modalities are needed for the management of PGAD to prevent distress, and/or unnecessary surgery, in these patients. Objectives To determine if local trigger point treatment of the area surrounding the Pudendal Nerve as it passes the piriformis muscle, will cause relief of Persistent Genital Arousal Disorder (PGAD) in a patient suffering for the 8 months since childbirth. Methods I present a case of a new mother who suffered from severe PGAD emerging following a precipitous and somewhat traumatic childbirth. The persistent arousal was distracting, upsetting, intolerable, and only somewhat (10-20%) temporarily mitigated by very regular self-stimulation, and also with regular pelvic floor physio, in a busy new mom, who had had no such concerns before-hand. She presented to me at 8 months post-partum, with an 8 month history of PGAD. Based on history of presenting illness, the source of problem was determined to be most likely in pelvis, and potentially caused by entrapment/compression of the Pudendal Nerve. Informed Consent was obtained to attempt trigger point release of the tissues surrounding the Pudendal Nerve posteriorly, as it enters the pelvis. Using a posterior approach, using a 27g 1.5cm bevelled needle, to an area cleaned by alcohol swab, micro-dissection release was performed of area surrounding tissue the Pudendal N as it passes the piriformis muscle. Patient reported immediate and sustained relief of symptoms. Results Trigger point needling to the tissue superior to, surrounding, and including the piriformis muscle via the posterior approach caused immediate and sustained relief of the patient’s symptoms. Repeat needle treatment to this area, alternating with physiotherapy for guided relaxation and release of surrounding tissues, resolved patient’s PGAD symptoms by >95% during treatment and >85% 1 year after treatment cessation. Conclusions Trigger Point needle treatment of tissues of the muscles and piriformis muscles relieved PGAD symptoms initially caused by Pudendal Nerve entrapment/compression second to precipitous childbirth. This non-invasive approach for immediate and sustained relief of Persistent Genital Arousal Disorder should be widely taught to practitioners of Sexual Medicine, and considered in patients with neurological causes for their distressing symptoms, arising from the pelvic area. Disclosure No.

(002) Neuroproliferative Vestibulodynia as a Cause of Persistent Genital Arousal Disorder: A First-Ever Case Series

Abstract Introduction Persistent Genital Arousal Disorder (PGAD), a condition of unwanted, unremitting feelings of genital arousal, is associated with significant morbidity including catastrophizing, depression, anxiety, and/or suicidal ideation. There are multiple diverse triggers of PGAD that may originate in one or more of five regions in a patient: end organ, pelvis/perineum, cauda equina, spinal cord, and/or brain. Regarding the contributions to PGAD in the end-organ region, it is hypothesized that vestibulodynia may be a trigger for PGAD. The vestibule has unique sensory qualities, as this region receives sensory innervation from branches of both the somatic pudendal and visceral pelvic nerves. Objectives Neuroproliferative vestibulodynia is a disorder of excess deposition of mast cells with resultant excess c-afferent nociceptors in the vestibule. To the best of our knowledge, vestibulodynia, specifically neuroproliferative vestibulodynia, has not been reported in the literature as a cause of PGAD. The purpose of this study was to report on four women with lifelong PGAD suspected of having neuroproliferative vestibulodynia. Methods These women underwent: i) a detailed biopsychosocial assessment including sex therapy and diagnostic testing, evaluation of baseline PGAD intensity, vulvoscopy, cotton swab testing of the vestibule, PGAD intensity post-cotton swab test, and vestibular anesthesia testing (VAT); ii) treatment by complete vestibulectomy with vaginal advancement flap reconstruction; iii) staining of vestibular tissue with CD 117 (for mast cells) (Figure 1) and PGP 9.5 (for nerves) (Figure 2) and iv) measurement of clinical outcome with patient global impression of improvement. The VAT was performed with a topical anesthetic carefully applied to the vestibule between Hart’s line and the hymen. Complete anesthesia was assessed by cotton swab testing. Pre- and post-VAT intensity levels were compared. Results These patients had lifelong PGAD with a history of frequent masturbation at a very young age and feelings of catastrophizing, depression, anxiety, and/or suicidal ideation. Three patients had experienced sexual trauma, eating disorders, and had stressful relationships with family members. All four used various SSRI medications for depression/anxiety disorders and PGAD management from a young age. The youngest patient presented at 13 years with a presumptive diagnosis, primarily based on VAT, of neuroproliferative vestibulodynia. Surgery was delayed until she stopped growing at age 18. The other three presented at ages 20, 24, and 24. All four had full, although temporary, resolution of PGAD symptoms post-VAT. Each underwent a complete vestibulectomy with vaginal advancement flap procedure; the mean age at time of surgery was 22 +/− 3 years. Stained vestibular tissues showed in excess of 20 mast cells and nerves per high power field, consistent with neuroproliferative vestibulodynia. Curiously, post-operatively, none of the patients required the usual post-op opioid pain medications typical of patients undergoing vestibulectomy. While all four still experience mild PGAD symptoms when stressed, their PGAD symptoms are very much improved post-op with significant symptom resolution, with a mean follow-up of 11 months, range 4 – 26. Conclusions This is the first case series to document that neuroproliferative vestibulodynia is a treatable cause of PGAD, although more research is needed. Disclosure No.

(089) Regional Vestibulectomy and Buccal Mucosal Graft Reconstruction for Refractory Neuroproliferative Vestibulodynia

Abstract Introduction Buccal mucosal grafts (BGM) are widely used in male urethral reconstruction and have more recently been reported for female urethral reconstruction. We report the first case of using a buccal mucosa graft (BMG) to cover the excised 12:00 vestibule in a 19 year old woman with lifelong persistent genital arousal disorder (PGAD) presumed secondary to congenital neuro-proliferative vestibulodynia. She presented to our clinic at 17 and underwent lysis of clitoral adhesions, excision of the core 12:00 region with primary closure, and complete vestibulectomy with vaginal advancement flap. Her vestibular specimen positively stained for CD117 and PGP9.5 consistent with excess mast cells and nerves, respectively. Post-operatively, there was marked reduction of vestibular pain in the 1:00 to 11:00 region posteriorly, however she had persistent PGAD and significant residual tenderness to cotton-tipped swab testing at the 12:00 region. Her PGAD was medically managed successfully with tramadol, clonazepam and low dose zolpidem. Desiring to eliminate the need for systemic medications, the patient returned to the clinic at age 19. Again, local anesthesia applied to the clitoris and 12:00 vestibule region resulted in clinically significant PGAD symptom reduction and 12:00 vestibulodynia. We discussed repeat clitoral lysis and re-excision of the 12:00 region with BMG reconstruction. Objective To report on a novel technique using BMG for 12:00 region vestibular reconstruction in one woman with distressing vestibulodynia and PGAD. Methods Pre-operative counseling included discussion of routine surgical risks, benefits, alternatives, with additional possible complications including failure of the procedure to relieve PGAD or vestibulodynia, graft contracture, buccal harvest site contracture, sexual dysfunction, and genital disfigurement. The patient gave consent for the procedure and underwent a repeat lysis of clitoral adhesions and 12:00 regional subepithelial vestibulectomy. The defect measured 2.5 cm x 2.5 cm. A non-tubularized onlay patch of buccal mucosa was harvested and used for vestibular reconstruction. The procedures were performed by a single surgeon. The patient was discharged the same day. Results The patient’s post-operative course was notable for acute urinary retention in the recovery room. She was discharged with a foley catheter and passed a voiding trial on post-op day 1. Her pain was well-controlled with non-opioid medications and she was able to resume a soft food diet immediately after surgery. At post-op week 5, the clitoral area, buccal harvest site, and graft site were healed without complication. The patient reports that her 12:00 pain to touch has resolved. Her PGAD has decreased slightly, although she has not yet attempted to discontinue oral medications. Conclusions For this patient, regional vestibulectomy with BMG to the 12:00 region of the vestibule appears to have been a safe and feasible technique for refractory neuroproliferative vestibulodynia. Given that the vestibule is of endodermal origin derived from the urogenital sinus, and neuroproliferation may represent a congenital anomaly, there is a rationale to replace urogenital sinus endoderm with a non-urogenital sinus endoderm such as buccal mucosa. Pre-operative counseling should include surgery specific adverse events like mouth opening restriction and genital disfigurement. Longer follow up and larger studies are needed. Disclosure No

(076) History of Sexual Coercion, PGAD Symptoms, and Sexual Function: Evidence for a Mediational Model

Abstract Introduction Past research on Persistent Genital Arousal Disorder (PGAD) has shown that a history of sexual abuse is common among women with PGAD (Leiblum et al., 2007; Pink et al., 2014), with higher rates of abuse among those who are most symptomatic (Leiblum et al., 2007). However, there is a need for replication and for developing a theoretical understanding of the mechanisms and developmental course of this association. Moreover, although little is known about the relation between PGAD symptoms and sexual functioning (Jackowich et al., 2016) research has suggested that women with PGAD show FSFI scores that are low but within the normal range (Leiblum & Seehuus, 2009), and that those with subthreshold PGAD symptoms associate those symptoms with positive feelings. Objective The goal of the present study was to test a mediational model in which history of sexual coercion is directly associated with PGAD symptoms, and indirectly associated with sexual functioning (desire, masturbation, lubrication), with mediational effects passing through PGAD symptoms. Methods A sample of n = 138 female university students completed questionnaires measuring past experience of sexual coercion, PGAD symptoms, sexual desire, masturbation, and lubrication. Structural equation modeling was used to test a theoretical model in which a history of sexual coercion was allowed to directly predict PGAD symptoms and all three sexual function constructs, and PGAD symptoms were allowed to predict all sexual function constructs (see Figure 1). Results The SEM model fit the data well (CFI = .96; NFI = .92; RMSEA = .07). As presented in Figure 1, past experience of sexual coercion was positively associated with PGAD symptoms and negatively associated with sexual desire, but had no direct association with masturbation or lubrication. PGAD symptoms were associated with increased desire and masturbation, but decreased lubrication, and sexual desire was positively associated with lubrication. In addition to the directs effects on PGAD symptoms and sexual desire, past experience of sexual coercion also demonstrated indirect effects on all sexual function constructs (positive effects on desire and masturbation, and negative on lubrication). Conclusions Based on these results we propose a developmental model in which the effects of PGAD symptoms on desire, arousal, and pleasure, change across time and symptom severity. Specifically, increased attention to genital and sexual sensations is expected to result from past sexual coercion. Then, in the context of this heightened genital awareness, when persistent non-painful genital stimulation is perceived, in the early stages of PGAD symptom development, the combination of those sensations and the heightened attention to them is expected to result in perceived pleasurable sensation and arousal, thus increasing desire and masturbation. This is expected to be limited to the early stages of PGAD development, whereas, during later stages, when PGAD symptoms are severe and unrelenting, this is expected to change (see Figure 2). The overall level of PGAD symptoms in this sample was low (consistent with other non-clinical samples; Jackowich & Pukall, 2020), and thus these results cannot be generalized to women who live with a diagnosis of PGAD. Disclosure No

(065) Let’s Talk about Sex: Resident Run Didactic Curriculum

Abstract Introduction The Council on Resident Education in Obstetrics and Gynecology (CREOG) includes sexual health learning objectives as part of the core education for Ob/Gyn training. Residents are expected to gain understanding of normal sexual function as well as common areas of sexual dysfunction. Unfortunately, several studies have demonstrated a lack of knowledge in this area by Ob/Gyn residents and that educational didactic programs are not standardized on this topic. In 2010, over 90% of post graduate year (PGY)3 and PGY4 residents reported attending fewer than 5 didactic activities on sexual function/dysfunction, with only 50% feeling able to perform a targeted physical exam. Over the past decade, there has not been substantial improvement in this subject matter. In a 2021 survey evaluating the sexual health CREOG objectives showed that more than half of Ob/Gyn residents were not able to describe the disorders of sexual function or list common medications that effect sexual function. This is not isolated to the US, with studies in other countries including Singapore and Brazil, showing residents lack formal training and residents want increased didactic time focused on sexual health. Objective Our hypothesis was that at our institution the baseline knowledge of sexual dysfunction among Ob/Gyn residents would be low. The primary objective was formulating a needs assessment through implementation of a pre/post survey with a curriculum component. The secondary objective was to determine what areas of sexual medicine are most commonly areas of confusion or where residents lack comfort in regard to patient care. Methods The resident-designed curriculum was built with collaboration from a pelvic floor physical therapist. The journal club format was based on American College of Obstetricians and Gynecologists (ACOG) Practice Bulletins, the International Society for the Study of Women’s Sexual Health (ISSWSH) clinical pearls, and the North American Menopausal Society (NAMS) position statements. The pelvic floor physical therapy component focused on pelvic pain, perinatal considerations, and incontinence. The WCG IRB deemed this study exempt. After the pre-curriculum assessment was used to identify knowledge gaps, a month of one-hour weekly sexual health sessions were implemented followed by a post-curriculum survey. Results Due to small sample size, (N=14) there was no way to establish significance in our results. In general, areas that residents were weak and the curriculum focused on were: 1) Pelvic floor/vulvar/vestibular disorders. 2) Genitourinary syndrome of menopause and vasomotor symptoms of menopause. 3) Sexual medicine disorders (hypoactive sexual desire disorder, female sexual arousal disorder, persistent genital arousal disorder, female orgasm disorders, genitopelvic pain penetration dysfunction). Conclusions The baseline knowledge of sexual dysfunction and menopausal concerns among Ob/Gyn residents was low. However, implementation of a structured curriculum after a formal needs assessment improved comfort with these topics. Now that the baseline curriculum is designed it is imperative to expand to further residency programs (in Ob/Gyn as well as other specialties) to disseminate the knowledge to providers in training who require competency in sexual health concerns. Disclosure No

Persistent genital arousal disorder: clinical, differential diagnostic and care aspects (clinical report)

Persistent genital arousal disorder (PGAD) is a condition of persistent genital arousal, in the absence of a psychological component and organic pathology from the vascular, endocrine and nervous system. The aim of the study is to examine the symptoms, clinical picture, developmental dynamics, risk factors, and treatment for PGAD. Materials and methods. The clinical case of observation of PGAD in a 20-year-old female patient suffering from recurrent depressive disorder is presented. Methods included in clinical, psychopathological and psychodiagnostic examination have been with using the following techniques: Patient Health Questionnaire-9 (PHQ-9), Generalized Anxiety Disorder-7 (GAD-7), Visual Analogue Scales of pain intensity (VAS). Results. As a result of collection of life and disease history, analysis of examination findings by related specialists and additional research methods of patient with PGAD the next diagnosis has been made according to the International Classification of Diseases 10th Revision: Recurrent depressive disorder, current episode of moderate severity with somatic symptoms (F33.11). She has been treated with a number of drugs from the Selective serotonin reuptake inhibitors group and mood stabilizers, the combination of sertraline and lamotrigine appeared the optimal treatment option. The results of the treatment have been satisfactory, the symptoms of PGAD have stopped bothering the patient, the emotional state has improved significantly. Conclusions. The case of the PGAD is presented. Clinical picture of the case turned out to be typical in comparison with the results of other researchers. The peculiarity is the possible association of symptoms with withdrawal of escitalopram. The case confirms the data upon the high suicidal risk in this disorder. The patient’s treatment requires intervention of different medical specialists to rule out organic pathology and using of multidisciplinary approach. Sertraline and lamotrigine appeared effective in the treatment of PGAD.

On the Borderline of Pleasure and Pain

This case highlights the challenges that patients with both persistent genital arousal disorder and borderline personality disorder face, as well as the multidisciplinary approach needed to provide evidence-based care.