Director of Sexual Medicine University of California San Diego
Introduction: Urologists encounter both women and men who experience unwanted persistent, distressing, atypical sensations such as arousal (including erection, burning, itching, pain in the clitoris/penis and other genito-pelvic regions (e.g. vulva/scrotum, pelvic floor, bladder, urethra, perineal/perianal region, prostate). Genito-pelvic dysesthesia (GPD) is usually thought to emanate from pathology in the end organ (e.g., clitoris/penis) or pelvis/perineum (e.g., pelvic floor or pudendal nerve). Recently GPD has been shown to be associated with sacral radiculopathy from annular tear lumbosacral disc pathology impacting the cauda equina. In such cases, the GPD may be a result of nerve root irritation in the cauda equina producing sensations perceived as originating in the peripheral genito-pelvic region. This is analogous to sciatica where pain is perceived in the lower extremities but is commonly the result of “upstream” cauda equina pathology. We utilized a novel management algorithm to identify GPD patients with sacral radiculopathy from annular tear lumbosacral disc disease who underwent spine surgery and evaluated their long-term outcome.
Methods: A chart review of patients with GPD who underwent spine surgery between 2016 and 2019 was performed. The management algorithm involved ruling out pathology in the genito-pelvic regions; identifying pathology in the cauda equina on lumbosacral MRI; finding abnormal neurogenital testing of the pudendal/sciatic nerves; having a positive diagnostic response to a transforaminal epidural spinal injection; and undergoing lumbar endoscopic spine surgery. All patients had at least 1 year follow-up post-spine surgery. Treatment outcome was based on the Patient Global Impression of Improvement (PGI-I), measured every 3 months post-operatively.
Results: A total of 15 women and 5 men (mean age 40.3 16.8) with GPD underwent spine surgery and were discharged the same day. Lumbosacral disc pathology was identified at multiple levels, the most common being L4-L5 and L5-S1. Patients were followed for an average of 20 months (range 12-37 months). 80% (16/20 patients) reported improvement on the PGI-I. There were no serious surgical complications.
Conclusions: When assessing GPD the urologist should look beyond the genito-pelvic region. GPD can be a result of sacral radiculopathy from lumbosacral disc disease. Long-term alleviation of GPD symptoms is achievable with spine surgery.
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