FEMALE SEXUAL DYSFUNCTION AND DISORDERS (M CHIVERS AND C PUKALL, SECTION EDITORS) Persistent Genital Arousal Disorder: Current Conceptualizations and Etiologic Mechanisms Barry R. Komisaruk 1 & Irwin Goldstein 2 # Springer Science+Business Media, LLC 2017 Abstract Purpose of review Persistent genital arousal disorder (PGAD), characterized in 2001, persists as a distressing mal- ady that is not well appreciated, understood, or treated by healthcare providers. This review describes the characteristics of PGAD, hypotheses regarding its etiology, therapies, and recent findings that provide evidence of PGAD as a genital sensory neuropathy. Recent findings PGAD can result from (a) Tarlov cysts, which contain aberrant sensory nerve fibers and form on the genital sensory nerves where they abrade on the entrance to the sa- crum, and/or (b) herniated intervertebral disc-produced irrita- tion of the roots of those genital sensory nerves as they course through the cauda equina within the spinal canal. Summary Local genital anesthesia or peripheral nerve block often fails to alleviate PGAD symptoms. In that case, the possibility that genital sensory nerve root irritation (i.e., radiculopathy) “upstream” at the entrance to, or within, the spinal canal should be suspected and assessed, optimally by lumbo-sacral-oriented MRI. Imaging can reveal the presence of Tarlov cysts and/or herniated intervertebral disc impinge- ment on the cauda equina, which could provoke PGAD symptoms in women and men and may be treatable. Chronic irritative radiculopathy could eventually affect nerve conduc- tion deleteriously and thereby attenuate genital afferent and/or efferent activity, leading to genital paresthesias, anorgasmia, or anejaculation. Keywords Persistentgenitalarousal disorder . PGAD . Tarlov cyst . Cauda equina syndrome . Genital nerve . Anorgasmia Introduction Characteristics of Persistent Genital Arousal Disorder (PGAD) Persistent genital arousal disorder (PGAD) has been charac- terized as a complicated pathology having multiple etiologies and therapies that are inconsistently effective. Persons with PGAD complain of genital arousal that is intrusive, uninvited, and not accompanied by sexual interest or desire. The symp- toms are characteristically unrelenting and may persist for hours, weeks, and even years. Genital stimulation or orgasm may provide transient relief from the symptoms but may also trigger or exacerbate the symptoms. Sandra Leiblum and col- leagues first characterized the condition as “persistent sexual arousal syndrome (PSAS) [1, 2], but subsequently revised the terminology as “persistent genital arousal disorder” [3] to em- phasize its genital and de-emphasize its sexual nature. The descriptors provided by PGAD sufferers include “clitoral pain, pressure, or tingling, irritation, vaginal congestion or contractions, and in multiple cases, spontaneous orgasms.” [1, 3]. A consensus report by the International Society for the Study of Women’s Sexual Health (ISSWSH) Consensus Nomenclature Conference [4•] characterized PGAD as This article is part of the Topical Collection on Female Sexual Dysfunction and Disorders * Barry R. Komisaruk brk@psychology.rutgers.edu Irwin Goldstein dr.irwingoldstein@gmail.com 1 Department of Psychology, Rutgers University-Newark, 101 Warren Street, Newark, NJ 07102, USA 2 Sexual Medicine, Alvarado Hospital, 5555 Reservoir Drive, San Diego, CA 92120, USA Curr Sex Health Rep https://doi.org/10.1007/s11930-017-0122-5