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Introduction: In 2012, Komisaruk et al introduced the concept that neurologic-based women's sexual health issues, genito-pelvic dysesthesia (GPD), could be caused by radiculopathy of sacral spinal nerve roots within the cauda equina. Over the last 4 years, to more effectively manage patients with suspected cauda equina pathology, a robust collaboration among sexual medicine, spine surgery and neurophysiology disciplines has been established. Objectives: The aim of this study is to review the collaborative experience in managing patients with genito-pelvic dysesthesia. Methods: We defined GPD in the broadest sense to include both unwanted, unrelenting, distressing arousal, pain and/or itching symptoms >6 mo (hyperfunction), and also persistent degrees of genital anesthesia leading to orgasmic dysfunction >6 mo (hypofunction). Charts from 2015 to 2019 of GPD patients presenting to our sexual medicine facility where neurogenital testing results were consistent with radiculopathy of sacral spinal nerve roots within the cauda equina were reviewed retrospectively. Lumbar and sacral MRIs were obtained and reviewed simultaneously in collaborative bi-monthly meetings and identified as having or not having treatable spinal abnormalities, subdivided into subtle or obvious. When appropriate, a transforaminal epidural spinal injection (TFESI) or caudal block with anesthetic agent and/or steroid was administered and the outcome measured by Patient Global Impression of Improvement (PGI-I). Those with clinically significant symptom reduction were considered for minimally invasive spine surgery (MISS). Results: 734 patients (586 women; 80%; mean age 47 +/− 24) met criteria for this retrospective chart review. 637 lumbar and/or sacral MRIs were reviewed. A total of 112 TFESI were performed, 90 of which showed positive responses with more than 60% improvement on PGI-I of 1,2. 57 surgeries were performed. 17 patients (71% women) with PGAD underwent MISS for herniated nucleus pulposus and or annular tear. 76% declared post-op clinical improvement with PGI-I 1,2,3 with mean follow-up of 12 months (4 - 30 months). Conclusions: Cauda equina pathology can cause unwanted, unrelenting, distressing neurologic-based GPD from radiculopathy of sacral spinal nerve roots. In selected cases these GPDs may be reversed by MISS. There are management benefits from collaboration among sexual medicine, spine surgery and neurophysiology specialists. Disclosure: No. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

In 2012 Komisaruk reported that women with persistent genital arousal disorder could have a neurologic pathophysiology within the cauda equina. Charts of GPD patients presenting to our sexual medicine facility were reviewed retrospectively from 2015 - 2019 where neurogenital testing results were consistent with radiculopathy of sacral spinal nerve roots within the cauda equina. [Extracted from the article]

The most commonly treated sexual dysfunctions in men are erectile dysfunction, Peyronie's disease, premature and delayed ejaculation, and decreased sexual desire. While urologists have expertise treating these sexual dysfunctions, there are unusual sexual health concerns in men that can prove a management quandary to many clinicians. These include persistent genital arousal, spontaneous ejaculation/orgasm, penile pain with arousal, and severe ejaculatory pain, which may be secondary to a radiculopathy of the sacral spinal nerve roots (SSNR). Men with these unusual problems often experience despair, emotional lability, catastrophization, and/or suicidality. The objective was to examine the management of men presenting to our multidisciplinary sexual medicine clinic with unusual sexual dysfunctions including persistent genital arousal, spontaneous ejaculation/orgasm, penile pain with arousal and severe ejaculatory pain, using a novel diagnostic and treatment algorithm. We performed a retrospective chart review of men who presented to our clinic from 2015 through 2020 with a history of an unusual sexual dysfunction lasting for more than 3 months and had, at minimum, a follow-up of one year post treatment. All were managed using the novel algorithm, which included a sex therapy evaluation, neurogenital sensory testing of both the pudendal and sciatic nerves, measurement of the bulbocavernosus reflex latency, regional dorsal and pudendal nerve diagnostic anesthesia testing, lumbosacral MRI, and diagnostic transforaminal epidural spinal injection (TFESI) with an anesthetic. If the unusual sexual dysfunction was suspected to be secondary to SSNR radiculopathy, lumbar endoscopic spine surgery (LESS) was performed. 5 patients (mean age at presentation 26, range 17 – 38 years) meeting the criteria had the following symptoms: persistent genital arousal (3/5), distressing penile pain with arousal (3/5), spontaneous ejaculation/orgasm (2/5), and/or severe ejaculatory pain (2/5). Significant psychological distress was noted including suicidal ideation in 3/5 of patients. Neurogenital testing was abnormal in all. Mean perception of finger/glans vibration, cold and heat were 4/11 volts; 21.2/15.8° and 31 /37° respectively. Mean perception of finger/buttock vibration, posterior thighs and posterior calf were 4/14.3 volts. Mean value of bulbocavernosus reflex latency testing was 93 msec (normal 30-50 msec). Regional dorsal and pudendal nerve diagnostic anesthesia tests failed to temporarily resolve unusual sexual dysfunction symptoms in 100%. MRI findings showed annular tears in 5/5: L5-S1 (2/5), L4-L5 (4/5). Diagnostic TFESI resulted in clinically significant symptom reduction in 5/5. Based on these results, sexual dysfunctions were highly suspected to be secondary to SSNR radiculopathy. All patients underwent LESS, were discharged the same day, and had no surgical complications. All reported improvement on Patient Global Impression of Improvement of very much better (2/5) or much better (3/5). Mean follow-up was 21.6 months post-LESS treatment. Unusual sexual dysfunctions can be a management challenge to urologists. Although persistent genital arousal, spontaneous ejaculation/orgasm, penile pain with arousal, and severe ejaculatory pain are perceived to be in the genitals, in this patient population these unusual sexual dysfunctions were actually caused by an upstream mechanical/inflammatory SSNR radiculopathy from lumbosacral annular tears. Symptom alleviation was achieved by LESS in all patients. Work supported by industry: no. A consultant, employee (part time or full time) or shareholder is among the authors (Elliquence, Lumenis). [ABSTRACT FROM AUTHOR]

The most commonly treated sexual dysfunctions in men are erectile dysfunction, Peyronie's disease, premature and delayed ejaculation, and decreased sexual desire. While urologists have expertise treating these sexual dysfunctions, there are unusual sexual health concerns in men that can prove a management quandary to many clinicians. These include persistent genital arousal, spontaneous ejaculation/orgasm, penile pain with arousal, and severe ejaculatory pain, which may be secondary to a radiculopathy of the sacral spinal nerve roots (SSNR). Men with these unusual problems often experience despair, emotional lability, catastrophization, and/or suicidality. The objective was to examine the management of men presenting to our multidisciplinary sexual medicine clinic with unusual sexual dysfunctions including persistent genital arousal, spontaneous ejaculation/orgasm, penile pain with arousal and severe ejaculatory pain, using a novel diagnostic and treatment algorithm. We performed a retrospective chart review of men who presented to our clinic from 2015 through 2020 with a history of an unusual sexual dysfunction lasting for more than 3 months and had, at minimum, a follow-up of one year post treatment. All were managed using the novel algorithm, which included a sex therapy evaluation, neurogenital sensory testing of both the pudendal and sciatic nerves, measurement of the bulbocavernosus reflex latency, regional dorsal and pudendal nerve diagnostic anesthesia testing, lumbosacral MRI, and diagnostic transforaminal epidural spinal injection (TFESI) with an anesthetic. If the unusual sexual dysfunction was suspected to be secondary to SSNR radiculopathy, lumbar endoscopic spine surgery (LESS) was performed. Five patients (mean age at presentation 26, range 17 – 38 years) meeting the criteria had the following symptoms: persistent genital arousal (3/5), distressing penile pain with arousal (3/5), spontaneous ejaculation/orgasm (2/5), and/or severe ejaculatory pain (2/5). Significant psychological distress was noted including suicidal ideation in 3/5 of patients. Neurogenital testing was abnormal in all. Mean perception of finger/glans vibration, cold and heat were 4/11 volts; 21.2/15.8° and 31 /37° respectively. Mean perception of finger/buttock vibration, posterior thighs and posterior calf were 4/14.3 volts. Mean value of bulbocavernosus reflex latency testing was 93 msec (normal 30-50 msec). Regional dorsal and pudendal nerve diagnostic anesthesia tests failed to temporarily resolve unusual sexual dysfunction symptoms in 100%. MRI findings showed annular tears in 5/5: L5-S1 (2/5), L4-L5 (4/5). Diagnostic TFESI resulted in clinically significant symptom reduction in 5/5. Based on these results, sexual dysfunctions were highly suspected to be secondary to SSNR radiculopathy. All patients underwent LESS, were discharged the same day, and had no surgical complications. All reported improvement on Patient Global Impression of Improvement of very much better (2/5) or much better (3/5). Mean follow-up was 21.6 months post-LESS treatment. Unusual sexual dysfunctions can be a management challenge to urologists. Although persistent genital arousal, spontaneous ejaculation/orgasm, penile pain with arousal, and severe ejaculatory pain are perceived to be in the genitals, in this patient population these unusual sexual dysfunctions were actually caused by an upstream mechanical/inflammatory SSNR radiculopathy from lumbosacral annular tears. Symptom alleviation was achieved by LESS in all patients. Any of the authors act as a consultant, employee or shareholder of an industry for: Elliquence, Lumenis [ABSTRACT FROM AUTHOR]

Penile numbness is an unusual, troubling symptom that may cause delayed/muted orgasm. Spinal cord and/or brain pathologies were found in 4/48 (8%) patients based on abnormal vibration/cold/heat perception threshold values in the genitals, normal bulbocavernosus reflex latency testing and abnormal sacral/foot dermatome testing. [Extracted from the article]

This is the first-ever long-term MISS treatment outcome study in PGAD patients with suspected radiculitis of sacral spinal nerve roots from lumbar spine abnormalities. Based on this initial series of PGAD patients with symptomatic lumbosacral disc abnormalities, treatment with endoscopic spine surgery was associated with a long-lasting beneficial treatment option in better than 4 of 5 patients. [Extracted from the article]

PGAD may be considered a chronic GU dysesthesia disorder characterized by persistent unwanted, intrusive, distressing feelings of genital arousal, or genital itch, or genital pain not associated with concomitant sexual interest, thoughts, or fantasies. In selected patients with PGAD suspected to have radiculopathy of SSNR, spine surgery may be a successful disease modification strategy. [Extracted from the article]