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Persistent Sexual Arousal Syndrome

This program was held for those with PSAS and their loved ones. The opening session was on psychological considerations, presented by Dr. Stanley Ducharme and Julie Johnson. This was followed by a presentation of the biological issues by Dr. Irwin Goldstein.

Psychological Considerations

The occurrence of PSAS for a woman is unrelated to demographic concerns such as age, socioeconomic level, childhood experiences, marital status, education level or family history. Distinguishing characteristics are genital and breast vasocongestion and sensitivity, with little or no relief form orgasmic experience. The arousal is unrelated to sexual excitement or desire. PSAS can be triggered by sexual or non-sexual stimuli or no stimuli at all, and is generally unwanted and intrusive.

Living with PSAS is a psychological continuum. It is a unique experience for each person: each woman with PSAS and her partner undergoes an individual emotional experience. Initial reaction to PSAS may be confusion and lack of understanding, inability to access health care, difficulty with people confusing the syndrome with hypersexuality, shame and embarrassment, feelings of self-blame and personal distress, invalidation, and feelings of isolation and withdrawal. The impact on the partner can be helplessness and confusion, uncertainty in providing relief, feelings of inadequacy, isolation and lack of support from family and peers, frustration and anger, and gradual decline in quality of life for the man and woman.

There are long term emotional consequences of living with PSAS. These include disruptions in occupational, educational and social functioning, a continued sense of shame and isolation, feelings of helplessness, vulnerability and sadness, being awakened in the morning by hot flashes, and a feeling of a lack of normalcy. In order to cope with PSAS it is important to recognize that this is a couple’s issue. It is necessary for the sufferer to communicate with her partner and overcome shame in order to seek proper treatment as well as support. The woman must act as educator.

PSAS was first diagnosed in 2001 and little is still known about the disorder. Pubic education and information about PSAS is critical. Empirical research is leading to more effective treatment options. Medical and psychological assistance is now available at programs such as at the Center for Sexual Medicine.

Biologic Aspects

Physiologic sexual function requires mind, relationships and body including hormones, nerves and genital blood flow. The classification of female sexual dysfunction is based on the sexual response cycle: desire leads to arousal leads to orgasm, satisfaction and resolution. Sexual dysfunctions are defined as disorders of desire, arousal and orgasm. Sexual dysfunctions in women are common, complicated, multidimensional, interrelated with wide overlap among the dysfunctions of desire, arousal and orgasm. Sexual dysfunctions that are considered treatable are associated with personal distress related to the sexual dysfunction in terms as anger, dissatisfaction, distress, embarrassment, frustration, guilt, inadequacy, inferiority, regret, stress, unhappiness and worry. In contemporary management of female sexual dysfunction, a 70% success in management can be anticipated using sex therapy, physical therapy, medical therapy, hormone therapy and/or vasodilator therapy as indicated for an individual patient. This success rate is not yet applicable to women with persistent sexual arousal, although a better understanding of the syndrome has witnessed numerous patients realize marked improvement in function. Epidemiologically the most common sexual dysfunctions for women include: lack of interest in sex, inability to achieve orgasm, lack of pleasurable sex, pain during sex, and trouble with lubrication. The condition of persistent sexual arousal is not reported frequently enough to be included in national surveys on women’s sexual health. It is unknown how often women complain of persistent arousal but it is thought to be extremely rare.

The consensed defintions of sexual dysfunction.

In men, the condition of persistent arousal may be considered as the condition of priapism. Consensed definitions and management strategies exist for men with priapism. There is no parallel consensed definition for women with persistent sexual arousal. Based on patients who either presented for evaluation to the Center for Sexual Medicine or who communicated by e-mail to the Institute for Sexual Medicine, we have gained data on this unusual sexual dysfunction. We propose new definitions based on existing definitions but await the medical community to consense these new definitions appropriately. Persistent Sexual Arousal Syndrome/Disorder may be considered as the persistent, recurrent or continuous ability to attain or maintain sufficient sexual excitement, causing personal distress. It may be expressed as excessive subjective excitement or excessive genital (lubrication, swelling, engorgement) or other somatic responses. Some patients are better classified as having Persistent Orgasmic Syndrome/Disorder. Persistent Orgasmic Syndrome/Disorder may be considered as the persistent, recurrent or continuous attainment of or need to attain orgasm following minimal or absent sexual stimulation and arousal, which causes personal distress. On the other hand, some patients are better classified as having Persistent Sexual Desire Disorder. Persistent Sexual Desire Disorder may be considered as the persistent, recurrent or continuous presence of sexual fantasies, thoughts, and/or desire for, or receptivity to, sexual activity, which causes personal distress.

Women with PSAS share common features of their sexual dysfunction. The most common is the torment and the ruling of their lives by the persistent sexual arousal. There is a universal feeling of despair in part because the medical community does not recognize the existence of the condition and because the patients feel that they will therefore have to live the rest of their lives with the PSAS-hell. Phrases mentioned by patients in this regard include, “my life has been sheer hell” and.”I want my LIFE BACK!”.

“Sitting is unbearable, sometimes causing pressure to orgasm. Standing is the only time I feel nothing. Sitting in a car is torture.” “The opening of the vagina is just as sensitive and a mere touch will bring me to orgasm. My husband is very sympathetic and relieves the terrible pressure anytime I ask. Those close to me that I’ve told about this at first think it’s funny and then realize that indeed it is not.”

“It’s so hard for me to feel any hope when I am in the middle of this. For the last couple of weeks I have just been practicing thinking that I may have to go on with my life in spite of this.” “I have made such a wonderful life for myself and I am just so terrified that this will finally be the thing that pushes me over the edge. Because I am so blessed, I have so much to lose.”

“I was constantly feeling overwhelming sensations of sexual arousal, which were purely physical and not accompanied by romantic or sexual fantasies. Basically I felt the need to have repeated orgasms which was never relieved by normal orgasmic experience.” “I was so uncomfortable I thought about jumping off the roof just to make it go away.”

Based on data from these and other patients we have treated or communicated over the last several years, we propose a new classification of PSAS based on suspected pathophysiology (causation): Neurologic – Central, Neurologic – Peripheral, Pharmacologic, Vascular and Other. Diagnosis of the underlying PSAS pathophysiology is essential to correct patient management. It is our belief that all patients with PSAS should have a psychologic interview, medical history (medication use, onset), physical examination (local genital pathology), neurologic sensation testing, blood flow tests before and after arousal, arteriography if indicated and hormone blood tests. All patients should have access to ongoing psychologic care and management. All PSAS patients should have a thorough neurologic assessment. All patients should have detailed assessment of their medication (prescribed and non-prescribed) use.

Neurologic – Central: The central nervous system (brain and spinal cord) is critical in regulating sexual function, especially desire, arousal and orgasm. What if there was persistent neurologic stimulation of the autonomic nerves to the clitoris, labia, vagina secondary to central nervous system pathology? The result would theoretically be PSAS. We are aware of several patients with PSAS based on Neurologic – Central causes. One patient developed PSAS following surgery on a mass of blood vessels in the brain. One patient developed PSAS after stopping estrogen replacement therapy and soon thereafter developed a stroke (cerebral vascular accident). One patient developed PSAS after stopping cholesterol-lowering therapy and soon thereafter developed a stroke (cerebral vascular accident). One patient developed PSAS after developing severe neck pain and underwent surgery to relieve the neck pain. For patients suspected of Neurologic – Central pathophysiology, we consider the following treatments – 1. Medications that stabilize nerve transmission and/or effect mood such as Depakote, Celexa, Neurontin, Clonipin, Tofranil, Prozac, Paxil, Zyprexa and/or Ativan 2. Local topical anesthetic agents, ice 3. Medical treatment of irritating neurolgic lesion: Physical Therapy, acupressure, pain meds, muscle relaxants 4. Hormonal milieu normalization; normal hormones allow for improved orgasmic function (this offers women with PSAS the ability to achieve release through orgasm) 5. Surgical excision of irritating neurologic lesion. All medication prescribed for PSAS must be followed with frequent doctor visits.

Neurologic – Peripheral: The peripheral nervous system (local genital nerves – motor and sensory) is critical in regulating sexual function, especially arousal and orgasm. What if there was persistent neurologic stimulation of the autonomic nerves to the clitoris, labia or vagina secondary to local peripheral nervous system pathology? The result would theoretically be PSAS. We are aware of one patient with PSAS based on Neurologic – Peripheral causes. One patient developed PSAS following surgery for urethral prolapse. Physical examination revealed a raspberry red, swollen urethral meatus with bulging tender and painful prolapsed mucosal edges. She suffered from PSAS for 2 1/2 years. Based on her successful resolution, we recommend: 1. Local estrogen to external genitalia 2. Local topical anesthetic agents, ice 3. Steroid nerve blocks (repeated) 4. Medical treatment of irritating lesion 5. Hormonal milieu normalization; normal hormones allow for improved orgasmic function (this offers women with PSAS the ability to achieve release through orgasm) 6. Surgical excision of irritating lesion.

Pharmacologic: Sexual arousal involves release of chemicals into the genital tissue that induces genital smooth muscle relaxation. Medication has the ability to inhibit contraction or enhance relaxation of the smooth muscles of the genitals. What if there was persistent pharmacologic-induced inhibition of contraction or enhanced relaxation of the clitoral, labial, vaginal smooth muscle? The result would theoretically be PSAS. We are aware of several patients with PSAS based on exposure to certain medication. One medication in particular is trazodone. Persistent painful clitoral engorgement has been reported as secondary to trazodone use. We are now observing PSAS secondary to trazodone use. Based on successful resolutions with this pathophysiology we recommend: discontinuing the offending medication.

Vascular: Blood supply is critical to genital swelling and lubrication responses to sexual arousal. What if there was persistent high inflow arterial communication to the clitoral, labial, vaginal tissue? The result would theoretically be PSAS. We are aware of one patient with PSAS based on a pelvic arterial venous malformation (AVM) communicating to the arteries of the clitoris. Duplex Doppler ultrasound revealed marked increased blood flow to the clitoris. A selective internal pudendal arteriogram revealed the pelvic AVM. The patient has ultimately achieved great relief from PSAS symptoms after multiple embolization episodes.

Other: Sexual arousal involves release of chemicals into the genital tissue which induces genital smooth muscle relaxation. Under normal circumstances, the released chemicals are broken down by enzymes in the genital tissue. What if the enzyme was inactive or missing that was needed to break down the chemicals released by sexual stimulation? The result would theoretically be PSAS. While there is no proof yet that this situation exists, there are some data to suggest that this possibility could exist. Laboratory animals (males) were treated so that these “breakdown” enzymes were inactive and the result was priapism. For patients with PSAS suspected of this pathophysiology (other causes were excluded), we recommend: 1. Discontinue offending medications 2. Medications that stabilize nerve transmission and/or effect mood: Depakote, Celexa, Neurontin, Clonipin, Tofranil, Prozac, Paxil, Zyprexa, Ativan 3. Local topical anesthetic agents, ice 4. Hormonal milieu normalization; normal hormones allow for improved orgasmic function (this offers women with PSAS the ability to achieve release through orgasm).

We look forward to basic science and clinical research expanding our understanding and management options for PSAS patients in the future.

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of BU School of Medicine