(071) SEXUAL DYSFUNCTIONS SECONDARY TO LUMBOSACRAL ANNULAR TEAR-INDUCED SACRAL RADICULOPATHY: “GENITO-PELVIC SCIATICA”
Authors: Goldstein I , Goldstein SW , Komisaruk B , Kim NN , Kim C 
Published: December 2024

Abstract

Introduction
Sacral radiculopathy is defined as inflammatory irritation in the cauda equina of S2-S3 nerve roots formed by the convergence of the pelvic, pudendal, and sciatic nerves. Sacral radiculopathy can cause unwanted or intrusive, persistent or recurrent, distressing clinical symptoms involving the sensory fields of these nerves in the genito-pelvic region termed genito-pelvic dysesthesia (GPD). Specifically, pelvic nerve (visceral afferent)-associated symptoms involve the clitoris/penis vestibule, urethra, bladder (frequency/urgency), umbilicus, vagina, epididymis/prostate and rectum; pudendal nerve (somatic)-associated symptoms involve the clitoris/penis, vestibule, vulva/scrotum, perineum, perianal region, pelvic floor (high tone); and sciatic nerve (somatic)-associated symptoms involve the lower back, buttock, thigh, calf, foot, and restless legs. We have previously reported that lumbosacral annular tears can induce sacral radiculopathy and result in PGAD/GPD symptoms. Lumbosacral annular tears that induce sacral radiculopathy can result in other distressing sexual dysfunctions including vestibulodynia, clitorodynia, sleep related painful erections (SRPE), and hard flaccid syndrome (HFS). Many clinicians are unaware that sexual dysfunctions involving genito-pelvic based symptoms can result from pathology in a remote location, essentially a genito-pelvic sciatica, specifically from a lumbosacral annular tear in the cauda equina.

Objective
To perform a chart review of patients with sexual dysfunctions secondary to lumbosacral annular tear-induced sacral radiculopathy.

Methods
Charts of individuals presenting to our sexual medicine clinic between January 2019 and December 2023 were examined. Patients who were evaluated by history/physical examination, regional anesthesia testing, neurogenital testing, lumbosacral MRI and transforaminal epidural spinal injection (TFESI) with an anesthetic agent were included in this study. To be diagnosed with lumbosacral annular tear-induced sacral radiculopathy, individuals had to meet the following criteria based on a previously reported management algorithm: i) history/physical examination findings consistent with any of the following: persistent arousal/awareness (PGAD), feelings of pain, itch, pressure, engorgement, throbbing, heat, “electric shocks”, “broken glass” in the genito-pelvic region (GPD), or specifically localized to the clitoris (clitorodynia) or vestibule (vestibulodynia), multiple painful nocturnal erections that awaken the individual and result in sleep deprivation (SRPE), genital engorgement when lying; supine, flaccid penis that feels firm, shrunken, contracted, non-compressible and tender (HFS); ii) symptoms unresolved with genital and/or pelvic/pudendal anesthesia testing; iii) abnormal integrity of the sciatic and pudendal nerves based on neurogenital testing; iv) obvious high-intensity zone or a disc bulge/protrusion with no accompanying high-intensity zone visualized on lumbosacral MRI; and v) clinically significant symptom reduction that lasted for approximately 4 hours after administration of TFESI.

Results
Our study cohort included 132 patients (79 with a vulva and 53 with a penis; mean age 37, range 18– 72 years. Sexual dysfunctions associated with sacral radiculopathy included: genito-pelvic dysesthesia 49%, persistent genital arousal disorder 33%, sleep related painful erection 6%, hard flaccid syndrome 5%, vestibulodynia 4%, and clitorodynia 3%. Lumbar endoscopic spine surgery was performed in 78 cases, with improvement noted in 65% as reported on PGI-I 1-2 (very much better - somewhat better).

Conclusions
Clinicians should be aware that a variety of sexual dysfunctions with bothersome genito-pelvic dysesthesia symptoms can occur from lumbosacral annular tear-induced sacral radiculopathy.

Disclosure
Any of the authors act as a consultant, employee or shareholder of an industry for: Elliquence.