(022) SEXUAL DYSFUNCTION DUE TO LUMBOSACRAL RADICULOPATHY
Authors: Goldstein I , Goldstein S , Komisaruk B , Kim Phd N , Coorapati S , Mccann A , Kim C 
Published: December 2024

Abstract

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

Objective
A chart review of patients with sexual dysfunctions secondary to lumbosacral annular tear-induced sacral radiculopathy was performed.

Methods
Charts of individuals presenting to our sexual medicine clinic between September 2016 and August 2023 were examined. To be included, patients had to have been evaluated by history/physical examination, regional anesthesia testing, neurogenital testing, lumbosacral MRI and transforaminal epidural spinal injection (TFESI) with an anesthetic agent. Lumbosacral annular tear-induced sacral radiculopathy was diagnosed 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 89 patients (60 with a vulva and 29 with a penis; mean age 45.0, range 17– 76 years). Of these 89 patients, we chose to further analyze 56 patients with a most recent follow up visit of 6 months or greater (38 with a vulva and 18 with a penis; mean age 42.9, range 17– 75 years). Sexual dysfunctions associated with sacral radiculopathy included: persistent genital arousal disorder (53.57%), genito-pelvic dysesthesia (23.21%), sleep related painful erection (7.14%), hard/flaccid syndrome (5.36%), genital pain (3.57%), pain (3.57%), vulvodynia (3.57%), pelvic dysesthesia (3.57%), dyspareunia (1.79%), and pleasure dissociative orgasmic disorder/persistent genital arousal disorder (1.79%). Lumbar endoscopic spine surgery was performed in all 56 cases. 80% of those were documented as positive diagnostic injections, and among this subset, 78% of patients experienced significant improvement from surgery with a Patient Global Impression of Improvement (PGII) score of 1, 2, or 3 (Very much improved, Much improved, Minimally improved). 11% of the surgical cases had negative diagnostic injections, and only 33% of this subset experienced significant improvement from surgery with a Patient Global Impression of Improvement (PGII) score of 1, 2, or 3 (Very much improved, Much improved, Minimally improved). The remaining 9% of surgical patients did not undergo diagnostic injections. The groups that performed poorly are the Hard/Flaccid and the SRPE. There were 4 SRPE patients and 3 Hard/Flaccid patients in our dataset. The SRPE group had a 25% success rate, while the Hard/Flaccid group had a 33% success rate. However, the 2 patients that had success both had a recent follow up visit that was at least 1.5 years postop. In further analyzing the 2 patients that had success, their PGII scores were initially worse than their most recent follow-up visits by a significant number. Although we know this is a small dataset, we suppose there may be a possible trend of Hard/Flaccid and SRPE patients noticing their symptoms resolving over a greater period of time when compared with patients that have other primary diagnoses.

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.