(135) DYSORGASMIA IN A FEMALE PATIENT FOLLOWING TRAM RECONSTRUCTIVE SURGERY
Authors: Pondicherry N , Rowen T 
Published: June 2024

Abstract

Introduction
Many women struggle with sexual dysfunction, either in desire, arousal, orgasm, and/or pain. Despite the incidence of dysorgasmia in the general population, there is a paucity of literature focusing on its causes and treatment, especially when attributed to medical conditions and surgery.

Objective
This case report describes an unusual presentation of post-orgasmic pain following breast reconstruction surgery using abdominal tissue.

Methods
A 73-year old woman presented with chronic orgasmic pain in the deep pelvic area following transverse rectus abdominal muscle (TRAM) flap reconstruction for a mastectomy in the setting of breast cancer treatment. The patient was diagnosed with ductal carcinoma breast cancer in 2011, where she received a lumpectomy with radiation. After 2 years, in 2013, she was diagnosed with a recurrence of breast cancer. She underwent a mastectomy with no complications, with a transverse rectus abdominal muscle flap reconstruction surgery conducted five days later. Following the TRAM reconstruction, the patient consistently began to observe pain with orgasm.

Results
Prior to this surgery, the patient had experienced normal sexual intercourse and orgasm throughout her life. The patient describes pain with orgasm associated with self-stimulation, manual stimulation, oral stimulation, and vaginal penetration. The patient describes the pain associated with orgasm as a “deep, dull pain” causing nausea and is often associated with abdominal spasms. The pain lasts 2-3 minutes following orgasm and is rated as a 5-6/10 on the pain scale. The pain is not associated with urinary incontinence, urinary fullness, or bowel dysfunction. Physical exam revealed a tense abdominal wall consistent with TRAM reconstruction, well healed incisions, a normal clitoris in terms of appearance and sensation and normal pelvic floor muscles.

Conclusions
An orgasm is a complex process which involves interplays between the clitoris, the glans pubis, and the sympathetic activation system. A four-phase model for orgasm has been explored, which separates the orgasm response into: desire (the urge to participate in sexual activities), arousal (increased genital blood flow and clitorial erection), orgasm (after the threshold for stimulation has been reached), and resolution. Dysorgasmia can be multifactorial, and while still unclear, etiologies include pelvic floor dysfunction and/or spasm. While the pathophysiology of how the pelvic floor is connected to orgasm is not exactly understood, it is theorized to be due to dysregulated coordination of pelvic floor muscles. A transverse rectus abdominis muscle (TRAM) flap is a common breast reconstructive procedure following mastectomy. The most common complications of a TRAM flap surgery are hernias/abdominal bulges, fat necrosis, and loco-regional occurance. Interestingly, TRAM surgeries have previously been associated with pelvic floor dysfunction in women due to an increase in abdominal pressure. Since the pelvic floor is tightly connected to the mechanism of an orgasm, it is possible that disruptions to the pelvic floor may lead to painful spasms during orgasms. This is also consistent with the patient’s sensation of abdominal “spasms” during/after orgasm. While not all TRAM surgeries cause dysorgasmia, this patient’s dysorgasmia may be postulated to be secondary to pelvic floor dysfunction.

Disclosure
No.