(148) “Zebras” in Sexual Medicine from Cauda Equina Pathology
Authors: Kim CW , Goldstein I , Goldstein SW , Komisaruk BR , Kim NN , Yee A 
Published: February 2024

Abstract

Introduction
Unrelenting, bothersome sexual medicine problems in individuals with a vulva or penis sometimes do not respond to conventional therapies, frustrating both patient and provider. These distressing problems can be categorized as a genito-pelvic dysesthesia (GPD), including genito-pelvic (penile, scrotal, clitoral, vulvar, vestibular, vaginal, bladder, rectal) pain, persistent genital arousal disorder (PGAD), sleep related prolonged erections (SRPE) and hard-flaccid syndrome (HFS), currently considered as “zebras” in sexual medicine. We recently published a study on 20 patients with PGAD/GPD who underwent a multi-disciplinary management algorithm, were determined to have lumbosacral annular tear induced sacral radiculopathy, and with one year follow-up post-spine surgery, 80% revealed improvement in symptoms.

Objective
To apply our (spine-sexual medicine) multi-disciplinary management algorithm to sexual medicine “zebras”.

Methods
Patients who presented between July 1, 2021, and June 30, 2023, to our sexual medicine clinic were included in the study cohort. The management algorithm was as follows: biopsychosocial history, multiple validated instruments, physical examination, neurogenital testing, regional anesthesia testing, lumbosacral MRI, and when appropriate, a caudal epidural or transforaminal epidural spinal injection. Those with clinically significant symptom reduction from the spinal injection were offered appropriate spine surgery. Patient Global Impression of Improvement (PGI-I) was assessed post-operatively (1 = very much better, 2 = much better, 3 = better, 4 = no change, 5 = worse, 6 = much worse and 7 = very much worse.

Results
Our study cohort consisted of 24 patients, 14 with a vulva and 10 with a penis, mean age 42 years (range 25-69) who presented to our clinic over a period of two years. The patients' GPD complaints included genital pain (13), PGAD (6), SRPE (2), HFS (1), bladder pain (1) and rectal pain (1). All patients had results of neurogenital and regional anesthesia tests consistent with sacral radiculopathy, then underwent a diagnostic focal lidocaine spinal injection. Each had a positive response to either a transforaminal epidural spinal injection and underwent lumbar endoscopic spine surgery (n = 21) or a caudal epidural and underwent Tarlov cyst surgery (n = 3). PGI-I scores after surgery indicative of improvement (PGI-I = 1, 2, 3) at one week was 10/22 (45%), at 6 weeks was 9/17 (53%) at 3 months was 9/16 (56%) and at 6 months was 5/6 (83%).

Conclusions
Patients presenting with sexual medicine complaints not successfully managed by routine treatment strategies often experienced delay in diagnosis and excessive healthcare-seeking behavior resulting in significant distress. In our experience, GPD can result from triggers in the cauda equina, far from the location of the presenting genito-pelvic symptom(s). Our cohort of sexual medicine “zebras” who underwent our multi-disciplinary management algorithm were diagnosed with sacral radiculopathy. These patients opted for spine surgery and reported improvement of symptoms that continued to get better over time.

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