A 44-year-old previously healthy woman with a body mass index of 33.5 sustained a motor vehicle accident in March 2018. Patient's vehicle was rear-ended on the driver's side, in a diagonal manner. She was restrained with a seatbelt. She sustained lower back injury and reported experiencing numbness and tingling in the legs, as well as headaches and muscle spasms.
MRI of the lumbar spine done at that time showed multilevel disk pathology, including disk herniation at L2/L3, L3/4, L4/L5, and L5/S1. Additional findings at the L5/S1 level also demonstrated a radial tear and impingement on bilateral lateral recesses. There was no fracture noted. Approximately 3 months later, she started experiencing an intermittent tingling feeling in her clitoris, which progressively worsened to constantly feeling like she was on the verge of orgasm. Orgasm did not provide any relief of her symptoms and at times the patient felt like it was worsening them. Of note, the patient had not been on antidepressant medication before or during the onset of undesired genital arousal.
When asked about her quality of life, the patient stated, "It was terrible, you can't focus on anything, you can't wear any clothes from the waist down to try not to put any pressure at all in that area." Driving, sitting in church, studying at her desk, and any other kind of pressure or vibrations in the genital area exacerbated her symptoms.
After 3 months of undesired genital arousal and feeling ashamed, "dirty and perverted," she expressed her concerns to her medical team and was subsequently referred to the gynecology team. MRI of the pelvis 6 months after the injury showed disk pathology within the visualized lumbar spine (consistent with initial post-trauma MRI), no Tarlov cysts or bony fractures were identified. There was no radiological evidence of peripheral pudendal nerve compression. Physical examination revealed no abnormalities but was limited by her fear of response.
After careful review of her symptoms, medications, and contributing factors, a trial of lidocaine 4% patches, measuring 10 x 14 cm, applied to the sacrum was initiated. The patient was instructed to place the lidocaine patch centrally, right above the buttock crease.
She subsequently stated that the patches provided significant relief of symptoms. At her 3-month follow-up visit, she reported that, while wearing the patch, she experienced full resolution of the clitoral tingling sensation. She also reported the emergence of a new tingling sensation in the vagina. She was prescribed lidocaine gel, which initially provided limited relief. Overall, she reports great improvement in her quality of life since the onset of treatment with lidocaine patches. Although response to therapy has been adequate, she would prefer a more long-term alternative treatment over having to constantly reapply the lidocaine patch. She was presented with the various options to include pudendal nerve block and various medications but elected to continue with lidocaine as needed.
She returned to the office a year after the motor vehicle accident. At that visit, the patient was still experiencing residual back pain and reported that PGAD symptoms appeared to be linked to exacerbations in her back pain. She denied urinary urgency, urinary frequency, bladder or pelvic pain, or symptoms of restless leg syndrome. She started attending physical therapy for back pain and has noticed improvement with her back pain and associated PGAD symptoms. She reported being able to sleep through the night now, without having to wake up due to the genital arousal.
At 18 months follow-up, patient reported continued improvement but incomplete resolution. She experiences about one episode per week, which is always associated with increased lower back pain. She uses lidocaine patches during these episodes, which continue to provide relief. As of her last visit, she plans to continue using lidocaine and focus on improving back pain.