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The Journal of Sexual Medicine Apr 2021Persistent genital arousal disorder (PGAD), a condition of unwanted, unremitting sensations of genital arousal, is associated with a significant, negative psychosocial...
International Society for the Study of Women's Sexual Health (ISSWSH) Review of Epidemiology and Pathophysiology, and a Consensus Nomenclature and Process of Care for the Management of Persistent Genital Arousal Disorder/Genito-Pelvic Dysesthesia (PGAD/GPD).
BACKGROUND
Persistent genital arousal disorder (PGAD), a condition of unwanted, unremitting sensations of genital arousal, is associated with a significant, negative psychosocial impact that may include emotional lability, catastrophization, and suicidal ideation. Despite being first reported in 2001, PGAD remains poorly understood.
AIM
To characterize this complex condition more accurately, review the epidemiology and pathophysiology, and provide new nomenclature and guidance for evidence-based management.
METHODS
A panel of experts reviewed pertinent literature, discussed research and clinical experience, and used a modified Delphi method to reach consensus concerning nomenclature, etiology, and associated factors. Levels of evidence and grades of recommendation were assigned for diagnosis and treatment.
OUTCOMES
The nomenclature of PGAD was broadened to include genito-pelvic dysesthesia (GPD), and a new biopsychosocial diagnostic and treatment algorithm for PGAD/GPD was developed.
RESULTS
The panel recognized that the term PGAD does not fully characterize the constellation of GPD symptoms experienced by patients. Therefore, the more inclusive term PGAD/GPD was adopted, which maintains the primacy of the distressing arousal symptoms and acknowledges associated bothersome GPD. While there are diverse biopsychosocial contributors, there is a common underlying neurologic basis attributable to spontaneous intense activity of the genito-pelvic region represented in the somatosensory cortex and its projections. A process of care diagnostic and treatment strategy was developed to guide the clinician, whenever possible, by localizing the symptoms as originating in any of five regions: (i) end organ, (ii) pelvis/perineum, (iii) cauda equina, (iv) spinal cord, and (v) brain. Psychological treatment strategies were considered critical and should be performed in conjunction with medical strategies. Pharmaceutical interventions may be used based on their site and mechanism of action to reduce patients' symptoms and the associated bother and distress.
CLINICAL IMPLICATIONS
The process of care for PGAD/GPD uses a personalized, biopsychosocial approach for diagnosis and treatment.
STRENGTHS AND LIMITATIONS
Strengths and Limitations: Strengths include characterization of the condition by consensus, analysis, and recommendation of a new nomenclature and a rational basis for diagnosis and treatment. Future investigations into etiology and treatment outcomes are recommended. The main limitations are the dearth of knowledge concerning this condition and that the current literature consists primarily of case reports and expert opinion.
CONCLUSION
We provide, for the first time, an expert consensus review of the epidemiology and pathophysiology and the development of a new nomenclature and rational algorithm for management of this extremely distressing sexual health condition that may be more prevalent than previously recognized. Goldstein I, Komisaruk BR, Pukall CF, et al. International Society for the Study of Women's Sexual Health (ISSWSH) Review of Epidemiology and Pathophysiology, and a Consensus Nomenclature and Process of Care for the Management of Persistent Genital Arousal Disorder/Genito-Pelvic Dysesthesia (PGAD/GPD). J Sex Med 2021;18:665-697.
Topics: Arousal; Consensus; Female; Genitalia; Humans; Paresthesia; Pelvis; Sexual Dysfunctions, Psychological; Sexual Health
PubMed: 33612417
DOI: 10.1016/j.jsxm.2021.01.172 -
European Journal of Medical Research May 2021Tarlov cysts are a commonly misdiagnosed condition, which can present with many rare symptoms. We report a case of a Tarlov cyst with spermatorrhea and review the...
BACKGROUND
Tarlov cysts are a commonly misdiagnosed condition, which can present with many rare symptoms. We report a case of a Tarlov cyst with spermatorrhea and review the pertinent literature.
CASE PRESENTATION
A 42-year-old male patient had a history of spermatorrhea for > 10 years, but was incorrectly diagnosed as the patient and the doctors consistently mistook the symptoms for a genitourinary disease. Magnetic resonance imaging showed that two cysts in the sacral canal. The diagnosis was Tarlov cyst. We performed surgery to remove the cyst and the symptoms of spermatorrhea disappeared after the operation.
CONCLUSIONS
This case demonstrates that orthopedics and urologists should improve their understanding of Tarlov cysts to avoid misdiagnosis and mistreatment.
Topics: Adult; Diagnostic Errors; Genital Diseases, Male; Humans; Male; Tarlov Cysts
PubMed: 33964972
DOI: 10.1186/s40001-021-00514-w -
Archives of Sexual Behavior Apr 2024Tarlov cysts adjacent to the spinal cord are usually asymptomatic and found incidentally via magnetic resonance imaging. On rare occasions, they increase in size to...
Tarlov cysts adjacent to the spinal cord are usually asymptomatic and found incidentally via magnetic resonance imaging. On rare occasions, they increase in size to produce symptoms resembling disk herniation. We report a rare case of a sacral cyst resulting in premature ejaculation in a 32-year-old man who presented with pelvic pain and acquired premature ejaculation. Spinal nerve root decompression, excision of intraspinal Tarlov cyst, and spinal nerve root adhesion release surgery significantly improved his pain and premature ejaculation at a six-month follow-up.
Topics: Male; Humans; Adult; Tarlov Cysts; Premature Ejaculation; Pelvic Pain; Magnetic Resonance Imaging
PubMed: 38366312
DOI: 10.1007/s10508-024-02815-7 -
International Journal of Surgery Case... Jan 2022Although asymptomatic Tarlov cysts (TCs) are reported in up to 13% of the population, symptomatic TCs are rare (less than 1%), making the management of the symptomatic...
INTRODUCTION AND IMPORTANCE
Although asymptomatic Tarlov cysts (TCs) are reported in up to 13% of the population, symptomatic TCs are rare (less than 1%), making the management of the symptomatic cysts controversial. The most common location of symptomatic TCs is sacral nerve roots where they can cause pelvic, perineal chronic discomfort and pain, and lower extremity sensory and motor changes. Ventral (intrapelvic retroperitoneal) sacral TCs are extremely rare with no management recommendations. Available surgical options include cyst resection, and inlet-obliteration, however, these methods are often considered invasive and not definitive.
CASE PRESENTATION
A 39-year-old woman presented with debilitating low back pain (LBP) radiating to her pelvis and the right lower extremity for 4 years. Magnetic Resonance Imaging (MRI) showed multiple sacral nerve root TCs including a large retroperitoneal right S3 TC. Surgical resection of the right S3 cyst was achieved utilizing a robot-assisted anterior approach which provided excellent visualization and maneuverability in the targeted retroperitoneal space. Postoperatively, the patient experienced significant pain relief, and she was able to perform activities of daily life and return to work.
CLINICAL DISCUSSION
Robotic-assisted pelvic surgery has gained widespread popularity in the last two decades due to its many potential benefits. Utilizing robotic systems in sacral nerve sheath lesions shows a promise to deliver effective minimally invasive surgical management without sacrificing good visualization or instrument maneuverability.
CONCLUSION
Robot-assisted resection of sacral nerve roots TCs represents a minimally invasive and safe surgical option to manage cysts located anterior to the sacrum in the pelvic retroperitoneal space.
PubMed: 34998266
DOI: 10.1016/j.ijscr.2021.106732 -
Journal of Spine Surgery (Hong Kong) Dec 2019Tarlov cyst disease is a collection of cerebrospinal fluid between the endoneurium and perineurium of spinal, usually sacral, nerve roots. These cysts can become...
BACKGROUND
Tarlov cyst disease is a collection of cerebrospinal fluid between the endoneurium and perineurium of spinal, usually sacral, nerve roots. These cysts can become symptomatic in 20% of patients, causing lower back pain, radiculopathy, bladder and bowel dysfunction necessitating medical or surgical intervention. Different surgical and non-surgical modalities have been described for the treatment of symptomatic Tarlov cysts. However, there has been no published study that examined types of surgical techniques side by side. Our study presents a preliminary experience in the surgical management of symptomatic Tarlov cysts using two surgical techniques: cyst fenestration and nerve root imbrication.
METHODS
Retrospective chart review and analysis was done for all patients who underwent surgical intervention for symptomatic Tarlov cyst(s) in the period 2007-2013. Operative reports, preoperative and postoperative clinic visit reports were reviewed. The surgical techniques of cyst fenestration and nerve root imbrication were each described in terms of intraoperative parameters, hospital course and outcome. Modified MacNab criteria were used for evaluation of the final clinical outcome.
RESULTS
Thirty-six surgical patients were identified. Three had repeat surgery (total of 39 operations). The median age was 51 years (range, 26-84 years). Eighty-six percent were females. The presenting symptoms were low back pain (94%), sensory radiculopathy (69%), bladder and bowel dysfunction (61%), sexual dysfunction (17%) and motor dysfunction (8%). Cyst fenestration was performed in 12 patients (31%) and nerve root imbrication was done in 27 (69%). All patients in the fenestration group but only 67% in the imbrication group had fibrin glue injection into the cyst or around the reconstructed nerve root. The overall surgery-related complication rate was 28%. The complication rate was 5/12 (42%) in the fenestration group and 6/27 (22%) in the imbrication group. At the time of the last clinic visit, improved clinical outcome was noted in 9/11 (82%) and 20/25 (80%) in the fenestration and the imbrication group, respectively.
CONCLUSIONS
Cyst fenestration and nerve root imbrication are both surgical techniques to treat symptomatic Tarlov cyst(s), and both can result in clinical improvement.
PubMed: 32043000
DOI: 10.21037/jss.2019.11.11 -
Surgical and Radiologic Anatomy : SRA Jun 2021Spinal perineural Tarlov's cysts (TCs) are considered incidental findings that occasionally might exert pressure upon nerve roots and correspond with patients' signs and... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Spinal perineural Tarlov's cysts (TCs) are considered incidental findings that occasionally might exert pressure upon nerve roots and correspond with patients' signs and symptoms. Purpose of this meta-analysis is to deliver global incidence and characteristics (location, size, and shape) of TCs.
METHODS
Following PRISMA checklist, all major databases were searched by two authors for radiologic studies reporting incidence and morphologic features (location, size, and shape) of TCs. Anatomical Quality Assessment tool was applied for risk of bias evaluation. Meta-analysis of random-effects model was employed. Subgroup analysis for regional distribution, gender, sacral levels, age, correspondence with symptoms, and persistent genital arousal disorder (PGAD) were planned ahead.
RESULTS
22 radiologic studies of level 3 evidence involving 13,266 subjects were included. Global pooled prevalence of TCs was 4.18% (95% CI 2.47-6.30). Mean pooled sagittal diameter was 11.86 mm (95% CI 10.78-12.93). Sacral cysts strongly prevailed over the other segments. Of the sacral, S2 level was the most common (46.7% [95% CI 29.4-60.5]). Geographically, the highest incidence was found in Europe (6.07% [95% CI 1.49-13.00]), followed by North America (3.82% [95% CI 0.49-9.44]), and Asia (3.33% [95% CI 1.52-5.75]). TCs were more common in women than in men (5.84% vs 3.03%, p < 0.001, test of homogeneity, χ). Subjects with PGAD had incidence of 37.87% (95% CI 2.45-81.75). TCs in pediatric population are rare-0.53% (95% CI 0.02-1.51). 15.59% of TCs corresponded with symptoms.
CONCLUSIONS
Spinal perineural (Tarlov) cysts are found in a minority of population. S2 level of the sacral bone is affected most frequently. There is female predominance. Correspondence with symptoms is seen in less than one-fifth of TCs. Studies with stronger evidence level are needed to corroborate the results. The purported high incidence in PGAD requires confirmation in case-control studies for the risk-ratio calculation.
Topics: Global Burden of Disease; Humans; Incidence; Sacrum; Spinal Nerve Roots; Tarlov Cysts
PubMed: 33452905
DOI: 10.1007/s00276-020-02644-y -
The British Journal of Radiology Nov 2021Determining the prevalence of Tarlov cysts in low back pain patients. (Observational Study)
Observational Study
OBJECTIVE
Determining the prevalence of Tarlov cysts in low back pain patients.
METHODS AND MATERIALS
The picture archiving & communication system (PACS) & hospital information system (HIS) of a corporate hospital were retrospectively analyzed to determine the percentage of Tarlov cysts among patients undergoing spinal MRI for back pain over 3 years (January 2017 to December 2019).
RESULTS
384 patients had undergone spinal MRI for back pain over the study period, and 25 of them (6.51%) had Tarlov cysts. Vast majority (15 cases) showed cysts located at S2/S3 level, and few were found at S1/S2 and other levels. Single cysts were found in most (=18) of the cases, while 7 cases of multiple / bilateral cysts were found. Cyst dimensions were higher in craniocaudal than anteroposterior or transverse directions. In case of multiple cysts, one or two cysts were noted as dominant, having higher dimensions than the others. The study data revealed no gender or age predilection.
CONCLUSIONS
We conclude that including the entire sacrum with a T2 sagittal sequence in all MRI for low back pain can increase detection of Tarlov cysts, and thereby provide more data for further analysis.
ADVANCES IN KNOWLEDGE
We propose the concept of one "dominant" cyst when there are multiple Tarlov cysts. We recommend that diameter or size of Tarlov cysts be specified to their craniocaudal dimension. We also suggest reporting points for contextual structured reporting, viz. presence or absence of bony scalloping, neural foraminal narrowing, nerve root compression or extraforaminal extension.
Topics: Adult; Bangladesh; Causality; Female; Humans; Low Back Pain; Magnetic Resonance Imaging; Male; Middle Aged; Prevalence; Retrospective Studies; Tarlov Cysts; Young Adult
PubMed: 34538080
DOI: 10.1259/bjr.20210505 -
Cureus Jun 2021Lumbosacral Tarlov cysts (TCs) have rarely been seen to rupture. Here, we report an unusual presentation of a ruptured TC with intraspinal hemorrhage mimicking...
Lumbosacral Tarlov cysts (TCs) have rarely been seen to rupture. Here, we report an unusual presentation of a ruptured TC with intraspinal hemorrhage mimicking carcinomatosis. Pathological diagnosis was obtained using percutaneous biopsy. A conservative approach was utilized and an excellent outcome was achieved. Thus, in cases such as this, a ruptured hemorrhagic TC should be on the differential diagnosis to drive appropriate clinical management decisions.
PubMed: 34249569
DOI: 10.7759/cureus.15423 -
Frontiers in Medicine 2020A Tarlov cyst (TC) is a perineural cyst filled with cerebrospinal fluid that originates from the dorsal ganglion or the spinal posterior nerve root. TCs are usually...
A Tarlov cyst (TC) is a perineural cyst filled with cerebrospinal fluid that originates from the dorsal ganglion or the spinal posterior nerve root. TCs are usually asymptomatic and incidentally found in the sacral region. Endopelvic extension of TCs is uncommon and can be misdiagnosed as an adnexal mass on gynecological ultrasound imaging. We performed a search for all clinical studies of TCs that mimicked adnexal masses that had been published through October 12, 2020. We placed no restrictions on language or year of publication in our search, and we performed searches with the following keywords: perineural cyst, Tarlov cyst, sclerotherapy, management, and prognosis. We included all misdiagnosed cases or cases considered as adnexal masses on pelvic sonography. We identified 21 cases of TCs mimicking adnexal masses and conducted a comprehensive analysis of these 21 cases to assess the epidemiology, symptoms, initial diagnoses, provisional ultrasound diagnoses, confirmative modalities, sizes, locations, treatments, and outcomes. The 21 cases included 16 symptomatic cases (76%) and 5 cases with incidental findings (24%), and the average patient age was 41.3 years. The initial diagnosis was performed with ultrasonography in all cases. The most frequent misdiagnosis was unspecified adnexal mass. Confirmative diagnostic modalities were MRI only (67%), CT only (5%), and both MRI and CT (28%). Treatments were surgery (33%), conservative treatment (19%), percutaneous intervention (5%), and alcohol sclerotherapy (5%). In two symptomatic cases misdiagnosed as pelvic masses, cystectomy was performed and leakage of cerebrospinal fluid occurred, necessitating repair of the leak. In one of the asymptomatic patients, cauda equina syndrome occurred after alcohol sclerotherapy for misdiagnosed TC. However, the patient improved with no neurologic deficit after 18 months of conservative treatment. The possibility of large TCs should be considered when assessing adnexal masses in sonography. Since TCs can masquerade as pelvic masses, they should be considered if the mass appears tubular/cystic or multilocular/multiseptate, does not move with respiration, and originates from the sacrum in sonography with or without neurologic symptoms. Accurate diagnosis can prevent medical mismanagement and reduce patient discomfort.
PubMed: 33425933
DOI: 10.3389/fmed.2020.577301