Reversible neurogenic sexual dysfunction caused by lumbar and/or sacral pathology within the cauda equina
Goldstein, I1; Komisaruk, BR2; Biewenga, ED3; Goldstein, SW3; Hanley, J4; Kim, CW4
1: Alvarado Hospital, USA; 2: Rutgers, USA; 3: San Diego Sexual Medicine, USA; 4: Spine Institute of San Diego, USA
Objectives: Neurogenic sexual dysfunction is usually considered irreversible, secondary to such pathophysiologies as spinal cord injury, multiple sclerosis, or post-radical pelvic surgery. We describe our experience with a reversible form of neurogenic sexual dysfunction caused by sacral or lumbar spine pathology within the cauda equina (CE), identified as radiculopathy of the sacral spinal nerve root (SSNR), that may be cured surgically.
Material and Methods: 14 men and women (mean age 37 +/- 11 years) were included. They had at least 6 months follow-up and presented with bothersome neurogenic sexual dysfunctions of hyper-functioning radiculopathy: persistent genital arousal disorder (PGAD) (n=6), severe genital pain during both arousal and ejaculation/orgasm (n=3), and genital itching (n=1); or hypo-functioning radiculopathy: delayed or absent ejaculation/orgasm (n=4). The diagnostic work-up consisted of neuro-genital testing: genital biothesiometry, sacral dermatome, bulbocavernosus reflex latency, and urethral and vaginal pelvic nerve afferent nerve testing. Sacral and lumbar MRI studies assessed for presence of treatable lumbar and/or sacral spine pathology. Epidural nerve blocks under fluoroscopy at the site of suspected pathology using steroid with local anesthesia for hyper-functioning cases or steroid alone for hypo-functioning radiculopathy identified amelioration of symptoms. Subsequently, minimally-invasive out-patient spine surgery was performed.
Results: Neuro-genital diagnostic testing was abnormal in all 14 patients who underwent spine surgery. Patho-physiologies included Tarlov cyst (n=2), annular tear (n=7), disc impingement (n=2), facet cyst (n=1), and spinal stenosis (n=2). Epidural nerve blocks (n=12) showed symptom reduction. At total of 4/6 with PGAD were cured, 2/3 with severe genital pain during both arousal and ejaculation/orgasm were cured, and 1/4 with delayed or absent ejaculation/orgasm were cured. There were no surgical complications.
Conclusions: Reversible bothersome neurogenic sexual dysfunction may be caused by lumbar and sacral spine pathologies inducing either a hyper-functioning or hypo-functioning radiculopathy of the SSNR in the CE. Our diagnostic paradigm involves neuro-genital testing, lumbar/sacral MRIs and epidural nerve blocks. Minimally-invasive out-patient spine surgery has resulted in cure in 2/3 of patients with hyper-functioning radiculopathy.
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