Patients often present to urologists with complaints of bothersome or distressing penile or glans pain or other dysesthesia symptoms. These abnormal penile/glans sensations include feelings of pain, arousal, buzzing, tingling, burning, twitching, itching, pressure, engorgement, throbbing, heat, “electric shocks” and/or “broken glass.” These symptoms, often seen in sexual medicine, are now termed genito-pelvic dysesthesia (GPD).¹ GPD penile/glans symptoms may occur while flaccid, during erection or in both states. The urologist should have a management plan to address these troubled and often desperate patients with GPD, who regularly exhibit despair, emotional lability, catastrophization and/or suicidality.

Sensations from the penile/glans skin (heat, cold, vibration etc) and deeper structures including the corpora cavernosa and corpus spongiosum (pressure) are innervated by the dorsal nerve branch of the pudendal somatic nerve (S2-4) and by the visceral afferent pelvic nerve (S2-4), respectively. Sensations from these nerves are ultimately processed in the paracentral lobule of the somatosensory cortex. Injuries and neuropathies of the pudendal somatic nerves and/or visceral afferent pelvic nerve pathways may occur at various locations, including the end organ (region 1), pelvic/perineum (region 2), cauda equina (region 3), spinal cord (region 4) and/or brain (region 5).¹ A typical history where region 1 should be considered would be penile/glans pain after direct penile trauma, such as following jelqing, penile fracture or wearing a penile constriction ring for too long. A typical history involving region 2 would be penile/glans pain after bicycle riding or straddle injury.

In particular, in the cauda equina (region 3), the pelvic, pudendal and sciatic nerves merge at the S2-4 foramina, where they coalesce to form the S2-4 nerve roots. These sacral spinal nerve roots (S2-4) ascend to the first synapse in the conus medullaris and, along the way, are subject to compression or impingement radiculopathies from cauda equina pathologies such as Tarlov cysts, annular tears, facet cysts and/or spinal stenosis (see Figure). In such patients with sacral radiculopathy-induced penile/glans symptoms, there may be concomitant 1) sciatic nerve (S2-3) symptoms such as lower back, buttock, thigh, calf, foot or restless leg pain/dysesthesia, 2) pelvic nerve (S2-4) symptoms such as prostate, epididymal, bladder (frequency/urgency), umbilicus or rectal pain/dysesthesia, and/or 3) pudendal nerve (S2-4) symptoms such as scrotal, perineal or perianal region pain/dysesthesia.

Figure. Cauda equina pathology such as lumbar annular tears and/or sacral Tarlov cysts can cause symptoms of sacral radiculopathy including penile pain that involve the pathways of the pelvic, pudendal and sciatic nerves where they merge at the S2-3 foramina.

To manage patients with GPD, the urologist should identify, whenever possible, the biopsychosocial triggers of the GPD symptoms in regions 1–5 in order to determine rational psychological and biological treatments.¹ A comprehensive biopsychosocial diagnostic evaluation includes a detailed psychosocial and medical history and conducting a comprehensive physical examination. Anesthesia testing of the penis/glans region with subcutaneous 1% lidocaine is a standard procedure in the diagnosis of the location of neuropathy.¹ If symptoms are clinically significantly reduced (“very much better” or “much better”), the implication is that pathology in the end organ contributes to the GPD. If, however, symptoms persist despite penis/glans anesthesia, the etiology is upstream, consistent with originating in other regions (2–5). If pudendal nerve anesthesia testing with 1% lidocaine results in clinically significant symptom reduction, the trigger is in region 2. If a diagnostic transforaminal epidural spinal injection with 1% lidocaine results in clinically significant symptom reduction, the trigger is in region 3. There are 3 office-based somatic neurogenital testing procedures used to ascertain neurological pathology in regions 1-5, including 1) genital quantitative sensory testing of the nerves of the penis/glans, 2) nongenital sacral dermatome testing of the S1-4 gluteal dermatomes, S1-2 posterior thigh dermatomes and S1-2 posterior calf dermatomes, and 3) bulbocavernosus reflex latency testing.¹ In patients with triggers in region 1 or 2, nongenital sacral dermatome testing is normal. For patients with pathology in regions 4 and 5, the bulbocavernosal reflex latency test is normal. For patients with region 3 pathology, all 3 neurogenital tests are abnormal. For patients with suspected region 3 pathology, sacral and lumbar magnetic resonance images (MRIs) using T2-weighted imaging are obtained to look for annular tears, which appear as high-intensity zones on MRI, nucleus pulposus herniation, spinal stenosis, spondylolisthesis and facet synovial cyst.

GPD symptoms are often associated with exposure to or withdrawal from selective serotonin reuptake inhibitors and/or selective serotonin-norepinephrine reuptake inhibitors and/or other central nervous system-active medications. In addition, it is common for psychological factors to contribute to the development, maintenance and consequences of GPD. In a comprehensive treatment approach, the urologist should engage a therapist to assess psychological, interpersonal and sociocultural factors in an attempt to reduce the stress associated with GPD and alleviate the distress and possible suicidality. Psychological interventions should be used in parallel with medical/surgical interventions throughout the treatment process. Additional medical assessments may include neurological, vascular and/or endocrinological aspects.

The following represents an example of GPD management.² The patient presented to our sexual medicine facility at 21 years of age. Since age 14 he had experienced extreme penile pain within seconds of sexual arousal through masturbation. The penile pain was so severe that he rarely proceeded to orgasm or ejaculation. After 7 years of multiple unsuccessful treatments, he was concerned about his long-term mental health and for his future ability to have relationships. The patient had concomitant restless legs syndrome, lower back pain, and bladder urgency and frequency, implying a region 3 pathology. A subsequent sacral MRI showed 4 sacral Tarlov cysts, with the largest measuring 18 mm. Neurogenital testing results were abnormal, consistent with a region 3 pathology. The neurophysiologist hypothesized that the patient’s pain at erection was from Tarlov cyst-induced neuropathic irritation of sensory fibers that course within the pelvic nerve. The spine surgeon directed a diagnostic injection of local anesthesia to the sacral nerve roots that alleviated the symptoms temporarily, consistent with radiculopathy, indicating that surgery to repair the Tarlov cysts would be appropriate. The collaboration among specialists led to the resolution of the pathology. The patient worked with a therapist to help alleviate his concerns regarding his inability to have a relationship. Long-term followup after surgical repair showed complete symptom elimination at 18 months after treatment, and he is now happily married.