Thread by @hyderabaddoctor

Long-standing unwanted & unpleasant genital sensations in a woman of neurological origin

1. 41-year old woman presented with 3-year history of persistent abnormal sensations involving vagina, #clitoris and labia, without #sexual interest or #desire.
#MedTwitter #neurotwitter

2. She found it hard to describe the sensations but used terms like vibrating, tingling, painful, throbbing, pulsating and numbness in vagina & surrounding regions. There was a sense of imminent #orgasm. Sexual activity & orgasm, however, did not relieve her symptoms.

3. Symptoms got worse on sitting and on lying down, but were lesser on standing or walking. Tight clothing or underwear aggravated her symptoms. She also had #pain in both legs, and felt the urge to constantly move her legs to reduce pain & discomfort (in legs & feet).

4. She initially visited a #gynecologist. Clinical examination and pelvic ultrasound were normal. There was no evidence of pelvic inflammatory disease. Pap smear was also negative.
She was evaluated by #psychiatrist. Anti-depressants and anti-anxiety medicines did not help.

5. The illness was taking a major toll on her mental well-being. She felt ashamed and guilty and even contemplated suicide. It was affecting her relationship with her husband. She became withdrawn.
She visited another gynecologist, who referred her for my opinion.

6. After detailed history, clinical examination was performed. Finger touch investigation of the dorsal #nerve of the clitoris (DNC) along the pubic bone provoked the symptoms. Skin in the affected area (supplied by #pudendal nerve) was very sensitive to cotton swab touch.

7. A final diagnosis of restless genital syndrome (RGS), in association with, restless legs syndrome (RLS) was made. She was started on medications (dopamine agonists). She responded well. Improvement was seen in a week, and she remained symptom-free until six months of follow up

8. Take home message:
a. RGS should be suspected in a woman with excessive and persistent sensations of genital and clitoral arousal, (especially in association with RLS or symptoms of an overactive bladder), in the absence of conscious feelings of sexual desire.

8b. RGS is caused by a small fiber sensory neuropathy of the dorsal nerve of the clitoris (a branch of pudendal nerve).
8c. Timely medical treatment can significantly improve the quality of life of women with this disease.