Full text of DOI:10.1080/713846813

Journal of Sex & Marital Therapy
ISSN: 0092-623X (Print) 1521-0715 (Online) Journal homepage: http://www.tandfonline.com/loi/usmt20
Female Neurogenic Sexual Dysfunction Secondary
to Clitoral Neuropathy
Daniel S. Sax , Jennifer R. Berman & Irwin Goldstein
To cite this article: Daniel S. Sax , Jennifer R. Berman & Irwin Goldstein (2001) Female
Neurogenic Sexual Dysfunction Secondary to Clitoral Neuropathy, Journal of Sex & Marital
Therapy, 27:5, 599-602, DOI: 10.1080/713846813
To link to this article: http://dx.doi.org/10.1080/713846813
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Date: 05 November 2015, At: 17:43

Journal of Sex & Marital Therapy, 27:599–602, 2001
Copyright © 2001 Brunner-Routledge
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Female Neurogenic Sexual Dysfunction
Secondary to Clitoral Neuropathy
DANIEL S. SAX, JENNIFER R. BERMAN, and IRWIN GOLDSTEIN
Department of Urology, Boston University Medical School, Boston, Massachusetts, USA
We herein present several cases of female sexual dysfunction re-
lated in part to organic neurologic pathophysiology. These cases
emphasize the role of the central and peripheral nervous systems in
female sexual function.
INTRODUCTION
Normal sexual function, including orgasm, engorgement, lubrication, and
appropriate motor responses, involves the endocrine, psychological, and
vascular systems, as well as the nervous system (somatosensory and auto-
nomic), to integrate these complex interactions. This article deals with often
unrecognized consequences of peripheral neuropathic pain and neuropathy
that arises from partial damage to the genital peripheral nerves. This condi-
tion is known by various names, including pudendal or clitoral neuralgia,
vulvodynia, or the hymenal syndrome, all of which fall under the more
recent term, chronic non-nociceptive pain. It is characterized by numbness
and pain in apparently normal tissue. There is poor correlation with signs of
tissue damage. Hypesthesia, hyperpathia (hyperalgesia) dysesthesia,
parasthesia, allodynia, and spatial and temporal summation occur following
stimulation of the affected area. These symptoms are expressed by radiation
and centrifugal spread of the sensation, accompanied by an increased la-
tency, and persistence of the unpleasant sensation. Classically this condition
has been called pudendal neuralgia or causalgia. A characteristic of neural-
gia in its pure form is that although the pain is in the distribution of the
nerve, it may not be associated with major loss of neural function.
The three cases reported in this article represent examples of posttraumatic
clitoral neuropathy and neuralgia resulting from trauma to the genitalia. The
consequent numbness, pain and dysautonomia have led to sexual dysfunction.
Address correspondence to Irwin Goldstein, M.D., Urology–BUMS, 720 Harrison Ave.,
Boston, MA 02118, USA.
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D. S. Sax et al.
SUMMARY OF CASES
Case 1
This 32-year-old woman with gestational diabetes had a prolonged labor
and traumatic delivery of a 10.5-lb. boy with Erb’s palsy. The patient had
clitoral numbness, loss of orgasm, and shooting, jabbing clitoral pain. She
had difficulty sleeping and was subject to early morning arousal. On exami-
nation she had decreased pinprick, touch, and vibration sensation of the
clitoris and a hyperpathia and dysesthesia at the base of the clitoris and
surrounding area. She had been treated with sildenafil and low dose tricyclics.
Sildenafil enhanced engorgement, but not sensation. The patient under-
went nerve conduction studies and genitocerebral evoked responses (GCER).
The neuralgic pain and sleep disturbance had been attenuated by tricyclic
medication.
Case 2
This 38-year-old woman had clitoral trauma following a sado-masochistic
assault during a postcollege graduation party. The patient went to a party
where she was drugged, given cocaine, assaulted, and found when she awoke
that spring-loaded clothespins had been attached to her nipples and clitoris.
Subsequently she developed numbness, clitoral pain, and difficulty in achiev-
ing orgasm. She married and during the birth of her second child, sustained
a right vaginal tear, resulting in an increase in sharp, shooting pain and
numbness in her clitoris and vaginal wall. Ten years following the onset of
her initial symptoms, she fell, sustained a back injury, and experienced a
worsening of her symptoms. In addition to the burning, stabbing pain, she
had a heavy feeling in her groin and vaginal dryness. On examination, she
had decreased pin prick, light touch, and temperature sensation involving
the left side of her clitoris, mons, and upper vulva. She had a hyperpathia to
repetitive pinprick in the involved area and surrounding regions, which ex-
tended to the right side. Her bulbocavernosus reflex was diminished. A lum-
bosacral MRI was obtained which showed the residua of the prior surgery
and changes in the roots extending to the midline. The patient was treated
with baclofen to reduce the neuralgic component of her pain. She also re-
sponded to physical therapy, NSAIDs, and low-dose tricyclics.
Case 3
This 42-year-old woman sustained a straddle injury at the age of 18 years
while performing gymnastics on uneven parallel bars. Since that time she
has had sharp, stabbing burning pain in her clitoral and vulvar areas, associ-
ated with dysesthesia and allodynia. Her symptoms became worse 12 years
after the original injury, following a fall backward while playing tennis. The

FSD Secondary to Clitoral Neuropathy
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fall caused transient total leg numbness and paralysis and marked bruising
of her lower back and upper buttocks. Although she recovered her strength
completely, she had worsening genital pain, numbness, and fibromyalgia.
She was able to have sexual intercourse and orgasm in spite of the persis-
tence of the pain, but had recently noted decreased orgasmic sensation and
increased latency. She also had a generalized burning, numbness, and itch-
ing dysesthesia of her genitalia and hypersensitivity to any stimulation. Topi-
cal treatment with salves and ointments had been ineffective. Low-dose
doxepin had reduced some of the itching and improved her sleep. On ex-
amination, she has a hyperpathia and hyperesthesia to repetitive stimuli to,
in, and around her clitoris, throughout the vulva and extending into her
saddle area. The sensory changes were in S2–S4 dermatomes. Her deep
tendon reflexes were normal, as was her anal sphincter tone. The bulbocav-
ernosus reflex was diminished. The patient had decreased clitoral blood
flow by Doppler measures and excellent response to sildenafil. The patient
had llumbosacral (LS) and pelvic MRI, EMG and NCS, including the puden-
dal nerve and GCERs. Oral sildenafil when given after the initial studies,
worsened the dysesthesia and resulted in extreme pain on urination. The
discomfort associated with sildenfil abated after 36 hours. Baclofen was given
to reduce the neuralgic component of the pain.
DISCUSSION
At the time of the Civil War, S. Weir Mitchell recognized that peripheral nerve
injuries could lead to persistent burning pain, which he called causalgia,
which at times was progressive and associated with trophic changes in the
affected area. These changes indicated hyperactivity of the sympathetic ner-
vous system, and have been called mimocausalgia, posttraumatic pain syn-
drome, and sympathalgia. These conditions are considered a form of reflex
sympathetic dystrophy, a syndrome that characteristically includes not only
pain, but also hyperpathia, dysesthesia, and pseudo and vasomotor changes.
It can follow trauma, surgery, infection, degenerative joint disease, or cere-
bral or myocardial infarction. The signs vary from minimal or no tissue change
to marked atrophy and profound bony and soft tissue change, as seen in
Sudek’s atrophy.
The LS roots originate at bony level Ti 2-Li, the beginning of the
caudaequina, and are considered part of the peripheral nervous system once
these nerves pass the pia and enter the subarachnoid space. The pudendal
nerve, which originates from S2 to S4 sacral roots, passes between the coc-
cygeus muscles and the piriformis. It exits from the pelvis through the distal
part of the greater sciatic foramen and reenters through the lesser sciatic
foramen, where it lies along the wall of the ischiorectal fossa. The nerve then
exits from the pudendal (Alcock’s) canal and branches to form the inferior
rectal nerve, which innervates the skin around the anus and the external

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D. S. Sax et al.
anal sphincter. The other branch, the perennial nerve, innervates the labia
major, the mucous membranes of the urethra and then becomes the dorsal
nerve of the clitoris. These nerves and their smaller branches can be easily
injured by blunt trauma during straddle injuries. Damage to the Genito-
femoral nerve, which comes from the L1-L2 lumbar segments, can also lead
to pain and numbness in the genital area.
Localizing where these nerves can be damaged, using appropriate ana-
tomic and physiologic tests, allows us to offer specific therapies, whether
surgical, medical, or psychological.
In the first case we assessed the full extent of the neuropathy, as well as
a diabetic tendency, which can act synergistically with the trauma to pro-
duce the pain and numbness. The tricyclic, with its anticholinergic and anti-
depressant dopaminergic effects, helped to improve sleep and reduced dys-
phoria, that frequently accompanies chronic pain. In the second and third
cases, where both LS root and peripheral nerve damage occurred, identify-
ing contributing compressive features was important in preventing worsen-
ing symptoms. These could be surgically corrected.
Pharmacological and psychological treatment, as well as physical therapy,
are also indicated. Where vascular abnormality exists, leading to dryness and
decreased erectile function, medications such as sildenafil can be used.
Tegretol, Dilantin, or Neurontin, are examples of sodium channel modula-
tors that can be used to reduce the neuralgic pain. Gabaergic-enhancing
medications, such as baclofen, are also useful in reducing neuralgic pain, as
are the alpha 1-blockers, such as clonidine.
In conclusion, it is important to define and elucidate the neurologic
abnormalities, as these three cases illustrate, in order to help treat sexual
dysfunction arising from posttraumatic clitoral neuropathy.