Treatment of a female patient with persistent genital arousal and Parkinson’s disease with paliperidone

To the Editor

We report the case of a 62-year-old married female with three children who was initially hospitalized because of persistent genital arousal (PGA). The publication of the case was approved by the ethics committee, and the patient gave written consent. PGA started with an episode of whole body itching and a sense of clitoris irritation. The patient reported that she was experiencing orgasms at the rate of one every few minutes or even more frequently for the last 4 months. According to her history, she suffered from postnatal depression which developed into recurrent depressions. She was treated with a number of antidepressants and anxiolytics for the last 10 years. At the age of 48, she underwent total vaginectomy which was not followed by substitution hormone therapy. Since 1.5 months, she was also suffering from panic attacks (twice a day) and generalized anxiety.

A full clinical and laboratory examination revealed no abnormal findings. The patient reported that in the past she had used local anaesthetics without any effect. Currently, she responded to haloperidol 10 mg/day with a significant decrease in the frequency and intensity of orgasms. It was decided to switch to paliperidone 18 mg/day due to its more favourable side-effect profile. The patient had a stable response of around 50% (according to her subjective estimation). At 2 years of follow-up, the condition remained stable, but the patient developed Parkinson’s disease and treatment with levodopa was initiated. Parkinsonian symptoms and signs were controlled at a satisfactory extent, and the improvement in the arousal disorder did not change. Because of parkinsonism, it was decided to stop paliperidone, but this resulted in a significant relapse regarding both the returning of the full intensity and frequency of symptoms. The reintroduction of paliperidone resulted in the restoration of improvement at previous levels.

PGA is a potentially debilitating disorder of undesirable genital arousal which is unpreceded by sexual stimulation. Its aetiopathogenesis is elusive (Facelle et al., 2013; Gadit, 2013; Goldstein, 2013). In line with the broad aetiological spectrum, a number of different treatment options have been proposed ranging from local anaesthetics to antiepileptics and electroconvulsive therapy (ECT) with varying degrees of efficacy.

This is the first demonstration of a therapeutic effect of dopamine D2 receptor antagonists in PGA. The lack of response of PGA to dopaminergic agents alone and response to an antidopaminergic agent weaken a causative relationship with Parkinson’s disease but does not totally reject this theory.