Sacral Tarlov cysts and spontaneous persistent genital arousal: 2 unrecognized and underappreciated health conditions with an uncertain relationship

Tarlov cysts commonly occur in women but are often thought to be asymptomatic findings. However, recent studies have suggested that Tarlov cysts can be a contributing factor to various pain and neurologic dysfunctions with a significant effect on health-related quality of life. Tarlov cysts and various intrapelvic pathologies can result in compression or impairment of peripheral and spinal nerve roots and can potentially affect women's sexual function, particularly by causing persistent genital arousal disorder. Persistent genital arousal disorder is characterized by spontaneous and often unrelenting sensations of genital arousal in the absence of sexual desire or stimulation and, by definition, is intrusive, unwanted, and distressing. This review details the prevalence, characteristics, and treatments of persistent genital arousal disorder and Tarlov cysts and evaluates potential relationships between these conditions. The prevalence of persistent genital arousal disorder ranges from 1.6% to 11.1% in community-based surveys, and 33% of women who are referred to a sexual health clinic report at least 1 persistent genital arousal disorder screening question. The prevalence of Tarlov cysts ranges from 1.5% to 13.2% and is higher among women referred to pain centers, ranging from 16% to 39%. Despite the already high prevalence, these numbers for both conditions are likely underestimated as sexual dysfunction. Therefore, persistent genital arousal disorder is not readily disclosed, and optimal sacral magnetic resonance imaging is infrequently performed to detect Tarlov cysts. Persistent genital arousal disorder is a symptom complex for which psychological, vascular, central, and peripheral neurologic factors have been proposed as possible causes. When peripheral nerve entrapments are believed to be the cause of persistent genital arousal disorder, mechanical release of the nerve or nerve root is the generally accepted treatment. Several surgical and minimally invasive percutaneous procedures are effective treatments when Tarlov cysts are symptomatic, although evidence for their effectiveness for persistent genital arousal disorder is limited. For surgical/interventional failures to decompress nerves and decrease symptoms in patients with Tarlov cysts or persistent genital arousal disorder, neuromodulation is increasingly being performed as a rescue therapy. Because of the weak evidence base, the relationship between Tarlov cysts and persistent genital arousal disorder remains uncertain, and healthcare professionals are encouraged to inquire more broadly about the symptoms related to these conditions, conduct neurologic examinations, and order relevant sacral imaging to clarify the relationship further.