(401) Low Grade Papillary Urothelial Carcinoma of the Bladder Presenting as PGAD/GPD: A Case Report

Abstract Introduction Persistent Genital Arousal Disorder/Genito-Pelvic Dysesthesia (PGAD/GPD) is a rare and distressing condition characterized by unwanted genital arousal without associated sexual desire. While cases of PGAD/GPD caused by interstitial cystitis, urethritis, and urethral diverticulum have been described, PGAD/GPD secondary to bladder cancer has not yet been reported. As cases of young female patients without a significant family history of bladder cancer or smoking history are rare, the clinical presentation of these cases may not be well defined in the literature. Objective To describe the first known case of PGAD/GPD as the initial presentation of low-grade papillary urothelial carcinoma of the bladder in a young female. Methods This was a case report using retrospective chart review, a structured one-on-one interview, and validated measures to quantify PGAD/GPD-related distress and catastrophizing. Results A 26 year old healthy female presented with a three month history of constant, distressing clitoral throbbing and pain in her vulvar vestibule that began during masturbation. She also noted dysuria, urinary frequency, urgency, intermittent hematuria, and nocturia 2-3 times per night. She was displaying clinically relevant, distressing PGAD/GPD symptoms, scoring 60 out of 60 on the Persistent Genital Arousal Sensations Questionnaire (PGASQ) and 47 out of 52 on the Pain-Catastrophizing Scale (PCS). She denied any smoking history but did report a history of resin exposure in her career as an artist. She had been seen by psychotherapy, received topical lidocaine, and underwent pelvic floor physical therapy (PFPT) without relief. A urologist attempted a clitoral stretching procedure and recommended a clitoridectomy. After seeking a second opinion, she underwent a bladder ultrasound which revealed a 7 x 5 x 6 mm nonmobile lesion in the left posterior bladder wall, lateral to the ureteral orifice. Cystoscopy and pathology revealed low grade papillary (Ta) urothelial carcinoma of the bladder and trans-urethral resection of bladder tumor was performed. Symptoms had completely resolved three months after the procedure with continued use of topical lidocaine gel and PFPT. Two years later she underwent cystoscopy to evaluate recurrence of genitourinary symptoms and was found to have a large amount of squamous metaplasia in the left trigone on cystoscopy. After fulguration she continued to experience symptoms and was treated with one course of nitrofurantoin despite negative urine culture, after which her symptoms again resolved. At the time of writing, the patient is no longer displaying clinically relevant, distressing PGAD/GPD symptoms, scoring 18 out of 60 on the PGASQ and 19 out of 52 on the PCS. Conclusions This is the first known instance of bladder cancer diagnosis following presentation with PGAD/GPD. The proposed hypothesis involves stimulation of the pelvic nerves with subsequent crossed-central sensitization at the level of the sacral plexus sending efferent signals to both the pelvic nerve causing irritative voiding symptoms, and to the pudendal nerve causing clitoral and vestibular dysesthesia. Secondary hypertonic pelvic floor dysfunction may exacerbate symptoms. Further investigation is warranted to better understand the relationship between bladder tumors and PGAD/GPD. Disclosure No