A Novel Collaborative Protocol for Successful Management of Penile Pain Mediated by Radiculitis of Sacral Spinal Nerve Roots From Tarlov Cysts

Sexual Medicine - Tập 5 - Trang e203-e211 - 2017
Irwin Goldstein1, Barry R. Komisaruk2, Rachel S. Rubin3, Sue W. Goldstein3, Stacy Elliott4, Jennifer Kissee5, Choll W. Kim5
1Alvarado Hospital, San Diego, CA, USA
2Rutgers University Newark, NJ USA
3San Diego Sexual Medicine, San Diego, CA, USA
4University of British Columbia, Vancouver, BC, Canada
5Spine Institute of San Diego, San Diego, CA, USA

Tóm tắt

Abstract Introduction Since 14 years of age, the patient had experienced extreme penile pain within seconds of initial sexual arousal through masturbation. Penile pain was so severe that he rarely proceeded to orgasm or ejaculation. After 7 years of undergoing multiple unsuccessful treatments, he was concerned for his long-term mental health and for his future ability to have relationships. Aim To describe a novel collaboration among specialists in sexual medicine, neurophysiology, and spine surgery that led to successful management. Methods Collaborating health care providers conferred with the referring physician, patient, and parents and included a review of all medical records. Main Outcome Measure Elimination of postpubertal intense penile pain during sexual arousal. Results The patient presented to our sexual medicine facility at 21 years of age. The sexual medicine physician identifying the sexual health complaint noted a pelvic magnetic resonance imaging report of an incidental sacral Tarlov cyst. A subsequent sacral magnetic resonance image showed four sacral Tarlov cysts, with the largest measuring 18 mm. Neuro-genital testing result were abnormal. The neurophysiologist hypothesized the patient's pain at erection was produced by Tarlov cyst-induced neuropathic irritation of sensory fibers that course within the pelvic nerve. The spine surgeon directed a diagnostic injection of bupivacaine to the sacral nerve roots and subsequently morphine to the conus medullaris of the spinal cord. The bupivacaine produced general penile numbness; the morphine selectively decreased penile pain symptoms during sexual arousal without blocking penile skin sensation. The collaboration among specialties led to the conclusion that the Tarlov cysts were pathophysiologically mediating the penile pain symptoms during arousal. Long-term follow-up after surgical repair showed complete symptom elimination at 18 months after treatment. Conclusion This case provides evidence that (i) Tarlov cysts can cause sacral spinal nerve root radiculitis through sensory pelvic nerve and (ii) there are management benefits from collaboration among sexual medicine, neurophysiology, and spine surgery subspecialties. Goldstein I, Komisaruk BR, Rubin RS, et al. A Novel Collaborative Protocol for Successful Management of Penile Pain Mediated by Radiculitis of Sacral Spinal Nerve Roots From Tarlov Cysts. Sex Med 2017;5:e203–e211.

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Sexual Medicine

Tập 5

e203-e211

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