Tarlov cysts and sexual dysfunction: A multidisciplinary approach to evaluation and surgical treatment

Background: Persistent Genital Arousal Disorder/Genito-Pelvic Dysesthesia (PGAD/GPD) involves chronic, unrelenting arousal and dysesthesia of the genito-pelvic region. In 2012, Komisaruk and Lee identified a high incidence of sacral Tarlov cysts in patients with PGAD/GPD, prompting development of a multidisciplinary diagnostic and treatment algorithm. This study reviews surgical outcomes for patients with PGAD/GPD in whom a Tarlov cyst was identified as the symptomatic driver. Methods: A retrospective review of prospectively collected data was conducted on patients with PGAD/GPD who underwent Tarlov cyst excision and imbrication from 2017 to 2023. The diagnostic algorithm included neurogenital testing, sacral MRI, and assessment for pelvic or end-organ triggers.When one or more cysts were suspected as the etiology, a targeted diagnostic injection with anesthetic and steroid confirmed the diagnosis.Operative reports, imaging, and pre/postoperative clinic visits were reviewed to assess complications, readmissions, reoperations, and symptom changes. Outcomes were measured using the Patient Global Impression of Improvement (PGI-I), Oswestry Disability Index (ODI), Sexual Distress Scale-Revised (SDS-R), and Visual Analog Scale (VAS) for back pain. Results: Nineteen patients (mean age 45.5 ± 15.9 years) with an average follow-up of 18.2 ± 10.5 months were included. Fourteen patients (73.7%) reported postoperative improvement on the PGI-I: 2 "very much better," 9 "much better," 3 "little better," and 5 with no improvement. No patients reported worsening symptoms. All were discharged the same day, with no cerebrospinal fluid leaks, wound issues, or cyst recurrences. Oswestry Disability Index improved from 32.9 to 28.4, SDS-R from 30.9 to 26.8, and Visual Analog Scale back pain from 4.8 to 3.2. Conclusions: Symptomatic Tarlov cysts can contribute to PGAD/GPD and associated sexual dysfunction. Early detection with a structured diagnostic algorithm support accurate patient selection and safe, effective surgical treatment, offering meaningful symptom relief for appropriately selected patients.