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

Randa Yosef: Writing – review & editing, Writing – original draft, Validation, Formal analysis, Data curation, Conceptualization. Gaylene Pron: Writing – original draft, Investigation, Formal analysis, Data curation, Conceptualization. Nucelio Lemos: Writing – review & editing, Validation, Supervision, Methodology, Investigation, Conceptualization. Kieran Murphy: Writing – review & editing, Writing – original draft, Validation, Supervision, Investigation, Data curation, Conceptualization.

Perineural cysts first characterized in1938 by Isadore Tarlov 30 were initially seen as anatomic variants of uncertain clinical significance. Tarlov cysts are CSF-filled sacs commonly occurring at the junction of the posterior root and the dorsal ganglion. 31 Nerve root fibers and occasionally ganglion cells exist within the cyst wall or freely in the cyst, and the entire cyst may be surrounded by neural tissues. 32 , 33 Although the pathogenesis of Tarlov cysts is unclear, the currently accepted cause of cyst development is a disruption of the CSF-venous drainage mechanism at the perineurial-epineurium junction. 32 , 33 , 34 Cyst enlargement is thought to occur because microcommunication exists between the cyst and the subarachnoid space, and a ball-valve type mechanism allows CSF influx and restricts efflux, leading to an expansion of the cyst ( Figure ). 31 , 35 , 36 , 37 A potential association of inherited connective tissue disorder syndromes, such as Marfan syndrome and Ehlers-Danlos syndrome, with Tarlov cysts has been suggested, as these syndromes commonly have dural ectasia (widening of the dural sac) thought to be a precursor to the development of Tarlov cysts. 38 , 39 However, the prevalence of Tarlov cysts in these syndromes is unknown, reported only in case reports. 40 , 41 Figure Axial and sagittal imaging of the Tarlov cyst Axial (A) and sagittal (B) T2 magnetic resonance imagings show Tarlov cyst ( arrow ) within the sacral canal at the S1 level. Figure Yosef. Tarlov cysts can potentially cause persistent genital arousal disorder. Am J Obstet Gynecol Glob Rep 2025. Axial and sagittal imaging of the Tarlov cyst Axial (A) and sagittal (B) T2 magnetic resonance imagings show Tarlov cyst ( arrow ) within the sacral canal at the S1 level.

Sacral Tarlov cysts are described by the ISSWSH 2019 expert consensus as a potential cause of PGAD. 8 There are limited studies that directly investigate the relationships or associations between Tarlov cysts and PGAD. In Komisaruk and Lee’s 66 study of an Internet-based support group for women with PGAD, sacral Tarlov cysts were present in 12 of 18 self-selected MRIs submitted. In a surgical cohort 67 involving 1945 patients with cysts, 11 women were identified with PGAD symptoms and meningeal cysts, 8 of which were sacral Tarlov cysts. In a later report from the center 68 of 112 women who underwent surgery for Tarlov cysts, 49.0% of women reported sexual dysfunction, and 25.5% of women reported PGAD in response to a Tarlov cyst quality-of-life questionnaire. Lim et al 52 identified 2 women (5.1%) with PGAD from a cohort of 39 patients with Tarlov cysts and pudendal neuralgia referred to a pain center.

In addition, Tarlov cysts have been reported by ISSWSH to be potential triggers for PGAD. 8 Although there is no consensus on patient selection or management of Tarlov cysts, there is evidence to support interventional/surgical management of Tarlov cysts in patients who have had a positive response to cyst aspiration or sacral nerve root blocks. 103 Several systematic reviews 104 , 105 have identified both percutaneous cyst aspiration and fibrin sealant and various open surgical approaches to be effective treatments of symptomatic sacral Tarlov cysts. Interventional or surgical treatment objectives for Tarlov cysts are generally to relieve nerve compression and decrease symptoms. However, it is important to highlight that all studies in the recent review of 16 surgical studies 104 reported pain as the main presenting condition. Sexual dysfunction, without defined symptoms, was reported in 2 surgical studies for Tarlov cysts—4.3% (1/23) 106 and 7.7% (2/13), 107 although treatment effectiveness was only evaluated as pain palliation in both studies. However, sexual dysfunction, described as erectile dysfunction and loss of genital sensations, was reported as an overall postoperative complication in 27 of 333 patients (8.1%). Treatment for patients with Tarlov cysts and outcomes on sexual dysfunction or PGAD have been reported in several other studies. In 1 study, 27 women with PGAD (n=10) underwent a range of treatments, many of which providing ineffective or temporary relief ( Table 1 ). In addition, treatments for the 5 patients with PGAD and Tarlov cysts were variable, including surgical resection of cysts with complete remission in 1 case and ineffectiveness in the other cases. In the other case, a recommendation for Tarlov cyst resection was declined, an acetazolamide trial did not improve symptoms, and immunoglobulin therapy reduced PGAD symptoms from 30 to 4 days per month. A surgical series of women with PGAD and Tarlov cysts (n=8) causing sacral nerve root compression were treated with cyst removal, and symptoms were eliminated (n=7) or significantly better (n=3). 67 In their later report, 68 112 women with Tarlov cysts and 26 of 102 women (25.5%) in the cohort reporting PGAD were treated surgically for Tarlov cysts, and the prevalence of both sexual dysfunction and PGAD decreased postoperatively from 49.0% to 34.0% and from 25.5% to 17.0%, respectively. In another surgical cohort, 108 44 patients with large Tarlov cysts (at least the size of the S1 vertebral body) were treated with either partial cyst removal or cyst fenestration. Sexual dysfunctions (n=24) were commonly reported and were the primary complaint for 8 patients. All symptoms were reported to have improved within the first year. In another cohort of 213 patients with sacral Tarlov cysts treated with cyst aspiration and fibrin sealant, sexual dysfunction and bladder dysfunction were reported in 92 patients, and treatment outcomes for these symptoms were reported to be good or excellent for 74%. 6 Although both percutaneous minimally invasive and surgical approaches have been effective treatments of sacral Tarlov cysts, there is no agreed-upon optimal surgical treatment. 37 , 109 , 110 As the complication rate is higher and recovery is longer for surgical treatments, percutaneous interventions have been recommended as first-line treatments because of their more favorable risk-benefit profile. 103 In cases where interventions for Tarlov cysts have been unsuccessful in relieving symptoms, spinal cord stimulation has been successfully employed to treat pain symptoms in 2 case reports, 111 , 112 although neither involved PGAD. A 66-year-old woman with a history of chronic pain secondary to multiple Tarlov cysts was unsuccessfully treated with multiple medication trials, epidural steroid blocks, and superior hypogastric plexus blocks. 111 After surgery to remove the cysts and sacral lamina reconstruction, the patient’s symptoms worsened. High-frequency spinal cord stimulation with device lead placements at T8 and T9 improved her pelvic pain, back pain, and radiculopathy. The second case report, 112 a 45-year-old man with a history of back pain secondary to multiple Tarlov cysts, had achieved only temporary relief with multiple epidural steroid administrations and multiple cyst aspirations. A spinal cord stimulation with device lead placement at the T8 spinal level significantly reduced pain over an 8-month follow-up.

In different studies on patients referred for low back pain, sciatica, or other spinal pathology, the prevalence of Tarlov cysts ranged from 1.5% to 13.2%. 31 , 42 , 43 , 44 , 45 , 46 , 47 , 48 , 49 The highest prevalence was found for studies employing sacral MRIs. 42 , 45 , 49 Klepinowski et al’s 50 meta-analysis of 22 imaging studies reported a prevalence rate of 4.18% (95% confidence interval, 2.47%–6.30%) for Tarlov cysts. However, Tarlov cysts have been generally underestimated in these studies as other spinal causes of pain and neurologic dysfunctions were mainly investigated. 46 In studies targeting women referred for gynecologic or urologic conditions, 51 , 52 , 53 the prevalence of Tarlov cysts was reported to be higher. In a cohort of 197 patients (180 women and 17 men) referred to an outpatient musculoskeletal pain clinic diagnosed with fibromyalgia or chronic fatigue syndrome, Tarlov cysts were seen on lumbosacral MRIs in 39% of patients (75 women and 2 men). 51 In an American cohort of 242 patients presenting to an academic chronic pain center with pudendal neuralgia and chronic pelvic pain, 16% of patients (34 women and 5 men) had at least 1 Tarlov cyst. 52 In a Japanese cohort of 102 women who underwent pelvic MRI and subsequently sacral MRI, Tarlov cysts were diagnosed in 6.9% of patients. 53

This narrative review provides a comprehensive overview of spontaneous PGAD, an uncommon distressing condition occurring with and without Tarlov cysts. Women with these conditions often suffer from long-standing debilitating pain and neurologic dysfunctions. Both PGAD and Tarlov cysts frequently go undetected, and when detected, they present diagnostic and therapeutic challenges requiring multidisciplinary investigations. For patients with urinary complaints or genital pain/dysesthesias, discussing sexual function is crucial due to the shared neural pathways for bladder and sexual functions. PGAD is thought to have a multifactorial basis, and before considering treatment, detailed medical history and physical examinations are essential to evaluate relationships between symptoms, cysts, and other pathologies. In addition, the variable presentation and previous histories of women with PGAD suggest that there may be different subgroups of women with different triggers for their condition, complicating assessment, treatment approaches, and generalization of results. Pharmacologic therapies are often first-line treatments for PGAD, although results are mixed, and other physical therapies are primarily supported by case reports. In addition to intrapelvic neuropathies, lumbosacral pathologies, including Tarlov cysts, can compress spinal and peripheral nerves, particularly the pudendal nerve and its branches, affecting urologic, GI, and sexual functions. In patients with PGAD or Tarlov cysts who have had a positive response to nerve root blocks or cyst aspiration, there is evidence supporting interventional/surgical decompression. Minimally invasive outpatient procedures, such as percutaneous cyst aspiration and fibrin administration, are recommended as first-line treatments of Tarlov cysts due to their lower complications and faster recovery compared with surgery. However, information on the success of these procedures for PGAD in women with Tarlov cysts is limited, as studies focus on pain reduction rather than PGAD specifically. For patients failing surgical interventions to decompress nerves and relieve symptoms associated with PGAD and Tarlov cysts, neuromodulation has been increasingly used as a rescue therapy. Overall, the relationship between Tarlov cysts and PGAD remains uncertain due to the weak evidence based on many factors. The Internet-based community studies, although involving large study sizes, were dependent on self-selection and self-diagnosis and respondents reporting reliably to Internet-based questionnaires. In addition, the clinical studies tended to be smaller, without control groups, and dependent on various selection criteria, referral patterns, and methodologic expertise of the study centers. A major oversight occurs because neurosurgeons treating PGAD are generally not looking for Tarlov cysts and those treating Tarlov cysts are not looking for PGAD, as suggested by a survey of neurosurgeons 57 admitting that they infrequently inquired about the sexual health of their patients. To clarify the relationship further, healthcare professionals should inquire more broadly about related symptoms, conduct relevant neurologic tests, and order sacral imaging. Given the complex interplay between neurologic, gynecologic, and urologic factors in PGAD and Tarlov cysts, increased awareness and standardized protocols for evaluating sacral pathology in patients with PGAD could improve diagnosis and guide more effective treatment strategies. Because most current studies are observational and not well controlled, it is still unclear how Tarlov cysts and PGAD are related. To better understand this connection, future research could use designs, such as prospective cohort studies or case-control studies, to systematically evaluate women with PGAD symptoms referred to different specialty centers. These studies would aid in determining how commonly PGAD symptoms are associated with and without Tarlov cysts and whether there is a timeline that supports a stronger link. Using consistent neurologic testing, sacral imaging, and standardized symptom questionnaires would help improve diagnosis. Overall, these steps could give clearer answers about whether Tarlov cysts are a cause, a contributing factor, or just a coincidence in these cases.

To determine whether a patient meets the criteria for PGAD/GPD, clinicians can use the ISSWSH 2019 consensus expert opinion. 8 However, because of the multifactorial etiology of PGAD, clinicians should perform a detailed history exploring common gynecologic, medical conditions, and medication use, especially antidepressants, as PGAD has been reported after their initiation or withdrawal. 26 Patients should undergo a careful gynecologic examination, as many common gynecologic conditions are potentially relevant to sexual dysfunction. Bladder dysfunctions and pelvic and genital pain frequently co-occur with PGAD, and when neuropathy is suspected, neurologic testing and/or imaging should be performed to rule out intrapelvic or spinal-related pathologies potentially causative of PGAD or associated comorbidities. In addition, screening for Tarlov cysts involves multidisciplinary investigations. A sacral MRI is the optimal imaging technique to identify potential causes of nerve compression and confirm abnormalities in the nerve or adjacent structures, such as Tarlov cysts. 6 , 69 , 70 Neurologic testing has been used to describe the locations of suspected neurologic pathology. Moreover, there are several recommended office-based somatic neurologic testing procedures 71 , 72 for ascertaining neurologic pathology in sacral regions ( Table 2 ). A diagnostic strategy involving the abovementioned neurologic tests has been proposed to indicate when Tarlov cysts may be involved in patient symptoms. 8 In addition, the presence of symptomatic Tarlov cysts may be determined by other diagnostic tests, such as positive responses to nerve root blocks or cyst fluid aspirations, in which symptoms are significantly very much better or much better. 56 Table 2 Screening criteria for PGAD and Tarlov cysts Table 2 ISSWSH screening criteria for PGAD 1 Persistent or recurrent, unwanted or intrusive, distressing sensations of genital arousal. 2 Symptoms may include other types of genitopelvic dysesthesia (eg, buzzing, tingling, burning, twitching, itch, and pain). 3 Symptoms most commonly experienced in the clitoris but also in other genitopelvic regions (eg, mons pubis, vulva, vestibule, vagina, urethra, perineal region, bladder, and/or rectum). 4 Occurrence of symptoms can be varied from being on the verge of orgasm, experiencing uncontrollable orgasms, and/or having an excessive number of orgasms. 5 Symptoms are not associated with concomitant sexual interest, thoughts, or fantasies. Office-based somatic neurologic screening tests for Tarlov cysts 1 The first procedure is genital quantitative sensory testing of the nerves of the clitoris, vestibule, and perianal regions(S2–S4), which consists of vibration perception threshold testing for large myelinated AB fibers and temperature perception threshold testing for small myelinated AD fibers (cold) and for unmyelinated C fibers (warm). 2 The second procedure is nongenital sacral dermatome testing in which the patient is asked to lie in the prone position, and vibration perception threshold values are obtained separately on the left and right sides in sacral innervated regions, including S1–S4 gluteal dermatomes, S1–S2 posterior thigh dermatomes, and S1–S2 posterior calf dermatomes. 3 The third procedure is bulbocavernosus reflex latency testing, which involves electromyographic monitoring of the bulbocavernosus muscle or external anal sphincter muscle contraction in response to mechanical stimulation of the left and right sides of the glans clitoris. ISSWSH , International Society for the Study of Women’s Sexual Health; PGAD , persistent genital arousal disorder. Yosef. Tarlov cysts can potentially cause persistent genital arousal disorder. Am J Obstet Gynecol Glob Rep 2025. Screening criteria for PGAD and Tarlov cysts Persistent or recurrent, unwanted or intrusive, distressing sensations of genital arousal. Symptoms may include other types of genitopelvic dysesthesia (eg, buzzing, tingling, burning, twitching, itch, and pain). Symptoms most commonly experienced in the clitoris but also in other genitopelvic regions (eg, mons pubis, vulva, vestibule, vagina, urethra, perineal region, bladder, and/or rectum). Occurrence of symptoms can be varied from being on the verge of orgasm, experiencing uncontrollable orgasms, and/or having an excessive number of orgasms. Symptoms are not associated with concomitant sexual interest, thoughts, or fantasies. The first procedure is genital quantitative sensory testing of the nerves of the clitoris, vestibule, and perianal regions(S2–S4), which consists of vibration perception threshold testing for large myelinated AB fibers and temperature perception threshold testing for small myelinated AD fibers (cold) and for unmyelinated C fibers (warm). The third procedure is bulbocavernosus reflex latency testing, which involves electromyographic monitoring of the bulbocavernosus muscle or external anal sphincter muscle contraction in response to mechanical stimulation of the left and right sides of the glans clitoris. ISSWSH , International Society for the Study of Women’s Sexual Health; PGAD , persistent genital arousal disorder.

Tarlov cysts are cerebrospinal fluid (CSF)-filled sacs from the spinal nerve root sheath that commonly develop along the sacral spine. Historically, these cysts have been described as an incidental finding on magnetic resonance imaging (MRI) with little clinical relevance. 1 , 2 , 3 Tarlov cysts commonly exist in women but are often overlooked as a cause of various pain, neurologic disorders, and dysfunctions. However, recent studies suggest that Tarlov cysts can be a contributing factor to such conditions. 4 , 5 , 6 Persistent genital arousal disorder (PGAD) is a condition of spontaneous, unrelenting sensations of genital arousal in the absence of sexual desire or stimulation and, by definition, is intrusive, unwanted, and distressing. 7 In addition, the sensations were noted to typically be unresolved with an ordinary orgasmic experience and could be accompanied by uncontrollable orgasms and/or having an excessive number of orgasms. Moreover, the condition may include lower extremity genital paresthesia or dysesthesia (GPD) because of the involvement of common sacral nerve roots. 8 Both conditions affect the quality of life of patients who experience them. There has been uncertainty over the etiology of PGAD. However, PGAD has been increasingly thought to be a symptom resulting from different possible underlying causes. 9 , 10 In some cases, medical management, particularly for depression, has been reported to trigger PGAD, particularly selective serotonin reuptake inhibitors (SSRIs). 11 In addition, there have been some suggestions that vascular disruptions with pelvic varices occur commonly with PGAD. 12 Moreover, neurologic damage or abnormalities attributable to intrapelvic nerve entrapment, small fiber neuropathy, or compression in the spine involving Tarlov cysts or intervertebral disk pathology have been implicated, especially when PGAD is associated with genital, gluteal, and/or lower extremity dysesthesia or paresthesia. 7 , 8 , 13 , 14 , 15 The International Society for the Study of Women’s Sexual Health (ISSWSH) 2021 PGAD consensus outlined a range of potential psychosocial and comorbid factors organized over 5 regions contributing to PGAD—the end organ, pelvis/perineum, cauda equina, spinal cord, and brain. 8 The focus of this report is on Tarlov cysts, which have a potential role in PGAD related to their location in the sacral spinal region, particularly when located at the S2 to S3 level, which originate from fibers forming the pudendal and pelvic splanchnic nerves innervating the genitopelvic region. These nerves have important sensory and motor functions that innervate the perineum, external genitalia, and pelvic floor muscles. Thus, cysts, depending on their size and location, compressing or irritating the nerve roots can contribute to various dysesthesias and pain in these regions. 8 The objectives of this narrative review are to detail the prevalence, characteristics, and treatments of PGAD and Tarlov cysts, evaluate their potential relationships, and provide some guidance to clinicians on how to determine whether a Tarlov cyst is the cause of PGAD in their clinical practice. Peer-reviewed studies evaluating these topics without date restrictions were included in the review.

Tarlov cysts have commonly been reported to be associated with isolated lower limb radiculopathy and paresthesias, but their correlation with genital pain, urinary, and sexual dysfunction has been much less studied. 54 , 55 In an early report 46 of Australian patients with sacral Tarlov cysts referred for a surgical opinion, MRI studies were conducted to clarify the relationship between Tarlov cysts and typical symptoms of spinal stenosis. Consequently, focus on these symptoms and lack of gynecologic or urologic investigations are reasons why the broader clinical effects of sacral Tarlov cysts have been overlooked. 2 Inquiry into other symptoms, particularly sexual function, is rare as many spine surgeons focus on the disk space and are uncomfortable discussing genital pain and sexual dysfunction. 56 Dutch neurosurgeons reported that they felt that sexual health was affected in 34% of their patients and that responsibility was with the neurosurgeon (partly) to investigate. However, 73% of neurosurgeons reported that they almost never do this. 57 Tarlov cysts were investigated more extensively in multidisciplinary investigations, 4 , 5 , 6 , 46 , 52 , 58 and pain symptoms in diverse regions and bowel and bladder dysfunctions were commonly reported ( Supplemental Table 4 ). Of note, 1 study 5 comparing patients with Tarlov cysts with age-matched controls reported higher frequencies for conditions in the lower limbs (pain/paresthesia in the feet and leg weakness) and pelvis (perineal pain/paresthesia or coccygodynia). Although sexual dysfunction was not reported, perineal paresthesia (24% [patients with Tarlov cysts] vs 5% [controls]) and dyspareunia (32% [patients with Tarlov cysts] vs 5% [controls]) were more commonly reported by patients with Tarlov cysts than by controls. Sexual dysfunctions, although without specific symptoms, were reported in other studies involving Tarlov cysts, with prevalence ranging from 25.0% in a cohort of 65 patients, 4 29.3% in a cohort of 157 patients, 58 and 43.0% in a cohort of 213 patients. 6 Of note, 1 study 52 involving a cohort of 242 patients with pudendal neuralgia identified 34 patients (34 women and 5 men) with at least 1 sacral Tarlov cyst. Of the women with Tarlov cysts, 2 (5.9%) reported PGAD. 52 Although women are more commonly affected by Tarlov cysts and sexual dysfunctions, these conditions can also occur in men, although they present differently than in women. 59 , 60 , 61 Singh et al 59 reported the case of a 28-year-old man with back pain and retrograde ejaculation supposedly resulting in infertility from 2 large Tarlov cysts at the S2 to S4 sacral regions. Cysts were surgically excised, and although back pain resolved significantly after surgery, sperm count and seminal volume remained lower than the values for natural conception. In another case report, 60 a 42-year-old man with symptoms of low back pain, weakness of the lower limbs, urinary incontinence, and complaints of nightly spermatorrhea (excessive involuntary seminal fluid discharge) underwent surgical removal of 2 Tarlov cysts at the S1 and S2 regions. Symptoms of spermatorrhea disappeared, and lower limb numbness and urinary incontinence improved. In addition, 2 other cases 61 involved a 74-year-old man and a 38-year-old man, both with unwanted, unpleasant genital sensations and overactive bladder. In both cases, genital sensory testing indicated hyperesthesia in the pudendal dermatome, and transcutaneous electrical nerve stimulation (TENS) reduced genital sensations and overactive bowel in the 74-year-old man but had no effect in the 38-year-old man. Although small fiber sensory neuropathy was suspected in both cases, nerve conduction tests or spinal imaging was not performed. Several investigators 62 , 63 , 64 , 65 have specifically assessed axon or nerve root injury associated with sacral Tarlov cysts. The sural nerve, composed mainly of fibers originating from the S1 and S2 sacral roots, was the target nerve. The presence and extent of nerve damage were found to be unrelated to the size of the cyst. 62 Sural nerve abnormalities have been documented with smaller Tarlov cysts of <1 cm, causing nerve damage and debilitating symptoms. 63 In addition, abnormal neurophysiological findings were reported in patients with Tarlov cysts referred to an American physical medicine outpatient clinic: a cohort of 30 patients and a later cohort of 31 patients. 64 , 65 Multiple abnormal nerve conduction studies and needle EMG abnormalities in nerve root myotomes corresponded with dermatomal pain or paresthesia. 63 Small fiber neuropathy evaluated with lower leg skin biopsies in patients with Tarlov cysts of ≥8 mm resulted in most biopsies being below the 5% percentile of reference values for this nerve damage. 65 Small fibers are responsible for nociceptive processing, thermal sensation, and autonomic functions, and damage to these fibers may produce commonly reported Tarlov cyst–related sensory symptoms, such as burning pain, hyperesthesia, and dysesthesia. The authors proposed that the increased pulsatile CSF pressure that initiates Tarlov cyst formation, particularly in nonvalved cysts, might damage axons and neurons inside the nerve root sheaths and dorsal root ganglia.