Restless Genital Syndrome (ReGS) should be distinguished from Spontaneous Orgasms: A case report of Cannabis induced spontaneous orgasm

Abstract

However, she did not fulfill to any of the five criteria of ReGS. It was concluded that her spontaneous orgasms were the result of the use of Cannabis combined with long duration of previous sexual activity. This is not only important for physicians but alsof for highly exposed subjects like those active in the sex industry.

Introduction

In 2001, the at the time completely unknown phenomenon of persistent intrusive genital sensations have for the first time been described by Leiblum and Nathan under the term persistent sexual arousal syndrome (PSAS) (Leiblum and Nathan, 2001Leiblum SR, Nathan SG (2001). Persistent sexual arousal syndrome: A newly discovered pattern of female sexuality. Journal of Sex & Marital Therapy, 27, 365–80[Taylor & Francis Online], [Web of Science ®], [Google Scholar]). Later, in 2006 it was redefined as Persistent Genital Arousal Disorder (PGAD) (Goldmeier and Leiblum, 2006Goldmeier D, Leiblum SR. P (2006). Persistent genital arousal in women – A new syndrome entity. International Journal STD Aids, 17, 215–6[Crossref], [PubMed], [Web of Science ®], [Google Scholar]) emphasizing the genital location of the disorder. 

PSAS or PGAD is characterized by five diagnostic criteria: (i) involuntary genital and clitoral arousal that persists for an extended period of time (hours, days, months); (ii) the physical genital arousal does not go away following one or more orgasms; (iii) the genital arousal is unrelated to subjective feelings of sexual desire; (iv) the persistent feelings of genital arousal feel intrusive and unwanted; and (v) distress is associated with persistent genital arousal (Basson, Leiblum Brotto et al, 2003Basson R, Leiblum S, Brotto L, Derogatis L, Fourcroy J,  Fugl-Myer K, Graziottin A, Heiman JR, Laan E, Meston C, van Lankveld J, Weijmar Schultz W. (2003). Definitions of women's sexual dysfunctions reconsidered: Advocating expansion and revision. Journal of Psychosomatic Obstetrics & Gynecology, 24, 221–9[Taylor & Francis Online], [Web of Science ®], [Google Scholar]). 

In 2009, and based on systematic investigation of 18 women who fulfilled to all 5 criteria of PSAS/PGAD, Waldinger and Schweitzer (Waldinger et al, 2009aWaldinger MD, van Gils APG, Ottervanger HP, Vandenbroucke WVA, Tavy DLJ (2009a). Persistent genital arousal disorder in 18 Dutch women: Part 1. MRI, EEG, and Transvaginal Ultrasonography Investigations. Journal of Sexual Medicine, 6, 474–481[Crossref], [PubMed], [Web of Science ®], [Google Scholar]; Waldinger and Schweitzer, 2009 Waldinger MD, Schweitzer DH (2009). 

Persistent genital arousal disorder in 18 Dutch women: Part II- A syndrome clustered with restless legs and overactive bladder. Journal of Sexual Medicine, 6, 482–497[Crossref], [PubMed], [Web of Science ®], [Google Scholar]) noted that in their sample of women these 5 criteria were insufficient to precisely describe their complaints and symptoms. In the majority of them the genitalsensations were felt as tingling, like ants walking, creeping sensations, spasms, electric-current like or little explosive sensations, together inducing the imminent urge of an orgasm and making them restless (Waldinger et al, 2009aWaldinger MD, van Gils APG, Ottervanger HP, Vandenbroucke WVA, Tavy DLJ (2009a). 

Persistent genital arousal disorder in 18 Dutch women: Part 1. MRI, EEG, and Transvaginal Ultrasonography Investigations. Journal of Sexual Medicine, 6, 474–481[Crossref], [PubMed], [Web of Science ®], [Google Scholar]; Waldinger and Schweitzer, 2009Waldinger MD, Schweitzer DH (2009). Persistent genital arousal disorder in 18 Dutch women: Part II- A syndrome clustered with restless legs and overactive bladder. Journal of Sexual Medicine, 6, 482–497[Crossref], [PubMed], [Web of Science ®], [Google Scholar]). 

Moreover, in all these women the unwanted restless genital sensations were associated with and/or restless legs, and/or complaints of overactive bladder and/or urethral hypersensitivity and not resolving by sexual activity. In order to clearly distinguish these symptoms from the symptoms of PSAS/PGAD, Waldinger and Schweitzer introduced the term Restless Genital Syndrome (ReGS) and defined it by five different diagnostic criteria: (i) a state of unwanted restless genital sensations that are associated with; (ii) and/or restless legs, (iii) and/or complaints of overactive bladder; (iv) and/or urethral hypersensitivity; (v) and not resolving by sexual activity (Waldinger and Schweitzer, 2009Waldinger MD, Schweitzer DH (2009). 

Persistent genital arousal disorder in 18 Dutch women: Part II- A syndrome clustered with restless legs and overactive bladder. Journal of Sexual Medicine, 6, 482–497[Crossref], [PubMed], [Web of Science ®], [Google Scholar]). Notably, of the five criteria of ReGS only the first criterion is identical to the five criteria of PSAS/PGAD. The other four criteria of ReGS have not been defined as criteria of PGAD. In other words, the five criteria of ReGS are not identical to the five criteria of PGAD. And therefore, ReGS is not similar to PSAS or PGAD. The symptoms of ReGS and also its pathogenesis and etiology differ from PSAS/PGAD. For example, masturbation and sexual activity trigger or aggravate ReGS, whereas it has been reported by Leiblum (Leiblum, Brown, Wan, Rawlinson, 2005Leiblum S, Brown C, Wan J, Rawlinson L. (2005). 

Persistent sexual arousal syndrome: a descriptive study. Journal of Sexual Medicine, 2, 331–7[Crossref], [PubMed], [Web of Science ®], [Google Scholar]) and Jackowich (Jackowich, Pink, Gordon, Poirier, Pukall, 2017Jackowich R, Pink L, Gordon A, Poirier E, Pukall CF (2017). Symptom characteristics and medical history of an online sample of women who experience symptoms of persistent genital arousal. Journal of Sex & Marital Therapy, 1, 1–16[Taylor & Francis Online], [Google Scholar]) that masturbation and sexual activity relieve PGAD in 51% and 38%, respectively. 

Moreover, there is not any scientific evidence that past sexual or domestic abuse is associated with ReGS, whereas – in contrast – an association of PGAD with psychological causes has been suggested (Leiblum, Seehuus, Goldmeier, Brown 2007Leiblum S, Seehuus M, Goldmeier D, Brown C. (2007). Psychological, medical, and pharmacological correlates of persistent genital arousal disorder. Journal of Sexual Medicine, 4, 1358–66[Crossref], [PubMed], [Web of Science ®], [Google Scholar]). Although the genital sensations in ReGS are often felt as being persistently on the verge of orgasm (Waldinger et al, 2009Waldinger MD, Schweitzer DH (2009). Persistent genital arousal disorder in 18 Dutch women: Part II- A syndrome clustered with restless legs and overactive bladder. Journal of Sexual Medicine, 6, 482–497[Crossref], [PubMed], [Web of Science ®], [Google Scholar]; Waldinger and Schweitzer, 2009Waldinger MD, Schweitzer DH (2009). 

Persistent genital arousal disorder in 18 Dutch women: Part II- A syndrome clustered with restless legs and overactive bladder. Journal of Sexual Medicine, 6, 482–497[Crossref], [PubMed], [Web of Science ®], [Google Scholar]), spontaneous orgasm is an extremely rare symptom (Waldinger et al, 2009aWaldinger MD, van Gils APG, Ottervanger HP, Vandenbroucke WVA, Tavy DLJ (2009a). Persistent genital arousal disorder in 18 Dutch women: Part 1. MRI, EEG, and Transvaginal Ultrasonography Investigations. Journal of Sexual Medicine, 6, 474–481[Crossref], [PubMed], [Web of Science ®], [Google Scholar]). Waldinger et al (Waldinger et al, 2009Waldinger MD, Venema PL, van Gils APG, Schweitzer DH(2009b). New insights into Restless Genital Syndrome: Static mechanical hyperesthesia and neuropathy of the nervus dorsalis clitoridis. Journal of Sexual Medicine, 6, 2778–2787[Crossref], [PubMed], [Web of Science ®], [Google Scholar]b; Waldinger et al, 2010aWaldinger MD, de Lint GJ, Venema PL, van Gils APG, Schweitzer DH (2010a). 

Successful Transcutaneous Electical Nerve Stimulation in two women with Restless Genital Syndrome: The role of Aδ- and C-nerve fibers. Journal of Sexual Medicine, 7, 1190–1199[Crossref], [PubMed], [Web of Science ®], [Google Scholar]) suggested that ReGS is associated with a small fiber sensoric neuropathy of the dorsal nerve of the clitoris, a pure sensory endbranch of the pudendal nerve (Waldinger et al, 2009Waldinger MD, Venema PL, van Gils APG, Schweitzer DH(2009b). New insights into Restless Genital Syndrome: Static mechanical hyperesthesia and neuropathy of the nervus dorsalis clitoridis. Journal of Sexual Medicine, 6, 2778–2787[Crossref], [PubMed], [Web of Science ®], [Google Scholar]b; Waldinger et al, 2010aWaldinger MD, de Lint GJ, Venema PL, van Gils APG, Schweitzer DH (2010a). 

Successful Transcutaneous Electical Nerve Stimulation in two women with Restless Genital Syndrome: The role of Aδ- and C-nerve fibers. Journal of Sexual Medicine, 7, 1190–1199[Crossref], [PubMed], [Web of Science ®], [Google Scholar]). ReGS mainly affects women (Leiblum and Nathan, 2001Leiblum SR, Nathan SG (2001). Persistent sexual arousal syndrome: A newly discovered pattern of female sexuality. Journal of Sex & Marital Therapy, 27, 365–80[Taylor & Francis Online], [Web of Science ®], [Google Scholar]; Goldmeier and Leiblum, 2006Goldmeier D, Leiblum SR. P (2006). Persistent genital arousal in women – A new syndrome entity. International Journal STD Aids, 17, 215–6[Crossref], [PubMed], [Web of Science ®], [Google Scholar]; Waldinger et al, 2009aWaldinger MD, van Gils APG, Ottervanger HP, Vandenbroucke WVA, Tavy DLJ (2009a). 

Persistent genital arousal disorder in 18 Dutch women: Part 1. MRI, EEG, and Transvaginal Ultrasonography Investigations. Journal of Sexual Medicine, 6, 474–481[Crossref], [PubMed], [Web of Science ®], [Google Scholar]; Waldinger and Schweitzer, 2009Waldinger MD, Schweitzer DH (2009). Persistent genital arousal disorder in 18 Dutch women: Part II- A syndrome clustered with restless legs and overactive bladder. Journal of Sexual Medicine, 6, 482–497[Crossref], [PubMed], [Web of Science ®], [Google Scholar]; Waldinger et al, 2009Waldinger MD, Venema PL, van Gils APG, Schweitzer DH(2009b). New insights into Restless Genital Syndrome: Static mechanical hyperesthesia and neuropathy of the nervus dorsalis clitoridis. Journal of Sexual Medicine, 6, 2778–2787[Crossref], [PubMed], [Web of Science ®], [Google Scholar]b; Waldinger et al, 2010aWaldinger MD, de Lint GJ, Venema PL, van Gils APG, Schweitzer DH (2010a). 

Successful Transcutaneous Electical Nerve Stimulation in two women with Restless Genital Syndrome: The role of Aδ- and C-nerve fibers. Journal of Sexual Medicine, 7, 1190–1199[Crossref], [PubMed], [Web of Science ®], [Google Scholar]; Waldinger et al, 2010bWaldinger MD, Venema PL, van Gils APG, Schutter EMJ, Schweitzer DH (2010b). Restless Genital Syndrome before and after clitoridectomy for spontaneous orgasms: A case report. Journal of Sexual Medicine, 7, 1029–1034[Crossref], [PubMed], [Web of Science ®], [Google Scholar]), although it rarely occurs in males (Waldinger et al, 2011Waldinger MD, Venema PL, van Gils APG, de Lint GJ, Schweitzer DH (2011). Stronger evidence for small fiber sensory neuropathy in Restless Genital Syndrome: Two case reports in males. Journal of Sexual Medicine, 8, 325–330[Crossref], [PubMed], [Web of Science ®], [Google Scholar]). 

A more appropriate neurologic term for the uncomfortable, intrusive and unwanted sensations in ReGS is dysesthesias (Waldinger et al, 2009Waldinger MD, Venema PL, van Gils APG, Schweitzer DH(2009b). New insights into Restless Genital Syndrome: Static mechanical hyperesthesia and neuropathy of the nervus dorsalis clitoridis. Journal of Sexual Medicine, 6, 2778–2787[Crossref], [PubMed], [Web of Science ®], [Google Scholar]b). It is important to understand that these genital dysesthesias may lead to an imperative urge to get rid of them by sexual activity, e.g., masturbation and/or intercourse. There is absolutely no conscious feeling of longing for sexual pleasure or orgasm. Moreover, this sexual response (masturbation or intercourse) to the genital dysesthesias is not only ineffective but also aggravates the intensity and frequency of occurrence of these genital sensations. 

Indeed, the by ReGS induced masturbation- or intercourse to stop the “non-sexual” genital sensations is considered as inadequate since the genital sensations have been shown of nonsexual origin (Waldinger and Schweitzer, 2009Waldinger MD, Schweitzer DH (2009). Persistent genital arousal disorder in 18 Dutch women: Part II- A syndrome clustered with restless legs and overactive bladder. Journal of Sexual Medicine, 6, 482–497[Crossref], [PubMed], [Web of Science ®], [Google Scholar]). The dysesthesias are located particularly at the clitoris and to a lesser extent at the vagina and labia, the pubic bone and groins (Waldinger et al, 2009aWaldinger MD, van Gils APG, Ottervanger HP, Vandenbroucke WVA, Tavy DLJ (2009a). 

Persistent genital arousal disorder in 18 Dutch women: Part 1. MRI, EEG, and Transvaginal Ultrasonography Investigations. Journal of Sexual Medicine, 6, 474–481[Crossref], [PubMed], [Web of Science ®], [Google Scholar]; Waldinger and Schweitzer, 2009Waldinger MD, Schweitzer DH (2009). Persistent genital arousal disorder in 18 Dutch women: Part II- A syndrome clustered with restless legs and overactive bladder. Journal of Sexual Medicine, 6, 482–497[Crossref], [PubMed], [Web of Science ®], [Google Scholar]). 

In the above-mentioned study among 18 women a majority of the patients reported symptoms of overactive bladder syndrome (OAB). The OAB symptoms often occurred at moments of worsened genital dysesthesias. In the same cohort, 67% of women reported disappearance of genital sensations for a short period after micturition. Interestingly, 50% of the women reported genital sensations by touching the urethral opening as if it was the clitoris (Waldinger et al, 2009aWaldinger MD, van Gils APG, Ottervanger HP, Vandenbroucke WVA, Tavy DLJ (2009a). 

Persistent genital arousal disorder in 18 Dutch women: Part 1. MRI, EEG, and Transvaginal Ultrasonography Investigations. Journal of Sexual Medicine, 6, 474–481[Crossref], [PubMed], [Web of Science ®], [Google Scholar]; Waldinger and Schweitzer, 2009Waldinger MD, Schweitzer DH (2009). 

Persistent genital arousal disorder in 18 Dutch women: Part II- A syndrome clustered with restless legs and overactive bladder. Journal of Sexual Medicine, 6, 482–497[Crossref], [PubMed], [Web of Science ®], [Google Scholar]), suggesting involvement of the urethra in the pathogenesis of ReGS. The genital sensations become aggravated by a sitting position, nervousness, urinary pressure and sexual activity (Waldinger et al, 2009aWaldinger MD, vanGils APG, Ottervanger HP, Vandenbroucke WVA, Tavy DLJ  (2009a). Persistent genital arousal disorder in 18 Dutch women: Part 1. MRI, EEG, and Transvaginal Ultrasonography Investigations. Journal of Sexual Medicine, 6, 474–481[Crossref], [PubMed], [Web of Science ®], [Google Scholar]; Waldinger and Schweitzer, 2009Waldinger MD, Schweitzer DH (2009). Persistent genital arousal disorder in 18 Dutch women: Part II- A syndrome clustered with restless legs and overactive bladder. Journal of Sexual Medicine, 6, 482–497[Crossref], [PubMed], [Web of Science ®], [Google Scholar]). In general, gynecological examination of the clitoris and genital area appears to be normal in women with ReGS. Nevertheless, for a correct diagnosis of ReGS, e.g. excluding gynecological disorders, a gynecological examination is required.

In very rare cases, ReGS may be associated with a spontaneous orgasm. This is usually induced by touching a specific part of the hypersensitive skin of the pudendal dermatome. A slight touch, for example by wearing tight underwear, may trigger a spontaneous orgasm. However, not all cases of spontaneous orgasms should be attributed to ReGS. In this article we report on a woman with spontaneous orgasms who was seen by the first author. She reported quite different symptoms as heard from patients with ReGS. The patient provided written informed consent for anonymous publication of her case report.

Case Report

Mrs A is a 40 year old woman. She presents with severe anxiety and feelings of panic that existed since one month. Her anxiety is related to progressively worsening of spontaneous orgasms during the night and on the verge of orgasmic feelings at day time without being actively involved in sexual activity with a partner. The spontaneous orgasms occur in waves and she describes this sensation as a whole body orgasm. This problem had occurred after a hard pounding sexual encounter for five hours with a male partner. In her own words ‘’ during that sexual encounter I had persistent orgasms during the entire period which I felt as ‘’Cervical Orgasms”. Both of them started sexual contact after smoking Cannabis. Mrs. A also reports to have participated in various Tantra Yoga sessions for improving her orgasmic experiences. 

She reported no complaints of overactive bladder, nor the occurrence of restless legs. Importantly, the orgasmic sensations were not triggered by a sitting position but on the contrary were triggered by a lying position. She reports spontaneous orgasms during the night, without any previous sexual excitement or stimulatory activity. The orgasms occur spontaneously and lasted for a few hours and were associated with a diminished consciousness and mild retrograde amnesia. Her greatest fear is losing control in public by overwhelming orgasmic feelings and bodily orgasmic movements. She became even more frightened after reading on the Internet about a syndrome called ReGS that is so similar to her own symptoms. 

In particular she became alarmed by reading about its permanent nature and consequent destruction of anybody's life. She did not use contraceptives or serotonergic antidepressants in the previous years. In order to show and discuss her problem she auto-filmed a spontaneous orgasmic period lasting for a few hours revealing frequent rhythmic coital movements of her pelvis together with dystonic movements of arms and legs, dorsal flexion of her fingers and of both arms, and frequent abrupt dorsal flexions of the neck and head. In addition, it also shows significant eye turning similar to seizures but no tongue bite. Mrs. A explained that she had two similar continuous orgasmic experiences after separate use of 3,4-methyleendioxymethamfetamine (MDMA; XTC) and Cannabis on two different occasions. 

On both occasions this was accompanied with retrograde amnesia and a loss of orientation in space and time with her body thrashing her around everywhere. Since her symptoms didn't fulfill to the five diagnostic criteria of ReGS, Mrs A was relieved to hear that she did not suffer from this notorious neurogenital disorder. Mrs. A reported not in any way to have been involved in sexual, physical or domestic abuse. In 2008 she has had a surgery for pelvic floor prolapse. She is not known with pelvic stretch trauma, such as related to squatting and bike riding. She is not known with epilepsia or problems with flashing strobe lights. There is no history of epilepsia in her family. On physical examination no aberration either in structure or colour were found at the clitoris, labia or vagina. In particular, no clinical signs of dorsal clitoral neuromas were found. The neurological examination was normal with particularly a normal skin sensitivity.

After she was advised to avoid hard pounding sex for several hours with concomitant use of Cannabis, Mrs A reported not to have had sex for five weeks. However, she continued to use Cannabis and reported to experience a little bit of a spontaneous orgasm that she was able to control after smoking a very small amount of Cannabis mixed with tobacco. However, when smoking a higher amount of Cannabis mixed with tobacco she experienced a spontaneous orgasm within 1 minute. However, the intensity of this spontaneous orgasm was incomparable with the intensity of the spontaneous orgasms she experienced after the use of Cannabis with hard pounding sexual activity. Moreover, during these spontaneous orgasms she did not anymore experience a retrograde amnesia of disorientation. Without the use of Cannabis, Mrs A did not experience spontaneous orgasms. As she did not weighted the Cannabis, Mrs A was unable to provide hard data of the amount of Cannabis. She could only report about it in terms of small and higher dosage.

Discussion

Mrs A reported the occurrence of spontaneous orgasms at night and sensations of being on the verge of orgasms at day time after a 5 hours encounter of hard pounding sex, as she described it herself. She did not report any of the very characteristic symptoms of ReGS, particularly that her complaints were not triggered by a sitting position, and were not aggravated by urinary pressure or were concurrent with complaints of overactive bladder and/or restless legs. Moreover, and importantly, she did not report on a genital localization of her orgasmic feelings but on the contrary she experienced a whole body orgasmic feeling. In ReGS, the on-the verge of orgasm sensations are always located at the genitals, particularly the clitoris, vagina, and labia.

Particularly, as she later also reported spontaneous orgasms occurring immediately after smoking Cannabis, we assume that the spontaneous orgasms of Mrs A have been triggered by a combination of the use of Cannabis and hard pounding continuing sex of many hours.
As is well-known, Cannabis is the most frequently abused recreational substance as it alters sensory perception, increases sociability and induces euphoria (Williamson and Evans, 2000Williamson EM, Evans FJ (2000). Cannabinoids in clinical practice. Drugs, 60, 1303–1314[Crossref], [PubMed], [Web of Science ®], [Google Scholar]). 

Its main psychoactive component is delta-9-tetrahydrocannabinol (delta9-THC) (Gaoni and Mechoulam, 1964Gaoni Y, Mechoulam R. Isolation, structure, and partial synthesis of an active constituent of hashish (1964). Journal of the American Chemical Society, 86, 1646–1647[Crossref], [Web of Science ®], [Google Scholar]). It acts on cannabinoid CB1 and CB2 receptors(Matsudaet al, 1990Matsuda LA, Lolait SJ, Brownstein MJ, Young AC, Bonner TI  (1990). Structure of a cannabinoid receptor and functional expression of the cloned cDNA. Nature, 346 (6284), 561–564[Crossref], [PubMed], [Web of Science ®], [Google Scholar]) in the endogenous cannabinoid system (ECS) in the brain (Androvicova et al, 2017aAndrovicova R, Horacek J, Stark T, Drago F, Micale V(2017a). 

Endocannabinoid system in sexual motivational processes: Is it a novel therapeutic horizon?Pharmacological Research, 115, 200–208[Crossref], [PubMed], [Web of Science ®], [Google Scholar]). Cannabis may affect sexual functioning depending on timing, dosage and users (Touw, 1981Touw M (1981). The religious and medicinal uses of cannabis in China, India and Tibet. Journal of Psychoactive Drugs, 13, 23–34[Taylor & Francis Online], [Web of Science ®], [Google Scholar]). Cannabinoids may change sense of time and Cannabis users often reported “increased sexual pleasure” and “increased sexual arousal’ (Green et al, 2003Green B, Kavanagh D, Young R (2003). 

Being stoned: a review of self-reported cannabis effects. Drug and Alcohol Review, 22, 453–460[Taylor & Francis Online], [Web of Science ®], [Google Scholar]). Interestingly, in a fMRI study it was recently found that Cannabis intoxication increases activation of the right nucleus accumbens to erotic stimuli in heterosexual cannabis users whose prolactin was not elevated in response to the Cannabis intoxication. 

Individual prolactin reactivity modulates response of nucleus accumbens to erotic stimuli during acute cannabis intoxication: a fMRI pilot study. Psychopharmacology, 234, 1933–1943[Crossref], [PubMed], [Web of Science ®], [Google Scholar]).
Apart from the use of Cannabis, we speculate that the continuous five hour duration of hard pounding sexual activity may have led to an overactivation of the pudendal nerve resulting in a rebound effect, which made the spontaneous orgasms completely uncontrollable giving rise to a very understandable anxiety and panic.

The slight retrograde amnesia and diminished consciousness during sexual activity with the partner is assumed to have been a toxic effect of Cannabis.
In support of our hypothesis it should be emphasized that five weeks after her initial complaints she reported that in the absence of any sexual activity, the spontaneous orgasms did reoccur immediately after smoking Cannabis. However, the intensity of these spontaneous orgasms was controllable when she only used a small amount of Cannabis, but became uncontrollable after a higher dosage. Importantly, these Cannabis-induced spontaneous orgasms did not became so uncontrollable and intensive combined with retrograde amnesia and disorientation as happened after the use of Cannabis combined with 5 hours of hard pounding sex. For this reason we assume that the disorientation was a toxic effect of Cannabis and decided not to make an additional EEG and MRI-scan of the brain, for example in order to exclude an epileptic origin of her complaints.

Conclusion

ReGS is a separate neurogenital syndrome and – in contrast to PGAD – always associated with a small fiber sensoric neuropathy of the dorsal nerve of the clitoris in females, and with the dorsal nerve of the penis in males. The occurrence of spontaneous orgasms is not characteristic for ReGS. Only in very rare cases of ReGS a spontaneous orgasm may be triggered by touch of a hypersensitive skin of the pudendal dermatome. Therefore, in cases of spontaneous orgasms one has to critically interview the patient for checking the five diagnostic criteria for RegS. In the case of Mrs A. the characteristic features of ReGS have not been present. Therefore it was concluded that the patient does not suffer from ReGS but that her spontaneous orgasms were triggered by a combination of the use of Cannabis and previous very long lasting continuous sexual activity. This is not only important for physicians but also for highly exposed workers in the sex industry. As far as we know this is the first case report of Cannabis-induced dose-dependant spontaneous orgasms.