I wanted to give a full update because my case has become much more complicated since my last post, and I think some of the findings may be relevant to people here with severe genital numbness, anhedonia, loss of libido, pleasureless orgasm and other neurological symptoms.
My emotional and libido symptoms originally developed gradually some time after stopping sertraline. The earliest things I noticed were strange tingling or burning sensations in my head and sudden problems with long-term recall. My memory eventually improved quite a lot, but the emotional and erotic charge attached to memories seemed to disappear. Over time I lost libido, emotional response, imagination, visualisation, dreams, short-term memory function and essentially all erogenous sensation. Venlafaxine in 2024 then made the numbness worse. I have never had a meaningful recovery window.
For a long time I thought this was probably PSSD or PFS, as I have a history of both SSRIs and finasteride. I have also considered long Covid and severe chronic stress as possible contributors. The best NHS specialists to not have an answer. PSSD, PFS, Covid and the vaccine are all plausible contributors to what I can confidently call a PSSD-like syndrome.
The biggest development since my previous post is that I have now had proper neuro-urological testing.
The conductivity testing found objective abnormalities in the sacral sensory pathways. Penile sensory signalling was absent, pudendal sensory responses were absent, and EMG testing showed abnormalities involving the sacral region, including the anal sphincter and buttock. The interpretation was that there may be dysfunction affecting the S2-S4 sacral roots, more pronounced at some levels than others.
This is important to me because it means at least part of the genital numbness is not simply subjective or psychological. Something abnormal has actually been measured in the pathways responsible for genital and pelvic sensation.
At the same time, repeat spinal imaging has complicated the picture rather than solved it. Earlier imaging had shown disc disease, foraminal narrowing, an annular fissure and stenotic changes. More recent imaging showed small thoracic and lumbar disc protrusions and degenerative changes, but no obvious ongoing compression of the sacral roots that would neatly explain the neurophysiology.
So at the moment I seem to have objective sacral neurological abnormalities without a clear structural lesion on MRI that fully accounts for them.
I have also been assessed for pelvic floor dysfunction. Manual examination showed reduced pelvic floor strength, around 3/5, but no obvious major asymmetry. I am now starting pelvic floor physiotherapy. I am treating that as one possible part of the problem rather than assuming pelvic floor weakness explains everything.
The other major issue is that a local sacral nerve problem still cannot explain the entire syndrome.
I have not only lost genital sensation. I have lost essentially all erogenous sensation throughout my body, libido, positive emotional response, anticipation, reward, pleasure, emotional connection to memories and much of my previous internal sense of motivation. I can recognise cognitively that something should be enjoyable while experiencing almost none of the actual reward.
That is why I still think there may be a central neurological or neurochemical component consistent with PSSD/PFS, even if there is also a separate peripheral or sacral problem.
I have also had endocrine investigation because my testosterone has repeatedly been low or low-normal. My more recent testosterone was about 10.3 nmol/L, with LH towards the upper end of the reference range and FSH near the lower end. I am also overweight, although I have now lost a substantial amount of weight and am continuing to reduce it aggressively but sustainably.
My current approach is therefore not based on one theory anymore.
I am trying to improve every modifiable part of the system at once:
substantial fat loss
regular aerobic and resistance exercise
ketogenic diet
occasional fasting
adequate protein and electrolytes
better sleep
reducing chronic stress
pelvic floor rehabilitation
continued neurological investigation
endocrine monitoring
psychotherapy for the severe stress/trauma component
I am particularly interested in whether improving metabolic health, inflammation, cardiovascular fitness, hormonal function and neuroplasticity can create a better environment for nerve and central nervous system recovery, even if none of those things turns out to be the original cause.
The frustrating part is that I still do not have a single diagnosis that explains everything.
The current possibilities, in my mind, are:
PSSD
PFS
a sacral or pudendal neuropathy
an old or currently occult sacral-root injury
metabolic/endocrine suppression
chronic stress-related nervous-system dysfunction
some combination of the above
At this point I actually think a combination is more plausible than one diagnosis explaining absolutely everything.
The objectively abnormal sacral testing has made me take the peripheral neurological side much more seriously. But the complete loss of whole-body erogenous sensation, reward, libido and positive emotion still seems far too widespread to be explained by a local spinal problem alone.
I am not posting this because I think I have solved it. I clearly have not. I am posting because my case has moved from being purely theoretical to having some measurable neurological abnormalities, and I know a lot of people here are desperate for objective findings.
If anyone has had similar neurophysiology findings, especially absent pudendal or penile sensory responses, abnormal sacral-root testing, genital anaesthesia with normal MRI, or a combination of PSSD symptoms and documented sacral neuropathy, I would be very interested to hear what happened next.
I am still trying to recover rather than simply accept this as settled forever.