Genito-Pelvic Pain/Penetration Disorder

Causes of genito-pelvic pain/penetration disorder may involve physical and psychological factors.

Superficial vulvar pain may result from provoked vestibulodynia, genitourinary syndrome of menopause, dermatologic disorders (eg, lichen sclerosus, vulvar dystrophies), congenital malformations, genital herpes simplex, vaginitis, Bartholin gland abscess, radiation fibrosis, postsurgical introital narrowing, or recurrent tearing of the posterior fourchette.

Provoked vestibulodynia can be primary or secondary:

• Primary: Is present from the first experience with penetration (whether by insertion of a tampon, a speculum examination, or sexual intercourse)

• Secondary: Develops in patients who have previously been able to have comfortable, pain-free penetration

The etiology of provoked vestibulodynia is not entirely understood and may result from multiple factors, possibly including an inflammatory or immune response, an increased number of nerve fibers resulting in hyperesthesia, a hormonal imbalance, and pelvic floor dysfunction. Provoked vestibulodynia can occur in chronic pain syndromes, including fibromyalgia, interstitial cystitis, and irritable bowel syndrome.

Deep dyspareunia may result from pelvic floor muscle hypertonicity or uterine or ovarian disorders (eg, fibroids, chronic pelvic inflammatory disease, endometriosis).

A history of trauma or sexual trauma can also contribute to a genito-pelvic pain/penetration disorder.

The term levator ani syndrome is being increasingly used to replace vaginismus because symptoms of vaginismus typically result from levator ani muscle dysfunction. Levator ani syndrome may combine pain and emotional components. This disorder may be primary, occurring with the first attempt at sexual intercourse or secondary, occurring after a period of pain-free sex.

Women with primary provoked vestibulodynia report that pain occurred during their first experience with penetration. Many notice the pain first in adolescence, when they first try to use a tampon. They may report that they have never been able to have had comfortable sexual intercourse. Often, pain is described as a burning or stabbing pain caused by insertion of something into the vagina. Women with secondary provoked vestibulodynia have similar symptoms, but they report symptoms after a period of sexual activity without pain.

Women with genito-pelvic pain/penetration disorder may develop a phobia-like avoidance of penetration. They may have an intense fear of and anxiety about pain before or during vaginal penetration. When women anticipate that pain will recur during penetration, their vaginal muscles tighten, making attempts at sexual intercourse even more painful. However, most women with this disorder can enjoy nonpenetrative sexual activity.

The inability to have sexual intercourse can strain a relationship. Women may feel ashamed, embarrassed, inadequate, or depressed. It causes significant stress for women who want to become pregnant.

• Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR) criteria (1)

Diagnosis of genito-pelvic pain/penetration disorder is based on symptoms and results of a pelvic examination, which can detect or rule out physical abnormalities.

The examination focuses on inspecting all the vulvar skin (including the creases between the labia minora and majora [eg, for fissures typical of chronic candidiasis]), as well as the clitoral hood, urethral meatus, hymen, and openings of major vestibular gland ducts (for atrophy, signs of inflammation, and abnormal skin lesions requiring biopsy).

A moist cotton swab can then be used to map out the woman's pain. Provoked vestibulodynia manifests with pain that is reproduced when the vestibule is palpated. The pain may occur along the entire vestibule (from 1 to 11 o'clock) or sometimes only posteriorly (from 4 to 8 o'clock). If only the posterior part of the vestibule is affected, pelvic floor dysfunction may also be present.

A digital examination is then done to check for pelvic floor hypertonicity, which can be elicited by palpating the levator ani muscles. The urethra and bladder should also be palpated anteriorly to identify abnormal tenderness. A speculum examination can be done to evaluate the cervix, and bimanual examination to palpate the uterus and ovaries can help identify causes of deeper pain.

Examination can sometimes be difficult because of the patient's pain and/or anticipation of pain. In many women with levator ani syndrome, the speculum and bimanual part of the examination cannot be done. Clinicians should explain each step of the examination to women to help them relax and to get as much information as possible from the examination.

Diagnosis of genito-pelvic pain/penetration disorder is based on specific criteria in the DSM-5-TR. The criteria require persistence or recurrence of one or more of the following:

• Marked vulvovaginal or pelvic pain during intercourse or penetration attempts

• Marked fear or anxiety about vulvovaginal or pelvic pain in anticipation of, during, or because of vaginal penetration

• Marked tensing or tightening of pelvic floor muscles during attempted vaginal penetration

Symptoms must have been present for ≥ 6 months and must cause significant distress in the woman. Also, the diagnosis of genito-pelvic pain/penetration disorder requires that sexual dysfunction is not better explained by the presence of another disorder, severe relationship distress (eg, intimate violence), or other significant stressors or by use a substance or medication.

• Treatment of cause when possible (eg, topical estrogen for genitourinary syndrome of menopause)

• Education about chronic pain and its effects on sexuality

• Pelvic floor physical therapy

• Progressive desensitization

• Psychological therapies

Management of genito-pelvic pain/penetration disorder frequently includes the following:

• Encouraging and teaching the couple to develop satisfying forms of nonpenetrative sex

• Discussing psychological issues contributing to and caused by the chronic pain

• When possible, treating the primarily physical abnormality that contributes to pain (eg, endometriosis, lichen sclerosus, vulvar dystrophies, vaginal infections, congenital malformations, radiation fibrosis)

• Treating coexisting pelvic muscle hypertonicity

• Treating comorbid sexual interest/arousal disorder

Topical estrogenestrogen receptor modulator [SERM]) may be useful in women with dyspareunia due to vulvar dystrophies, or genitourinary syndrome of menopause.

Data about the optimal treatment of genito-pelvic pain/penetration disorder are limited, and many approaches are currently used depending on the specific presentation.

The first approach is always a reminder to practice good vulvar hygiene, including wearing cotton underwear during the day, washing with a mild soap, and avoiding douching and over-the-counter vaginal deodorants. If a lubricant is used during sex, it should be nonscented and water-based.

Pelvic floor physical therapy can often benefit women with genito-pelvic pain/penetration disorder; it includes pelvic floor muscle training, sometimes with biofeedback, to teach pelvic muscle relaxation. Other therapies include soft-tissue mobilization and myofascial release, trigger-point pressure, electrical stimulation, bladder and bowel retraining, and therapeutic ultrasonography.

Prescription and nonprescription devices are available for self-dilation if women with genito-pelvic pain/penetration disorder have tight pelvic muscles that contribute to painful intercourse. Self-dilation in the presence of a therapist and the woman's partner plus psychotherapy has been shown to enable women with levator ani syndrome to have sexual intercourse more frequently (1).

Levator ani syndrome (previously called vaginismus) can be treated with progressive desensitization; women progressively accustom themselves to self-touch near, on, then through the introitus. Each stage in the progression begins only when the woman is comfortable with the previous stage.

• The woman touches herself daily as close to the introitus as possible, separating the labia with her fingers. (Once her fear and anxiety due to introital self-touch has diminished, the woman will be more able to tolerate the physical examination.)

• The woman inserts her finger past her hymen; pushing or bearing down during insertion enlarges the opening and eases entry.

• The woman inserts vaginal cones in gradually increasing sizes progressively; leaving a cone inside for 10 to 15 minutes helps perivaginal muscles become accustomed to gently increasing pressure without reflex contraction.

• The woman then allows her partner to help her insert a cone during a sexual encounter to confirm that it can go in comfortably when she is sexually excited.

• The couple includes penile vulvar stimulation during sexual play so that the woman becomes accustomed to feeling the penis on her vulva.

• Ultimately, the woman inserts her partner’s penis partially or fully, holding it like an insert. She may feel more confident in the woman superior position.

For provoked vestibulodynia, first-line treatment includes pelvic floor physical therapy because pelvic floor muscle hypertonicity is often present.

2). Topical estrogen is helpful for genitourinary syndrome of menopause and to prevent tissue fragility, which may result in recurrent posterior fourchette lacerations.

estrogen receptor modulator [SERM]) may be useful in women with dyspareunia due to genitourinary syndrome of menopause.

Medications used to treat neuropathic pain

Botulinum toxin type A, injected into the pelvic floor muscles, has been used to treat levator ani syndrome and provoked vestibulodynia, but it is normally used only for short-term treatment of refractory cases.

Vestibulectomy (removal of the vaginal vestibule) is not done often but can be considered on a case by case basis. Women with primary provoked vestibulodynia are usually the best candidates for this surgical procedure.

Referral to a certified sex therapist for psychological therapies such as cognitive-behavioral therapy, and mindfulness-based cognitive therapy can often help women manage their fear of and anxiety about pain and penetration.

• Genito-pelvic pain/penetration disorder is characterized by involuntary contraction of pelvic floor muscles, pain that occurs during vaginal entry and/or deep penetration, anxiety about penetration, and difficulty having sexual intercourse.

• Carefully examine the vulva and do a pelvic examination to localize the woman's pain and determine any underlying condition.

• Treat the cause if possible, and use various medication and/or psychological therapies to help women manage their fears and anxieties.

• Recommend pelvic floor physical therapy because it is useful for almost all women who have genito-pelvic pain disorder.