Jill M. Krapf1 and Andrew T. Goldstein2
(1)
Department of Obstetrics and Gynecology, George Washington University School of Medicine, Washington, DC, USA
(2)
The George Washington University School of Medicine, 3 Washington Circle NW, Suite 205, Washington, DC, 20027, USA
Andrew T. Goldstein
Email: obstetrics@yahoo.com
Keywords
DiagnosisManagementSexual pain disorderDyspareunia
25.1 Introduction
Pain with intercourse, or dyspareunia, may be one of the most common complaints in the gynecologic office setting. Despite this, it is one of the most difficult clinical problems to evaluate and treat, leading to understandable clinician discomfort. Based upon a systematic review by the World Health Organization (WHO), the incidence of painful intercourse ranges between 8 and 22 % [1]. In 2003, Basson et al. expanded the definition of dyspareunia to include women who experience pain with attempted vaginal entry, which is not included in the WHO definition and likely increases the true incidence of the condition [2].
To complicate these definitions further, the DSM-IV stipulates that dyspareunia should not include sexual pain resulting from a general medical condition or local pathology, but the recently released DSM-5 discarded the term vaginismus and introduced a combined definition: genito-pelvic pain/penetration disorder [3]. The decision that the two disorders could not be reliably differentiated was based on two primary considerations. First, the diagnostic formulation of vaginismus as “vaginal muscle spasm” was not supported by empiric evidence [4]. Second, fear of pain or fear of vaginal penetration is commonplace in clinical descriptions of vaginismus.
Pain with intercourse may also be a sign of vulvodynia , which is defined as chronic vulvar pain in the absence of infection, skin conditions, or neoplasia [5, 6]. Vulvodynia, and more specifically provoked vestibulodynia (pain at the vulvar vestibule), likely has a number of causes including inflammatory, hormonal, myofascial, and neurologic ones. Tight pelvic floor muscles (previously termed vaginismus, more appropriately termed hypertonic pelvic floor muscle dysfunction) may be a result, as well as a cause, of dyspareunia. This chapter will provide a general overview of diagnosis and management of dyspareunia, considering a broad differential diagnosis of painful intercourse. A comprehensive list of conditions associated with dyspareunia is summarized in Table 25.1.
Table 25.1
Conditions associated with dyspareunia
|
Hormonal: |
|
Vulvovaginal atrophy |
|
Hormonally mediated vestibulodynia |
|
Inflammatory: |
|
Skin allergy (semen allergy) |
|
Lichen simplex chronicus |
|
Vestibulodynia |
|
Desquamative inflammatory vaginitis |
|
Neurologic: |
|
Pudendal neuralgia |
|
Postherpetic neuralgia |
|
Neuroproliferative vestibulodynia |
|
Dermatologic: |
|
Lichen sclerosus |
|
Lichen planus |
|
Vulvar granuloma fissuratum |
|
Mucous membrane pemphigoid |
|
Infectious: |
|
Recurrent vulvovaginal candidiasis |
|
Pelvic inflammatory disease |
|
Sexually transmitted infection |
|
Neoplastic: |
|
Vulvar interepithelial neoplasm |
|
Pelvic neoplasms (cervical, uterine, ovarian, colon) |
|
Muscular: |
|
Pelvic floor dysfunction |
|
Vaginismus |
|
Structural: |
|
Endometriosis |
|
Leiomyoma |
|
Ovarian mass |
|
Pelvic adhesions |
|
Irritable bowel syndrome |
|
Interstitial cystitis |
|
Female genital cutting |
25.2 Diagnosis
25.2.1 Approach to the Patient
A woman’s experience of dyspareunia can be more complicated in presentation and evaluation than other medical conditions. Often, women do not disclose their symptoms to a health-care provider, and if they do, limitations of time and experience may hinder a comprehensive evaluation [7]. In addition to pain, an affected woman may experience embarrassment, shame, guilt, loss of self-esteem, frustration, depression, and anxiety related to her symptoms . It is not unusual for a woman with dyspareunia to have seen several health-care providers in an effort to evaluate and treat her condition [8]. It is important that the clinician promotes openness, comfort, trust, and confidence in the interaction with the patient. Assuring privacy and confidentiality is essential when conducting the medical interview. Although some patients may want their sexual partner present, this may also inhibit the patient from disclosing pertinent aspects of her medical or social history. Sensitivity to the patient’s own initial preference is paramount in maintaining rapport. A partner may always be brought in subsequently if needed at a follow-up session. An overly intrusive partner can often be successfully managed and yet not offended.
Displaying understanding and empathy when appropriate and repeating the information back to the patient for confirmation further help to establish a positive interaction. Frequently, a patient will become emotional or there may be moments of silence, which can be cathartic for the patient. If there is not enough time to focus on the patient’s concerns during a single visit, the patient should be reassured of the importance of her problem and scheduled for a follow-up visit to address the issue of sexual pain alone.
25.2.1.1 Medical History
After a chief complaint of painful intercourse is established, a history of the present illness should be obtained. Asking open-ended questions allows the patient to describe her experience of the condition. Encouraging the patient to give as much detailed information as possible and following a sequential timeline of her disease progression may facilitate this process. In regard to sexual pain, it is essential to determine timing, character, alleviating and aggravating factors, as well as associated symptoms.
The clinician should determine if the dyspareunia has been present since first attempt at intercourse (primary) or if the pain started after a period of pain-free intercourse (secondary). It is important to ask about first tampon use and experience with speculum examinations, as this may aid diagnosis. In cases of primary dyspareunia, it is more important to explore for a potential history of physical, sexual, and emotional abuse, as well as severe anxiety. If secondary, it is critical to ascertain whether or not the problem is partner-specific. In cases that are partner-specific, the following considerations should be explored: inadequate sexual technique, poor communication, incompatible sexual script, or no physical attraction. The provider may screen for severe difficulties in the couple’s relationship through inquiry with a reassuring, “No one’s relationship is perfect; are there any particularly difficult issues that exist at this time?” Monitor the degree of acrimony when the patient describes her complaints. For example, is the anger, hurt, or sadness a causative factor, or are these mild emotional frustrations of daily life? In practice, most providers lack the time for a thorough evaluation of all relationship issues, even if the partner joins the patient for the office visit. The goal is to pursue the diagnostic process sufficiently to determine if a referral for collaborative care with a sex or physical therapist is needed and/or identify an organic cause that may respond to a first-line treatment [9–11].
In a focused review, symptoms such as vaginal discharge, vulvar itching, irregular vaginal bleeding, and vulvar tearing can differentiate causes of dyspareunia. Changes in libido, decreased vaginal lubrication, and menopausal symptoms such as hot flushes and night sweats should be discussed. Use and effectiveness of artificial lubricant should be assessed. Urinary symptoms such as frequency, urgency, incomplete emptying, and leakage should be elucidated. It is also important to ask about bowel symptoms, including chronic constipation and rectal fissures.
After an accurate chief complaint, history of present illness, and review of symptoms have been established, additional information should be gathered to allow the clinician to narrow the differential diagnosis of dyspareunia. Depending on time, the sexual history can be expanded. It is of course important to obtain an obstetric and gynecologic history, as well as a past medical and surgical history. To the extent that time allows, additional elements of social history can be reviewed. Because certain medications may be associated with dyspareunia, it is essential to develop a timeline of medication use and compare this to the timeline of the patient’s sexual pain history. The clinician should specifically inquire about herbal supplements, as well as over-the-counter topical preparations. Finally, there is always value in asking the patient what she thinks the cause of her problem is, if she has not already been forthcoming with an opinion. Most importantly, the collection of a detailed and specific history must be balanced by the need to maintain rapport, as a follow-up visit can always be scheduled if more information is needed prior to initiating treatment.
Hormonal contraceptives, antidepressants, and antibiotics are medications that can very commonly contribute to dyspareunia. In one case-control study, women who used oral contraceptives were 9.3 times more likely to develop vestibulodynia than controls [12]. In addition, women who used low-dose ethinyl estradiol oral contraceptives were more likely to develop vestibulodynia [13]. Oral contraceptives decrease free circulating testosterone, which may be harmful to the androgen-dependent mucin-secreting glands and endothelium of the vulvar vestibule, leading to pain symptoms and decreased lubrication [14]. Psychotropic medications are often implicated in hypoactive sexual desire disorder (HSDD) and female sexual arousal disorder (FSAD) and may decrease vaginal lubrication and lead to dyspareunia [15]. Although antibiotics do not cause sexual pain directly, long-term exposure may predispose to chronic yeast infections, which may lead to dyspareunia.
It is also important to recognize that some aspects of a patient’s self-reported medical history may be inaccurate. For instance, a woman’s self-diagnosis of a vulvovaginal yeast infection is inaccurate about half the time. In addition, studies surprisingly show that physician-aided diagnosis of candidiasis is frequently incorrect in the absence of microscopy and culture [16].
25.2.1.2 Physical Examination
All women with dyspareunia should undergo a thorough physical examination (Table 25.2). While this exam focuses mainly on the urogenital system, examination of other areas, such as the oral mucosa, may be warranted based upon a detailed history. Visual examination of the vulva involves noting any signs of inflammation, lichenification, changes in pigmentation, loss of architecture, scarring, fissures, or ulceration. While erythema is often a nonspecific finding, redness at the ostia of the vestibular glands is suggestive of vestibulodynia. Vulvar skin abnormalities may indicate a dermatologic disease of the vulva and often warrant vulvar punch biopsy [17].
Table 25.2
Physical examination of dyspareunia
|
The vulva and vestibule |
|
–Visual examination |
|
–Vulvoscopy |
|
–Sensory exam with cotton swab |
|
–Consider biopsy |
|
The vagina and cervix |
|
–Visualization with speculum exam |
|
–Wet mount with pH and KOH prep |
|
–Vaginal culture |
|
The uterus, ovaries, and bladder |
|
–Bimanual exam to evaluate size, shape, and contour |
|
–Rectovaginal exam |
|
The pelvic floor |
|
–Levator ani muscle trigger points |
|
–Hypertonicity, weakness, tenderness |
|
–Pudendal nerve tenderness |
A moistened small cotton swab is used to perform a systematic sensory exam of the vulva. Women with sexual pain can exhibit allodynia, the perception of pain upon provocation by a normally non-painful stimulus, or hyperpathia, pain provoked by very light touch. Initially, the medial thigh, buttocks, and mons pubis are palpated to orient the patient to the examination. Then the labia majora, clitoral prepuce, perineum, and intralabial sulci should be palpated. Pain of the external vulva may indicate a vulvar dermatosis, vulvovaginal infection, or neuropathic process such as pudendal neuralgia. Attention is then turned to the labia minora, which are gently palpated first laterally and then medially to Hart’s line (the lateral boundary of the vulvar vestibule). Within the vulvar vestibule, the clinician palpates five specific locations: the ostia of the Skene’s glands (2 and 10 o’clock on the vulvar vestibule), the ostia of the Bartholin’s glands (4 and 8 o’clock on the vulvar vestibule), as well as the fossa navicularis (6 o’clock on the vulvar vestibule) (Fig. 25.1).
Fig. 25.1
A diagnostic and treatment algorithm for the treatment of dyspareunia and vulvar pain
Patients with vestibulodynia experience allodynia confined to the tissue of the vulvar vestibule, but have normal sensation of the external vulva, lateral to Hart’s line. If the pain is localized to the vestibule, it is important to determine if the pain affects the entire vestibule or just the posterior vestibule. Pain with palpation anywhere on the vestibular tissue indicates an intrinsic pathology within the mucosa of the vestibular endoderm. Pain confined only to the posterior vestibule suggests an extrinsic cause, most commonly related to the underlying musculature, such as hypertonic pelvic floor muscle dysfunction [18].
A speculum exam of the vagina should be performed next to evaluate vaginal pathology and discharge. An appropriately sized speculum, such as a pediatric Graves speculum, and avoidance of touching the vulvar vestibule allow for a more tolerable examination. The clinician should note evidence of vaginal atrophy, erythema, erosions, ulcerations, scarring, and abnormal discharge. A cotton swab should be used to collect vaginal discharge for pH testing, wet mount, and potassium hydroxide (KOH) prep. The saline slide is examined for normal squamous epithelial cells, parabasal cells, an increased number of white blood cells (WBCs), budding hyphae indicating yeast, trichomonads, clue cells, and normal flora such as lactobacilli. As microscopic examination frequently misses candidiasis and trichomoniasis, a culture obtained at the time of vaginal inspection should be sent for speciation and sensitivity.
A manual exam is then performed with one finger, attempting to avoid the vestibule. The urethra and bladder trigone are gently palpated. Intrinsic tenderness of the urethra may be suggestive of a urethral diverticulum or interstitial cystitis, while tenderness of the bladder may be suggestive of either interstitial cystitis or endometriosis. The trigger points of the levator ani muscles are then palpated for hypertonicity, weakness, and tenderness, which can be evidence of hypertonic pelvic floor muscle dysfunction (also known as levator ani syndrome and previously vaginismus).
The ischial spine is then located and the pudendal nerve palpated as it enters Alcock’s canal. Tenderness of the pudendal nerve is suggestive of pudendal neuralgia or pudendal nerve entrapment. Next, a bimanual examination is performed to assess the uterus and adnexa (ovaries and fallopian tubes). Abnormalities in the size, shape, or contour may be indicative of a leiomyoma or adenomyosis. Enlargement or tenderness of the adnexa may represent an ovarian mass, pelvic inflammatory disease, or endometriosis. A rectovaginal examination is then performed to assess the rectovaginal septum and the posterior cul-de-sac for findings suggestive of endometriosis. Women who have undergone prior vaginal surgery or perineal laceration repair may have traumatic neuromas, which can also be a source of significant pain.
25.2.1.3 Histology
If there are specific findings on vulvar colposcopic examination suggestive of dermatoses, intraepithelial neoplasia, or neoplasia, a vulvar or vaginal biopsy should be obtained. A 4 mm punch biopsy may be used to obtain a sample at the edge of any ulcerations or erosions, if present. All biopsies should be closed with one or two stitches of absorbable suture such as 4-0 Vicryl-rapide (Ethicon, Inc., Somerville, NJ). Ideally, biopsies should be sent to a pathologist who specializes in dermatologic disorders.
25.2.1.4 Serum Testing
If a hormonal cause of sexual pain is suspected or if the cause is unknown, blood work may be helpful in determining a diagnosis and planning treatment (Table 25.3). Blood should be obtained for evaluation of serum estradiol, total testosterone, free testosterone, albumin, sex hormone-binding globulin (SHBG), follicle-stimulating hormone, and prolactin. A decreased serum estradiol level is frequently found in women with atrophic vaginitis or a hormonally mediated provoked vestibulodynia. Elevated SHBG and decreased free testosterone and estradiol are frequently found in women with provoked vestibulodynia caused by hormonal contraceptives [19–22]. An elevated prolactin level in reproductive-aged women can cause anovulation, which leads to atrophic vaginitis. Herpes serology should be obtained in women with symptoms of generalized vulvar burning or tingling or in those with pain concentrated in the clitoris (clitorodynia).
Table 25.3
Serum testing
|
Estradiol |
|
Total testosterone |
|
Free testosterone |
|
Albumin |
|
Sex hormone-binding globulin (SHBG) |
|
Follicle-stimulating hormone (FSH) |
|
Prolactin |
25.2.1.5 Imaging and Diagnostic Procedures
Referrals for additional testing should be based on findings during the history and physical examination. Radiographic or ultrasonographic imaging may be appropriate to evaluate the uterus, ovaries, pelvis, or lower spine. Magnetic resonance imaging may help identify entrapment of the pudendal nerve.
Diagnostic laparoscopy may be necessary if there is significant evidence of endometriosis or utero-ovarian pathology that does not respond to initial conservative management. Colonoscopy, barium enema, and/or a CT scan with contrast may be used to rule out pathology of the lower gastrointestinal tract if deep thrusting dyspareunia is present along with dyschezia, hematochezia, or symptoms consistent with inflammatory bowel disease. Cystoscopy may be used to aid in the diagnosis of interstitial cystitis. An electromyelogram may be used to assess the tone and strength of the levator ani muscles when there is evidence of hypertonic pelvic floor dysfunction.
25.3 Management
25.3.1 Deep Dyspareunia
Dyspareunia may have a variety of causes. In order to determine the cause, the location of the pain must first be identified. Often, patients will describe pain with intercourse as deep and/or superficial. Deep dyspareunia may be attributed to a structural cause, including pathology of the genitourinary system, such as endometriosis, interstitial cystitis (painful bladder syndrome), or pelvic adhesions. Endometriosis is often difficult to manage, with treatment options ranging from a variety of hormonal preparations to surgical procedures including fulguration and excision of endometrial implants, as well as hysterectomy. Interstitial cystitis may be alleviated by dietary modification, although a referral to an urologist may be indicated for further workup or treatment. Treatment of pelvic adhesions is challenging, with management options involving both pain management as well as surgical lysis.
25.3.2 Vaginitis, Vulvovaginal Atrophy, and Vulvar Dermatoses
Pain with intercourse may occur with vaginal infection or cervicitis, vaginal atrophy, or vaginal scarring, such as that seen with intravaginal lichen planus. Vaginal infections such gonorrhea, chlamydia, and trichomonas should be treated per CDC guidelines [23]. Generally, treatment of bacterial vaginosis responds to a 5- to 7-day course of metronidazole, and uncomplicated vulvovaginal candidiasis is successfully treated using either a topical or oral azole medication. It should be noted that in the experience of the authors, recurrent bacterial vaginosis does not cause chronic dyspareunia.
Local estradiol preparations are the treatment of choice for vulvovaginal atrophy . These are available in many forms, including creams, tablets, and rings. A small amount of estradiol cream or gel applied to the vestibule may be necessary, in addition to vaginal or vulvar application, in cases of dyspareunia. Desquamative inflammatory vaginitis (DIV) is a poorly understood clinical condition involving diffuse exudative inflammation of the vagina leading to a profuse purulent discharge and dyspareunia. Although there are no controlled studies to inform management, intravaginal clindamycin and intravaginal hydrocortisone may alleviate symptoms [24]. Vulvar dermatoses , such as lichen planus and lichen sclerosus, are typically treated with a high-potency topical steroid, such as clobetasol [25].
25.3.3 Vulvodynia
Vulvar pai n , which is usually more superficial, should be further characterized as generalized vulvar pain or specific pain isolated to the vulvar vestibule. Generalized vulvar pain may be related to an autoimmune dermatologic vulvar condition, such as lichen sclerosus, or may be a result of decreased estrogen levels, such as in vulvar atrophy. Generalized vulvar pain may also have a neurologic cause such as pudendal neuralgia, an infectious cause such as herpes simplex virus, or a neoplastic cause such as vulvar intraepithelial neoplasia. In the absence of defined neurologic, infectious, or neoplastic causes, vulvar pain is referred to as vulvodynia.
The term vulvar vestibulitis is often used in the literature to describe pain isolated to the vulvar vestibule; however, this condition may be more accurately called “provoked vestibulodynia .” Emerging research supports possible hormonal, inflammatory, myofascial, and neurologic causes for provoked vestibulodynia [26]. A diagnostic and treatment algorithm for dyspareunia and vulvar pain was recently published and provides a systematic approach to management of women suffering from these symptoms. Figure 25.1 is an updated version of this algorithm.
Sexual pain due to hormonal causes includes vulvovaginal atrophy and hormonally mediated provoked vestibulodynia . The symptoms are often due to a decrease in estrogen and testosterone levels as a result of physiologic changes related to menopause or breastfeeding or due to the effects of a medication, such as combined oral contraceptives. Studies have shown that oral contraceptives may lower pain thresholds in the vestibular region and causes changes to the vaginal epithelium consistent with vulvovaginal atrophy [21, 22]. If oral contraceptive use is the main risk factor, the offending medication should be discontinued and alternative contraceptive methods may be considered, such as nonhormonal and progesterone-only options. In a non-placebo-controlled study , Burrows and Goldstein showed that a cream that combined estradiol 0.01 % and testosterone 0.1 % reduced visual analogue pain scores from 7.5 to 2.0 in 50 consecutive women who had developed provoked vestibulodynia from combined oral contraceptive pills [19]. In addition, an oral medication, ospemifene, was recently approved by the FDA for treatment of dyspareunia in postmenopausal women secondary to vulvovaginal atrophy [26].
Some research suggests a possible inflammatory cause of vestibulodynia. This may be the case in women with a history of chronic vulvovaginal infection or exposure-related sensitivities or allergic reactions in this area. To support this theory, Foster et al. [27] found that women with vestibulodynia exhibited increased levels of tumor necrosis factor beta and interleukin-1 alpha, which are inflammatory proteins. Several genetic defects have been identified that cause increased inflammation and increased susceptibility to vaginal infections [28]. Treatments using montelukast, submucosal betamethasone injections, and vestibular interferon injections have been tried with some success [29–31].
Several researchers have found that women with provoked vestibulodynia have up to ten times the density of c-afferent nociceptors nerve endings in their vestibular mucosa than normal women [32–34]. In addition, Bornstein et al. [35] found increased numbers of mast cells in vestibular tissue of women with vulvodynia. Persistently activated mast cells release nerve growth factor and heparinase that allow newly sprouted nerve endings to invade the superficial mucosa of the vestibule [36]. Topical lidocaine ointment has been used to treat “neuroproliferative vestibulodynia.” Lidocaine may be applied using a 2 % jelly or 5 % ointment as needed prior to intercourse. In addition, long-term use of overnight topical lidocaine 5 % has been shown to significantly decrease pain with sexual activity, although long-term follow-up is not available [37].
Other topical medications have been investigated for provoked vestibulodynia including topical gabapentin, amitriptyline, and capsaicin. A retrospective, non-blinded, non-placebo-controlled study performed by Boardman et al. [38] revealed that topical gabapentin is an effective treatment for women with vulvodynia. Participants with both generalized (37 %) and localized (63 %) vulvodynia were treated with 2–6 % gabapentin for at least 8 weeks. The average pain score decreased 4.77 points, from 7.26 to 2.49 on a ten-point pain scale (mean pain score among the 35 evaluable women was significantly reduced from 7.26 to 2.49). Approximately 80 % of participants experienced at least a 50 % reduction in their pain. Furthermore, sexual function improved in the majority of participants, and all participants who had reported decreased participation in intercourse prior to treatment due to pain reported increased intercourse frequency after treatment [38, 39].
Pagano and Wong [40] performed a prospective study using topical amitriptyline 2 % cream that included 150 patients with provoked vestibulodynia and dyspareunia. One hundred and two participants exhibited purely provoked vestibulodynia, and 48 participants demonstrated both provoked and unprovoked vestibulodynia. Participants were encouraged to apply a pea-size amount of amitriptyline cream to the vulvar vestibule twice daily for 3 months. Of the 102 participants with purely provoked vestibulodynia, 84 (56 %) responded to the treatment (25 exhibited slight yet appreciable improvement, 44 exhibited moderate improvement, and 15 exhibited an excellent response defined as completely pain-free intercourse). The response rate was similar in the group of participants who experienced both provoked and unprovoked vestibulodynia; 48 % of them exhibited a positive response to treatment [40]. Lastly, in a retrospective chart review, topical capsaicin 0.025 % applied 20 min daily for 12 weeks decreased pain scores in patients with vulvodynia, but its use was limited by local irritation [38, 39].
In the past, oral medications have also been used for the treatment of vulvodynia and provoked vestibulodynia. Classes of oral medications used include tricyclic antidepressants (TCAs) (amitriptyline, desipramine), selective norepinephrine reuptake inhibitors (venlafaxine, duloxetine), and anticonvulsants (gabapentin, lamotrigine). Leo and Dewani [41] performed a literature review regarding the effectiveness of oral antidepressant medications in treating vulvodynia. The research included two randomized controlled trials, one quasi-experimental trial, seven nonexperimental studies, and three case reports; the majority of the 13 studies are TCA treatment. The authors concluded that there was a lack of sufficient evidence to support the use of antidepressant medication for treatment of vulvodynia [41].
In women who fail conservative treatments, vulvar vestibulectomy with vaginal advancement can be performed to remove the abnormal vestibular mucosa [42]. In 1983, Woodruff and Parmley were the first authors to describe vulvar vestibulectomy. Their procedure consisted of the excision of a semicircular segment of perineal skin, the mucosa of the posterior vulvar vestibule, and the posterior hymeneal ring. Three centimeters of the vaginal mucosa was then undermined and approximated to the perineum. Several variations of the procedure have been described to help decrease complications, such as dehiscence of the vaginal advancement flap, as well as to improve operative success. A complete vulvar vestibulectomy includes the excision of the mucosa of the entire vulvar vestibule including the mucosa adjacent to the urethra, while a modified vestibulectomy limits excision of the mucosa to the posterior vestibule [43].
In 2010, Tommola and colleagues did a systematic review of success and complication rates of the several variations of vulvar vestibulectomy and concluded, “There is no straightforward recommendation of the best technique. Certainly the surgeon’s experience plays a critical role. As with all surgeries, the procedure should be extensive enough to remove all painful areas but also to avoid unnecessary risks.” They examined 33 studies that addressed improvement in dyspareunia as a measure of surgical success for patients who had a partial or complete vulvar vestibulectomy. Seventeen of the 33 of those studies based improvement in dyspareunia solely on a patients’ self-report on improvement of dyspareunia, alleviation of symptoms, or reduction in pain. Overall, these studies reveal that operative treatment provided significant relief in 78.5 % of patients, some relief in 88.8 % of patients, and no relief in 12.2 %. In nine studies that reported improvement in sexual function as a measure of success, all nine studies reported significant improvement in sexual function following vestibulectomy [44].
25.3.4 Hypertonic Pelvic Floor Muscle Dysfunction
It has been long acknowledged that tight pelvic floor muscles can contribute to provoked vestibulodynia. The muscles that compose the “floor of the pelvis” (levator ani muscles: the pubococcygeus, puborectalis, and transverse perineal muscles), which come together at the inferior aspect of the vestibule, can become tight and tender. Tight levator ani muscles cause a constriction of the arterioles, which leads to a decrease in blood flow to the muscles and the mucosa of the vestibule [45]. Decreased blood flow results in less oxygen delivery, leading to an increase in lactic acid in these tissues. This buildup of lactic acid causes the sensations of burning, rawness, throbbing, aching, and soreness. In response, the capillaries in the vestibule dilate to facilitate more blood to the area, causing an erythematous appearance of the vestibular mucosa [46].
Women with hypertonic pelvic floor dysfunction typically feel burning, rawness, and soreness. These symptoms can occur only with penetration or may be constant (non-provoked). In addition, there can be a sensation of ripping, tearing, or “hitting a wall” upon penetration. It is very important to understand that vestibulodynia caused by tight pelvic floor muscles only affects the back part of vestibule at 4, 6, and 8 o’clock because that is where the muscles attach directly under the mucosa of the vestibule. As there are no robust muscles in the vestibule around the urethra, tight pelvic floor muscles do not typically cause pain around the top part of the vestibule. Women with hypertonic pelvic floor dysfunction often have urinary symptoms such as frequency, urgency, and the sensation of incomplete emptying of the bladder. For this reason, women with hypertonic pelvic floor muscles are frequently misdiagnosed with a urinary tract infection or interstitial cystitis [45]. In addition, constipation, hemorrhoids, and rectal fissures are common. Women with hypertonic pelvic floor muscles frequently have low back pain and/or hip pain.
Women with other types of vestibulodynia (inflammatory, hormonally mediated, neuroproliferative) frequently will develop hypertonic pelvic floor dysfunction. In addition, women with more generalized vulvodynia almost always have some degree of hypertonic pelvic floor muscle dysfunction. The goal of treatment of hypertonic pelvic floor dysfunction is to relax and lengthen the pelvic floor muscles. As such, the mainstay of treatment is transvaginal pelvic floor physical therapy by a skilled women’s health pelvic floor physical therapist [49]. Pelvic floor physical therapy can be augmented with biofeedback, vaginal dilators, home pelvic floor relaxation exercises, rectal or vaginal diazepam suppositories [47], oral muscle relaxants, trigger point injections, and botulinum toxin type A injections [48]. Pelvic floor physical therapists can be located using the following websites: www.womenshealthapta.org, www.hermanwallace.com, and www.isswsh.org.
25.4 Conclusion
Dyspareunia can be one of the most challenging complaints that providers encounter in the office setting. Ensuring adequate time and a comfortable setting to address a woman’s concerns is essential in order to obtain an accurate and thorough history. Understanding the broad differential diagnosis of painful intercourse guides history taking. Certain medications and medical conditions may contribute to female sexual dysfunction. A thorough, yet focused, pelvic examination is necessary to determine the cause of the sexual pain.
Identifying the location of the pain is the first step in determining the diagnosis. Although specific conditions may be associated with dyspareunia, sexual pain often falls into the category of vulvodynia or more specifically provoked vestibulodynia. Vulvodynia has been historically considered a “diagnosis of exclusion,” but with continued research and understanding of the condition, separate etiologies are becoming clear. Decreased estrogen and testosterone levels, as seen with oral contraceptive use or in menopause, may lead to sexual pain as well as other forms of female sexual dysfunction. Inflammatory and neurologic causes are being investigated with corresponding treatment options, including topical medications and vulvar vestibulectomy. Hypertonic pelvic floor muscle dysfunction may be a result, as well as a cause, of dyspareunia. This condition can be identified on physical examination, marked by pain in the posterior vestibule. Restoring blood flow and oxygen through relaxation of the pelvic floor muscles is the goal of therapy. Often, pelvic floor tightness and possible anxiety surrounding sexual intercourse must be addressed in addition to the primary cause of dyspareunia.
Sexual pain can significantly affect a woman’s well-being and quality of life. Dyspareunia should be explored and addressed, either in the current or a separate medical visit. Restoration of lasting and satisfying sexual function often requires a multidimensional understanding of all of the forces that contribute to the condition. Each clinician should carefully evaluate his or her own competence and interest in treating female sexual pain, so that regardless of the treatment modality, the patient receives optimal care. Referral to a mental health profession and utilization of adjunctive consultation through sex therapists, psychologists, and physical therapists may help to alleviate physician time limitations and provide multimodal care.
Commentary: Diagnosis and Management of Sexual Pain Disorder—Dyspareunia
Caroline F. Pukall3 and Emma Dargie3
(3)
Department of Psychology, Queen’s University, Kingston, ON, Canada
Dyspareunia remains a diagnosis with substantial discussion around causes and treatments. The recent modification of the fifth edition of the Diagnostic and Statistical Manual (DSM-5) diagnosis of dyspareunia to incorporate all genito-pelvic pain and penetration disorders into a single diagnosis has engendered significant debate in the community. Regardless, female genital pain remains a common condition that can be debilitating to the patient and a treatment challenge to the care team. In the preceding chapter, Krapf and Goldstein provide an overview of painful intercourse including etiologies, approach to the patient, and treatments focused on pharmacotherapy, surgery, and pelvic floor physical therapy. The chapter addresses both deep and more superficial dyspareunia, with an emphasis on how to more generally address these conditions in affected women.
In the following commentary, Pukall and Dargie also provide a perspective on genital pain, but dive more deeply into vulvodynia and even more specifically into provoked vestibulodynia (PVD). Complementing Krapf and Goldstein’s chapter, the commentary hews more closely to a holistic approach integrating psychotherapy with physical therapy, and surgical intervention when appropriate, in the approach to PVD. By merging cognitive behavioral therapy (CBT) to alter thoughts and behaviors associated with pelvic pain with pelvic floor physical therapy to mitigate muscle tension, control, and awareness, significant gains can be made. In the absence of improvement, a surgical approach may be favored. Regardless of how dyspareunia is addressed, it is made clear in the chapter and accompanying commentary that a multidisciplinary approach tailored to the individual is likely to result in the most significant treatment benefit.
The Editors
Commentary
Introduction
Genital pain is a highly prevalent condition, with estimates ranging from 14 to 34 % in younger women and from 6.5 to 45 % in older women [1]. Genital pain conditions can affect women in mixed-sex and same-sex relationships [2], and they can have a negative impact on psychological and sexual relationship function and overall quality of life [3]. One of the most common characteristics associated with genital pain is dyspareunia (i.e., painful vaginal penetration in sexual situations). Pelvic floor muscle dysfunction, most commonly in the form of poor control and increased muscle tension, is also typically associated with pain in the genital area [4, 5]. The combination of intense genital pain and pelvic floor muscle dysfunction can result in significant issues with tolerating vaginal penetration, sometimes rendering penetration impossible (i.e., vaginismus).
Diagnosis
The International Society for the Study of Vulvovaginal Disease (ISSVD) proposed two main categories of chronic genital pain: vulvar pain related to a specific disorder (e.g., dermatologic, inflammatory, infectious) and vulvodynia [6]. When a medical cause is known, treatment is tailored to the presenting issue. Those patients who present with medically unexplained chronic vulvar pain would likely be diagnosed with vulvodynia. This diagnosis also applies in cases in which a condition that was believed to result in vulvar pain (e.g., bacterial vaginosis) was successfully treated without pain resolution. The ISSVD further defines subtypes of vulvodynia based on information such as location and temporal pattern, which is essential for diagnosis and treatment planning.
According to the ISSVD, vulvodynia is characterized as idiopathic burning pain with two main symptom presentations: localized, which involves only a portion of the vulva such as the clitoris or vulvar vestibule, or generalized, which involves the entire vulva [6]. The pain can be further specified according to its temporal pattern (i.e., when it occurs). If the pain is provoked, it occurs in response to contact; if it is unprovoked, it occurs spontaneously (i.e., independent of contact). The pattern of pain may also be mixed if the patient has a combination of both provoked and unprovoked pain. Provoked pain may occur in response to sexual, nonsexual (e.g., gynecological examinations), or both types of activities. In addition, research on a highly prevalent condition known as provoked vestibulodynia (PVD)—characterized as localized provoked pain upon the vaginal vestibule—has indicated that pain onset may also be an important factor to consider. The issue of whether the pain has been present since the patient’s first episode of vaginal penetration (i.e., primary PVD) or after a period of pain-free activities (i.e., secondary PVD) can influence pain sensitivity [7] as well as treatment outcome [8].
When a patient reports experiencing dyspareunia or genital pain, a detailed pain history should follow [9]. Questions should cover, at a minimum, the following domains: pain location, descriptors, onset (e.g., gradual or sudden; primary or secondary), temporal pattern (e.g., when the pain occurs; how long the pain has been present), what factors change (increase or decrease) the pain, how severe is the pain (e.g., on a scale of 0–10), and any related symptoms (e.g., bladder pain). Furthermore, any previous treatment attempts and outcomes and the patient’s personal explanation of the pain should be queried. Additionally, the impact of the pain should be thoroughly assessed in various domains, such as sexual functioning, body image, relationship adjustment, and psychological distress. A brief medical history should be ascertained, followed by a referral to knowledgeable medical professional for a complete medical history taking (including other pain conditions) and comprehensive gynecological examination. The gynecological examination should include a standard investigation (e.g., vaginal and cervical cultures) for routine infections and other issues, a full evaluation of potential causes of genital pain (e.g., dermatologic conditions, fissures), and the cotton swab test. This test consists of the palpation of various vulvar areas with a cotton swab while the patient rates her pain intensity; it is essential for determining the precise location and severity of the pain. Given the presence of sensory abnormalities and the contribution of the pelvic floor muscle dysfunction in the maintenance of PVD, referral to a pelvic health physical therapist for an in-depth pelvic floor assessment is also recommended.
Throughout the assessment process, health-care professionals should take care to ensure that they validate the patient’s pain experience. In many cases, women with vulvodynia have been indirectly or directly told that their pain may not be “real” given the lack of physical findings. Sending such messages may contribute to increased psychological distress and other symptoms, leading to a sense of hopelessness and worsening of psychological health. Instead, providing education about chronic pain and its usual lack of physical findings, the vicious cycle of pain (see Fig. 25.2), and genital anatomy can be helpful. Recommending appropriate resources to patients, such as the National Vulvodynia Association website (www.nva.org), can allow patients to learn about their condition and feel less “alone” in coming to terms with their diagnosis.
Fig. 25.2
The vicious cycle of pain. Once the experience of pain is initiated and continues for a prolonged period of time, the pain begins to influence and is influenced by many different factors (e.g., muscular, psychological, sexual). The involvement of these different factors can lead to increased pain and distress and can explain pain maintenance in the absence of physical findings. This cycle can start at any point or at multiple points simultaneously.
Proposed Etiologies
Countless etiological theories of genital pain exist, ranging from biomedical to psychosocial. It is likely that different combinations of factors lead to similar symptoms of genital pain and that discovering those factors does not always hold the key to successful treatment. As such, spending significant amounts of energy trying to find the “cause” may not be worthwhile. Indeed, what may start as an acute pain directly linked to a cause (e.g., infection) may—over time—evolve into chronic unexplained pain due to the involvement of other factors (e.g., psychological distress, muscular responses, central nervous system dysregulation; Fig. 25.2).
Two factors have been consistently identified as risk factors for the development of chronic vulvar pain. The first of these is the use of oral contraceptives and potentially other hormonal methods of contraception. In 1994, Bazin and colleagues [10] first reported the association between oral contraceptives and PVD in a small case-control study. This study was followed by Sjoberg et al.’s [11] investigation indicating that women with PVD used oral contraceptives for a longer period of time than did non-affected women. Other researchers have reported a similar pattern of findings [12–14]. It is possible that the use of oral contraceptives may increase vestibular sensitivity to the point of rendering touch to the area painful (i.e., allodynic), as has been demonstrated via quantitative sensory testing [15] and validated measures of sexual function [16]. However, these results may depend on the dose and composition of the oral contraceptives, given that a recent study demonstrated no significant differences in self-reported or vulvar sensitivity thresholds in women who used a low-dose oral contraceptive [17]. It is important to note that having ever used oral contraceptives is not a necessary and sufficient factor for the development of PVD or related genital pain conditions; not all affected women have used oral contraceptives, and many women use these medications for various periods of time without ever developing genital pain problems. It is possible that vulvodynia may be triggered by the use of oral contraceptives in women with certain predisposing factors.
The second factor that is consistently linked to PVD is a history of recurrent vulvovaginal candidiasis (i.e., three or more yeast infections annually; Farmer et al. [20]). Estimates indicate a strikingly higher prevalence of such infections in women with PVD (42–90 %) [17, 18] than in control women (5–8 %) [19]. Indeed, the vestibular hypersensitivity characteristic of PVD may be caused by previous inflammation from prolonged/repeated vaginal yeast colonization. Farmer and colleagues [20] investigated whether repeated, localized exposure of the vulva to Candida albicans could lead to the development of chronic pain in mice. A subset of the mice that had been infected developed prolonged vulvar mechanical allodynia (i.e., painful response to touch) and hyperinnervation (i.e., an increase in the number of nerve fibers). This pattern echoes research on women with PVD, with evidence pointing to vestibular allodynia (see [21] for a review) and hyperinnervation [22–24], lending credence to the possibility that repeated yeast infections can render the vestibule hypersensitive in some affected women.
Other factors are likely involved in the etiology and maintenance of chronic vulvar pain, and these influences may be less evident at a local (vulvar) level. Research increasingly suggests that both peripheral (i.e., vulvar) and central (e.g., spinal, neural, psychological) factors are involved in the expression of chronic genital pain conditions (Fig. 25.2) [21]. Although just beginning to be studied, there appears to be evidence of heightened sensitivity to stimulation outside of the genital region [25, 26], indications of increased neural response to stimulation [27–29], and suggestions of an increased number of functional pain and other conditions (e.g., fibromyalgia, irritable bowel syndrome, depression) [30, 31] in women with vulvodynia. For some women, the pain may start locally and, over time, involve more central mechanisms. For other women, there may be a central dysregulation associated with having a chronic pain condition that, with repeated local (vulvar) injury, develops into a genital pain condition. Still others may develop the local and more generalized pain simultaneously.
Treatment
Treatment algorithms for vulvodynia exist [32]; however, most of the evidence for these algorithms is based on nonempirical sources (e.g., clinical experience, descriptive/observational studies, committee reports). Although highly important for informing research, the use of such algorithms may not accurately guide treatment. For example, oral medications (e.g., tricyclic antidepressants) are commonly recommended for pain control in vulvodynia, yet a recently published review [33] indicates that there is currently no empirical evidence for such practices. Looking at the evidence-based literature, three major treatment avenues have shown the most promise for PVD: psychological approaches, pelvic floor physical therapy, and surgical intervention. Oftentimes, the first line of treatment recommended within these three is either psychological or pelvic floor physical therapy; they are sometimes recommended concurrently. If either or both of these treatments do not result in pain reduction, then surgical intervention (i.e., vestibulectomy) is recommended. Indeed, many patients must try different combinations of treatments before satisfactory results occur.
Cognitive behavioral therapy (CBT) is often recommended for women with vulvodynia. Similar to approaches taken with other pain conditions, CBT typically targets specific cognitive, emotional, relational, and behavioral goals related to the pain experience. For PVD, psychoeducation would be the first step, with an emphasis on the patient viewing her pain in relation to her thoughts, feelings, and behaviors as well as the interactions among these factors. Maladaptive patterns would be identified, with steps taken to modify them; positive coping strategies (e.g., relaxation, mindfulness, distraction) would be utilized. The maintenance of therapeutic gains would also be a focus of treatment. CBT can be particularly useful when patients with vulvodynia report unwanted cognitions or behaviors, difficulties with emotions, and/or issues with sexual/relationship function [9]. CBT for PVD has been shown to be more effective than other forms of therapy [34] and equally as effective as surgery in both a prospective randomized study [35] and a randomized treatment outcome study [36].
Pelvic floor physical therapy (PFPT) has also been shown to effectively treat PVD. PFPT targets muscle tension, control, and awareness through a variety of techniques (e.g., education, exercises, manual therapy, biofeedback). In a retrospective PFPT study, Bergeron and colleagues [37] found that self-reported pain during intercourse and gynecological examinations was reduced from pre- to posttreatment; in addition, significant increases in intercourse frequency, sexual desire, and sexual arousal were reported. A prospective study [5, 38] demonstrated reductions in pain during vaginal palpation, self-reported pain during intercourse, and self-reported pain during a gynecological examination from pre- to posttreatment. Furthermore, significant improvements in sexual function and a normalization of pelvic floor function were reported at posttreatment.
Vestibulectomy typically involves the surgical removal of parts or all (which leads to more successful outcomes) of the vaginal mucosa surrounding the opening to a depth of 1–2 mm. The success rates for vestibulectomy range between 60 and 90 % [32], and removal of all parts of the vaginal mucosa is more successful than removal of just the painful parts. However, given its invasiveness, the lack of a standardized definition of “successful” outcome, the relative lack of randomized comparisons, and the insufficient data on complication rates, it is not typically recommended as a first-line treatment [32].
Conclusions
Vulvodynia is a highly prevalent and distressing condition. Although the specific etiology or etiologies may never be uncovered for each patient, effective treatments exist. Empirically validated therapeutic interventions that focus on reducing pain intensity, coping with the presence of pain, enhancing muscular control, and potentially reestablishing sexual feelings and connections can be beneficial for many women. Validation of the pain as a chronic pain condition and education about pain processes and correlates should be provided to all patients presenting with vulvodynia and related conditions. Given the numerous factors involved in vulvar pain, treatment should ideally involve a variety of health-care professionals that work together in a collaborative manner.
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