Diagnosis and Management of Sexual Pain Disorders: Dyspareunia

Abstract

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 to evaluation and treatment. Understanding the broad differential diagnosis of painful intercourse guides history taking. 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. Sexual pain can significantly affect a woman’s well-being and quality of life. Restoration of lasting and satisfying sexual function often requires a multidimensional understanding of the condition. Providers should feel empowered to treat this condition with the information reviewed in this chapter.

Appendices

Commentary: Diagnosis and Management of Sexual Pain Disorder—Dyspareunia

• Caroline F. Pukall Ph.D. &
• Emma Dargie M.Sc. 

1. Department of Psychology, Queen’s University, Kingston, ON, Canada

   Caroline F. Pukall Ph.D. & Emma Dargie M.Sc.

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

2.1 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).

2.2 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.

2.3 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.

2.4 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].

2.5 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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