Painful intercourse is significantly associated with evoked pain perception and cognitive aspects of pain in women with pelvic pain

Vulvodynia-It Is Time to Accept a New Understanding from a Neurobiological Perspective

Vulvodynia is one the most common causes of pain during sexual intercourse in premenopausal women. The burden of vulvodynia in a woman's life can be devastating due to its consequences in the couple's sexuality and intimacy, in activities of daily living, and psychological well-being. In recent decades, there has been considerable progress in the understanding of vulvar pain. The most significant change has been the differentiation of vulvar pain secondary to pathology or disease from vulvodynia. However, although it is currently proposed that vulvodynia should be considered as a primary chronic pain condition and, therefore, without an obvious identifiable cause, it is still believed that different inflammatory, genetic, hormonal, muscular factors, etc. may be involved in its development. Advances in pain neuroscience and the central sensitization paradigm have led to a new approach to vulvodynia from a neurobiological perspective. It is proposed that vulvodynia should be understood as complex pain without relevant nociception. Different clinical identifiers of vulvodynia are presented from a neurobiological and psychosocial perspective. In this case, strategies to modulate altered central pain processing is necessary, changing the patient's erroneous cognitions about their pain, and also reducing fear avoidance-behaviors and the disability of the patient.

How Might We Screen for Psychological Factors in People With Pelvic Pain? An e-Delphi Study

OBJECTIVE

Persistent pelvic pain (PPP) is a complex condition often influenced by psychological factors that can alter treatment outcomes. These factors are potentially modifiable; however, currently there is no instrument to screen for them. The purpose of this study was to determine: (1) which psychological factors should be screened in individuals with PPP, and (2) the most appropriate statements to represent these psychological factors.

METHODS

The study used a focus group design followed by an electronic-Delphi (e-Delphi) process. A focus group consisting of 8 experts was conducted to determine the relevant psychological factors to screen. These results informed round 1 of the e-Delphi process, consisting of a panel of 14 pain/pelvic pain experts. The e-Delphi process consisted of 3 rounds of online surveys and 2 teleconference discussions to establish consensus on the most appropriate statement to screen for each of the psychological factors.

RESULTS

The focus group identified 13 relevant psychological factors. During the e-Delphi process, relevant screening statements were assessed using a 100-point allocation system. Experts could reword and suggest new statements. Statements were assessed for consensus and stability and were eliminated as the rounds progressed if they met the exclusion criteria. At the termination of round 3, there were 15 statements remaining.

CONCLUSION

The final list of 15 statements will assist clinicians in screening for psychological factors and is an important step for clinicians in providing psychologically informed care to people with PPP. Future research should determine the psychometric properties of the statements to determine their clinical utility as a questionnaire.

IMPACT

This study has refined a list of statements to help screen for psychological factors in individuals with PPP. Developed robustly using an e-Delphi method, this list is an important first step forward for clinicians to provide psychologically informed care to these individuals.

Predictors of Mucosal and Muscle Pain in Vulvodynia: A Cross-Sectional Analysis From the National Vulvodynia Registry

Diagnostic criteria for provoked vestibulodynia (PVD) rely on mucosal pain in the vulvar vestibule, with less emphasis on pain from pelvic floor muscles. It is unknown how psychosocial variables associated with PVD are differentially associated with mucosal versus muscle pain. Analysis of data from the National Vulvodynia Registry (n = 202) revealed several factors associated with increased mucosal pain: pain duration (P = .043), the McGill sensory subscore (P = .0086) and the Gracely pain scale (P< .001). Increased mucosal pain was also associated with decreased arousal (P = .036). On the other hand, factors significantly associated with greater muscle pain included number of comorbid pain conditions (P = .001), decreased intercourse frequency post PVD onset (P = .02) and higher scores on the McGill sensory (P = .0001) and affective (P = .0002) subscores, the Gracely pain scale (P = .0012), and state anxiety (P < .001). Sexual function was also significantly impacted by high pelvic floor muscular pain, with lower scores for arousal (P = .046), orgasm (P = .0014) and satisfaction (P = .013), and higher pain (P = .01). Significant differences in the relationship between muscle and mucosal pain for pain duration (P = .005), McGill affective score (P = .001), orgasm (P = .049), change in intercourse frequency (P = .027), and state anxiety (P = .030) suggest the possibility of mucosal or muscle pain predominant PVD subtypes. PERSPECTIVE: Patients with higher pelvic floor muscle pain scores than mucosal pain scores may represent different subgroups or characteristics of patients with provoked vestibulodynia. This research highlights the importance of assessment of the pelvic floor muscles in addition to the cotton swab test of the vestibule.

Sexuality and mood changes in women with persistent pelvic girdle pain after childbirth: a case-control study

Background

Pelvic girdle pain is a common problem during pregnancy. For most women, the symptoms cease within the first 3–6 months of giving birth, but in some women the pain persists. In this study we investigate the sexuality and frequency of depressive symptoms in women with persistent pelvic girdle pain after childbirth and in healthy women.

Methods

We conducted a case–control study of women with persistent pelvic girdle pain after childbirth and a control group of healthy women. The frequency of depressive symptoms and sexuality were measured using the self-rating version of the Montgomery–Asberg Depression Rating Scale and the McCoy Female Sexuality Questionnaire.

Results

Forty-six women with persistent pelvic girdle pain and thirty-nine healthy women were enrolled. The frequency of depressive symptoms and the total score on female sexuality did not differ between the groups. However, pain during intercourse was more frequent (P < 0.001) in women with persistent pelvic girdle pain and caused them to avoid sexual intercourse frequently (P < 0.001). In multiple linear regression a higher frequency of depressive symptoms was reversely correlated with a lower score on female sexuality (β₌ − 0,41, p < 0,001 95% CI -0,6 - -0,22) This association remained after adjusting for obstetric variables and individual characteristics.

Conclusion

Depressive symptoms and female sexuality were similar between women with persistent pelvic girdle pain after childbirth and healthy controls. However, pain during intercourse and avoidance of sexual intercourse were more frequent among women with pelvic girdle pain.

"The Overactive Pelvic Floor (OPF) and Sexual Dysfunction" Part 1: Pathophysiology of OPF and Its Impact on the Sexual Response

INTRODUCTION

Overactive pelvic floor (OPF) muscles are defined as muscles that do not relax, or may even contract, when relaxation is needed, for example, during micturition or defecation. Conditions associated with OPF are multifactorial and include multiple possible etiologies and symptom complexes. The complex interplay between biological and psychosocial elements can lead to the persistence of OPF symptoms along with psychological and emotional distress.

OBJECTIVES

(1) To review and contextualize, from a pathophysiologic perspective, the evidence for OPF, (2) to provide an overview of common clinical presentations and comorbidities of OPF, and (3) to discuss the effect of OPF on sexual function in men and women.

METHODS

Review of the updated literature on the pathophysiology of OPF was carried out. OPF-associated conditions were overviewed, with special emphasis on the impact on sexual function in men and women.

RESULTS

Individuals with suspected OPF often present with a combination of gastrointestinal, gynecological, musculoskeletal, sexual, and urological comorbidities, mostly accompanied by psychoemotional distress. In both women and men, sexual function is significantly impaired by OPF and genitopelvic pain penetration disorders are often the primary manifestation of this condition. Women with OPF report less sexual desire, arousal, and satisfaction; more difficulty reaching orgasm; lower frequencies of intercourse; more negative attitudes toward sexuality; and more sexual distress than women without sexual pain. The most frequently reported sexual dysfunctions in men with OPF include erectile dysfunction, premature ejaculation, and ejaculatory pain.

CONCLUSION

The complex pathophysiology of OPF involving multisystemic comorbidities and psychosocial factors emphasize the importance of a biopsychosocial assessment for guiding effective and personalized management. Padoa A, McLean L, Morin M, et al. "The Overactive Pelvic Floor (OPF) and Sexual Dysfunction" Part 1: Pathophysiology of OPF and Its Impact on the Sexual Response. Sex Med 2021;9:64-75.

Vaginal postcoital injuries requiring surgical intervention: a case series and literature review

This case series describes clinical features and management of women who required surgical repair of vaginal injuries following consensual intercourse in our institution during the last decade. As a secondary aim, we reviewed the literature on the topic. We searched our institution's database for procedures coded as "Suture of Vagina," excluding trauma not related to consensual sexual activity: between January 2008 and December 2017, 20 women underwent hemostatic suturing for vaginal injuries following intercourse. Mean age was 27.6 ± 12.5 (range, 16-63) years, 5 (25%) women were parous, 13 (65%) women used no contraception, and 1 (5%) used birth control pills. Three patients (15%) were postmenopausal. Eight injuries (40%) occurred following first-time intercourse, two (10%) occurred after intercourse with a new partner. Median time from bleeding onset to admission was 12 (range, 2-24) h. One patient (5%) was hemodynamically unstable and required treatment with packed cells. Median time from admission to surgery was 56 (range, 15-540) min. The laceration site was identified at the vaginal fornix in nine (45%) patients, at mid-vagina in four (20%), at the hymenal ring, or the posterior fourchette in six (30%). Tear of a longitudinal vaginal septum was identified in one patient (5%). To conclude, vaginal postcoital injuries are a rare occurrence, nevertheless they may involve significant blood loss and therefore require prompt evaluation and treatment. Once the patient is hemodynamically stable, psychosexual assessment and support should be offered to the patient and her partner.

Riding a Tiger: Maximizing Effects of Manual Therapies for Pelvic Pain

Manual therapy interventions are frequently used during the management of pelvic pain conditions. Pain relief after any intervention results from effects unrelated to the intervention, effects specific to the intervention, and effects of context in which the intervention is provided. Understanding these multiple mechanisms allows providers of manual therapy to maximize outcomes by deliberately harnessing each of these core elements of pain relief.

Dyspareunia and depressive symptoms are associated with impaired sexual functioning in women with endometriosis, whereas sexual functioning in their male partners is not affected

STUDY QUESTION

To what extent are endometriosis and its related physical and mental symptoms associated with the perceived level of sexual functioning in women and their male partners?

SUMMARY ANSWER

Dyspareunia and depressive symptoms are associated with impaired sexual functioning in women with endometriosis, whereas sexual functioning in their male partners is not affected.

WHAT IS KNOWN ALREADY

Women with endometriosis suffer from more dyspareunia, lower sexual functioning, and lower quality of life. In qualitative studies, partners of women with endometriosis report that endometriosis affected their quality of life and produced relational distress.

STUDY DESIGN SIZE, DURATION

In this cross-sectional study, sexual functioning in women with endometriosis (n = 83) and their partners (n = 74) was compared with sexual functioning in a control group of women attending the outpatient department for issues related to contraception (n = 40), and their partners (n = 26).

PARTICIPANTS/MATERIALS, SETTING, METHODS

Women and partners were recruited in the Maastricht University Medical Centre (MUMC) and the VieCuri Medical Centre Venlo between June 2011 and December 2012. All participants were asked to complete a set of online questionnaires.

MAIN RESULTS AND THE ROLE OF CHANCE

Response rates were 59.3% (83/140) for women with endometriosis and 52.3% (74/140) for their partners. Response rates in the control group were respectively 43.2% and 27.4% (41/95 and 27/95), of whom 40 women and 26 partners could be included in the study. Women with endometriosis as compared with the control group, reported significantly more frequent pain during intercourse (53% versus 15%, P < 0.001); higher levels of chronic pain (median VAS 2.0 cm versus 0.0 cm, P < 0.001); more impairment of sexual functioning (median Female Sexual Function Index 25.4 versus 30.6, P < 0.001); more impairment of quality of life (median Short Form-12 66.3 versus 87.2, P < 0.001); more pain catastrophizing (mean Pain Catastrophizing Scale 17.8 versus 8.5, P < 0.001), more depression and anxiety symptoms (median Hospital Anxiety and Depression Scale for depression 7 versus 4, P < 0.001 and for anxiety 4 versus 1, P < 0.001). Sexual functioning was comparable between male partners of women with endometriosis and male partners of the control group based on the International Index of Erectile Function. Logistic regression analyses showed that dyspareunia (OR 0.54; 95% CI 0.39-0.75) and depressive symptoms (OR 0.761; 95% CI 0.58-0.99) were independent and significant negative predictors for sexual functioning. Chronic pelvic pain (OR 0.53; 95% CI 0.35-0.81) and depressive symptoms (OR 0.65; 95% CI 0.44-0.96) were independent and significant negative predictors for quality of life.

LIMITATIONS, REASONS FOR CAUTION

Patient recruitment was performed in one tertiary care centre and to a lesser extent one general hospital, possibly leading to an over-representation of patients with more severe endometriosis. All participating women had a partner and are therefore 'survivors' in relationship terms. This may have led to an underestimation of the impact of endometriosis on sexual functioning.

WIDER IMPLICATIONS OF THE FINDINGS

It would be worthwhile to further explore the role of depressive symptoms in women with symptomatic endometriosis and to assess the effect of treatment of depressive symptoms on sexual functioning and quality of life. The fact that the partners did not report impaired sexual functioning could be a reassuring thought to women that might be discussed in the consulting room.

STUDY FUNDING/COMPETING INTERESTS

The study was funded by the MUMC. An unconditional research grant was given by the Dutch Society of Psychosomatic Obstetrics and Gynaecology (21 June 2011).

TRIAL REGISTRATION NUMBER

Not applicable.