Multimodal physical therapy versus topical lidocaine for provoked vestibulodynia: a multicenter, randomized trial.

BACKGROUND: Provoked vestibulodynia is the most common subtype of chronic vulvar pain. This highly prevalent and debilitating condition is characterized by acute recurrent pain located at the entry of the vagina in response to pressure application or attempted vaginal penetration. Although physical therapy is advocated as a first-line treatment for provoked vestibulodynia, evidence supporting its efficacy is scarce. OBJECTIVE: The purpose of this study was to establish the efficacy of multimodal physical therapy compared with topical lidocaine, a frequently used first-line treatment. STUDY DESIGN: We conducted a multicenter, parallel-group, randomized clinical trial in women diagnosed as having provoked vestibulodynia recruited from the community and 4 Canadian university hospitals. Women were randomly assigned (1:1) to receive either weekly sessions of physical therapy or overnight topical lidocaine (5% ointment) for 10 weeks. Randomization was stratified by center using random permuted blocks from a computer-generated list managed by an independent individual. Physical therapy entailed education, pelvic floor muscle exercises with biofeedback, manual therapy, and dilation. Assessments were conducted at baseline, posttreatment, and 6-month follow-up. Outcome assessors, investigators, and data analysts were masked to allocation. The primary outcome was pain intensity during intercourse evaluated with the numeric rating scale (0-10). Secondary outcomes included pain quality (McGill-Melzack Pain Questionnaire), sexual function (Female Sexual Function Index), sexual distress (Female Sexual Distress Scale), satisfaction (numeric rating scale of 0-10), and participants' impression of change (Patient Global Impression of Change). Intention-to-treat analyses were conducted using piecewise linear-growth models. RESULTS: Among 212 women who were recruited and randomized, 201 (95%) completed the posttreatment assessment and 195 (92%) completed the 6-month follow-up. Multimodal physical therapy was more effective than lidocaine for reducing pain intensity during intercourse (between-group pre-post slope difference, P<.001; mean group postdifference, 1.8; 95% confidence interval, 1.2-2.3), and results were maintained at 6-month follow-up (mean group difference, 1.8; 95% confidence interval, 1.2-2.5). The physical therapy group also performed better than the lidocaine group in all secondary outcomes (pain quality, sexual function, sexual distress, satisfaction, and participants' impression of change) at posttreatment and 6-month follow-up. Moreover, the changes observed after physical therapy were shown to be clinically meaningful. Regarding participants' impression of change, 79% of women in the physical therapy group reported being very much or much improved compared with 39% in the lidocaine group (P<.001). CONCLUSION: The findings provide strong evidence that physical therapy is effective for pain, sexual function, and sexual distress and support its recommendation as the first-line treatment of choice for provoked vestibulodynia.

Efficiency and Cost: E-Recruitment Is a Promising Method in Gynecological Trials.

BACKGROUND: Recruitment of participants is crucial to the success of any trial as it can have a major impact on study costs, the duration of the study itself, and, more critically, trial failure. Given that vulvodynia particularly affects young women, the use of social media and e-recruitment could prove efficient for enrollment. AIM: To compare the efficiency, effectiveness, and cost-effectiveness of three different recruitment methods. METHODS: The comparison data were collected as part of a bicentric randomized controlled trial evaluating the efficacy of physiotherapy in comparison with topical lidocaine in 212 women suffering from provoked vestibulodynia. The recruitment methods included: (i) conventional methods (eg, posters, leaflets, business cards, newspaper ads); (ii) health professional referrals, and (iii) e-recruitment (eg, Facebook ads and web initiatives). Women interested in participating were screened by telephone for eligibility criteria and were assessed by a gynecologist to confirm their diagnosis. Once included, structured interviews were undertaken to describe their baseline characteristics. MAIN OUTCOME MEASURES: The outcomes of this study were the recruitment efficiency (the number of patients screened/enrolled), recruitment effectiveness (the number of participants enrolled), cost-effectiveness (cost per enrolled participant), and retention rate, and baseline characteristics of participants were monitored for each method. RESULTS: The conventional methods (n = 101, 48%) were more effective as they allowed for greater enrollment of participants, followed by e-recruitment (n = 60, 28%) and health professional referrals (n = 33, 16%) (P < 0.007). Recruitment efficiency was found to be similar for e-recruitment and referrals (60/122 and 33/67, 49%, P = 0.055) but lower for conventional methods (101/314, 32%, P < 0.011). Nonsignificant differences were found between the three groups for baseline characteristics (P ≥ 0.189) and retention rate (91%, P ≥ 0.588). The average cost per enrolled participant was fairly similar for e-recruitment ($117) and conventional methods ($110) and lower for referrals ($60). CLINICAL IMPLICATIONS: Our results suggest that having a variety of recruitment methods is beneficial in promoting clinical trial recruitment without affecting participant characteristics and retention rates. STRENGTH & LIMITATIONS: Although recruitment methods were used concomitantly, this study gives an excellent insight into the advantages and limitations of recruitment methods owing to a large sample size. CONCLUSION: The study findings revealed that e-recruitment is a valuable recruitment method because of its comparable efficiency and cost-effectiveness to health professional referrals and conventional methods, respectively. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, number NCT01455350. Benoit-Piau J, Dumoulin C, Carroll MS, et al. Efficiency and Cost: E-Recruitment Is a Promising Method in Gynecological Trials. J Sex Med 2020;17:1304-1311.

Pelvic Floor Muscle Morphometry and Function in Women With Primary and Secondary Provoked Vestibulodynia.

INTRODUCTION: Provoked vestibulodynia (PVD) can be categorized as primary PVD affecting women from their first sexual intercourse or secondary PVD, which appears after a period of pain-free intercourse. There is growing evidence that these subgroups may be distinct entities presenting different pathophysiological mechanisms. Although there are documented pelvic floor muscle alterations in provoked vestibulodynia, no study has yet evaluated whether the pelvic floor muscle morphometry or function differed between women with primary and secondary provoked vestibulodynia. AIM: To assess and compare pelvic floor muscle morphometry and function in women with primary and secondary provoked vestibulodynia. METHODS: A total of 212 women with provoked vestibulodynia (primary = 75 and secondary = 137) participated in the study after completing a gynecologic exam to confirm their diagnosis. MAIN OUTCOME MEASURE: Pelvic floor muscle morphometry was evaluated at rest and during maximal contraction using 3D/4D transperineal ultrasound and pelvic floor muscle function (tone, strength, speed of contraction, endurance) was assessed with a dynamometric speculum. RESULTS: Pelvic floor muscle morphometry at rest and during contraction was not statistically different between women with primary and secondary provoked vestibulodynia (P > .327 adjusted for the duration of symptoms; P > .137 unadjusted t-tests). Regarding pelvic floor muscle function assessed with the dynamometric speculum, no differences were found in tone, strength, speed of contraction, endurance between the 2 groups (P > .144 adjusted for duration of symptoms; P > .118 unadjusted t-tests). CLINICAL IMPLICATIONS: Women with primary and secondary PVD do not differ on pelvic floor muscle morphometric or dynamometric characteristics, suggesting that physical therapy modalities should be offered to both subgroups of PVD. STRENGTHS & LIMITATIONS: The current study used a large and mixed clinical and community sample providing more representative findings. Moreover, the analyses were adjusted for relevant variables such as duration of symptoms. Although the inclusion of nulliparous women below 45 years of age ensured the homogeneity of the sample, it may limit the external validity. CONCLUSION: These findings suggest that primary and secondary subgroups of provoked vestibulodynia cannot be differentiated by morphometric or dynamometric characteristics. Pelvic floor muscles alterations in provoked vestibulodynia are therefore not influenced by the onset of the symptoms. Fontaine F, Dumoulin C, Bergeron S, et al. Pelvic floor muscle morphometry and function in women with primary and secondary provoked vestibulodynia. J Sex Med 2018;15:1149-1157.

Test-retest reliability of clitoral blood flow measurements using color Doppler ultrasonography at rest and after a pelvic floor contraction task in healthy adult women.

AIMS: Test-retest reliability assessment of the dorsal clitoral artery's blood flow at rest and after muscle activation has never been documented. If this outcome measure is to be used in conditions impeding vascularity, it requires a psychometric evaluation. The aim of this study was to assess the inter-session test-retest reliability of clitoral blood flow in healthy women using color Doppler ultrasonography at rest and after a pelvic floor muscle (PFM) contraction task. METHODS: Two assessment sessions were conducted using a clinical ultrasound system. Clitoral blood flow measurements were repeated at rest and after a PFM contraction task. Measurements of the peak systolic velocity (PSV), time-averaged maximum velocity (TAMX), end-diastolic velocity (EDV), pulsatility index (PI), and resistance index (RI) were taken. The test-retest reliability was assessed using paired t-test, intraclass correlation coefficient (ICC), and Bland-Altman plots. RESULTS: For reliability at rest, ICC values were 0.95 for PSV, 0.87 for TAMX, and 0.67 for both PI and RI. The variability between measurements, as per Bland-Altman plots, was small for PSV, TAMX, and RI and acceptable for PI. For reliability after the PFM contractions task, ICC values were 0.85 for PSV, 0.77 for TAMX, 0.79 for PI, and 0.81 for RI. The variability between measurements was small for PSV and RI and acceptable for TAMX and PI. EDV parameter did not perform as well in both conditions. CONCLUSIONS: Assessment of the clitoral blood flow with color Doppler ultrasound is reliable at rest and after a PFM contraction task.

Test-retest reliability of internal pudendal artery blood flow using color Doppler ultrasound in healthy women.

INTRODUCTION AND HYPOTHESIS: The internal pudendal artery (IPA) is one of the main arteries supplying the pelvic floor muscles (PFMs) and vulvo-vaginal tissues. Its assessment with color Doppler ultrasound has been documented previously, but the reliability of IPA measurements has never been assessed. This study evaluates the test-retest reliability of IPA blood flow parameters measured by color Doppler ultrasound under two conditions: at rest and after a PFM contraction task. METHODS: Twenty healthy women participated in this study. One observer performed two measurement sessions using a clinical ultrasound system with a curved-array probe on the participant's gluteal area. IPA measurements were repeated: at rest and after a PFM contraction task. Peak systolic velocity (PSV), time-averaged maximum velocity (TAMX), end-diastolic velocity (EDV), pulsatility index (PI), and resistance index (RI) were measured. Test-retest reliability was assessed using a paired t test, intraclass correlation coefficient (ICC), and Bland and Altman plots. RESULTS: There was no significant difference for all IPA blood flow measurements between the two repeated sessions. At rest, reliability was excellent for PSV and TAMX and the variability between measurements, as per Bland and Altman plots, was small. After PFM contractions, reliability was excellent for PSV and TAMX and fair to good for PI. The variability between measurements was small for PSV and acceptable for TAMX and PI. EDV and RI parameters did not perform as well. CONCLUSION: The assessment of IPA blood flow with color Doppler ultrasound to evaluate vascular change in women is reliable.

Heightened Pelvic Floor Muscle Tone and Altered Contractility in Women With Provoked Vestibulodynia.

BACKGROUND: Pelvic floor muscle (PFM) dysfunctions are reported to be involved in provoked vestibulodynia (PVD). Although heightened PFM tone has been suggested, the relative contribution of active and passive components of tone remains misunderstood. Likewise, alterations in PFM contractility have been scarcely studied. AIMS: To compare PFM tone, including the relative contribution of its active and passive components, and muscular contractility in women with PVD and asymptomatic controls. METHODS: Fifty-six asymptomatic women and 56 women with PVD participated in the study. The PVD diagnosis was confirmed by a gynecologist based on a standardized examination. OUTCOMES: PFM function was evaluated using a dynamometric speculum combined with surface electromyography (EMG). PFM general tone was evaluated in static conditions at different vaginal apertures and during repeated dynamic cyclic stretching. The active contribution of tone was characterized using the ratio between EMG in a static position and during stretching and the proportion of women presenting PFM activation during stretching. Contribution of the passive component was evaluated using resting forces, stiffness, and hysteresis in women sustaining a negligible EMG signal during stretching. PFM contractility, such as strength, speed of contraction, coordination, and endurance, also was assessed during voluntary isometric efforts. RESULTS: Greater PFM resting forces and stiffness were found in women with PVD compared with controls, indicating an increased general tone. An increased active component also was found in women with PVD because they presented a superior EMG ratio, and a larger proportion of them presented PFM activation during stretching. Higher passive properties also were found in women with PVD. Women with PVD also showed decreased strength, speed of contraction, coordination, and endurance compared with controls. CLINICAL IMPLICATIONS: Findings provide further evidence of the contribution of PFM alterations in the etiology of PVD. These alterations should be assessed to provide patient-centered targeted treatment options. STRENGTHS AND LIMITATIONS: The use of a validated tool investigating PFM alterations constitutes a strength of this study. However, the study design does not allow the determination of the sequence of events in which these muscle alterations occurred-before or after the onset of PVD. CONCLUSION: Findings support the involvement of active and passive components of PFM tone and an altered PFM contractility in women with PVD. Morin M, Binik YM, Bourbonnais D, et al. Heightened Pelvic Floor Muscle Tone and Altered Contractility in Women With Provoked Vestibulodynia. J Sex Med 2017;14:592-600.

HealthyDads.ca: What Do Men Want in a Website Designed to Promote Emotional Wellness and Healthy Behaviors During the Transition to Parenthood?

BACKGROUND: Up to 18% of men experience depression and/or anxiety during the transition to parenthood. Interventions designed specifically to promote the mental health of men during the transition to parenthood are scarce. Internet-delivered interventions may be acceptable and far-reaching in enhancing mental health, parenting knowledge, and healthy behaviors in expectant or new fathers. OBJECTIVE: To guide the development of Healthydads.ca, a website designed to enhance mental health and healthy behaviors in expectant fathers, a needs assessment was conducted to identify fathers' perspectives of barriers to seeking help for emotional wellness, informational needs, and factors affecting the decision to visit such a website. METHODS: One hundred and seventy-four men whose partners were expecting, or had recently given birth, in 3 Canadian provinces (Quebec, Ontario, and Alberta) completed a Web-based survey inquiring about information needs related to psychosocial aspects of the transition to parenthood, lifestyle behaviors, parenting, and factors associated with the decision to visit a father-focused website. RESULTS: Most men (155/174, 89.1%) reported accessing the Internet to obtain information on pregnancy and spent an average of 6.2 hours online per month. Seeking information about parenting on the Internet was reported by 67.2% (117/174) of men, with a mean of 4.4 hours per month of online searching. Top barriers to seeking help to improve emotional wellness during the perinatal period were: no time to seek help/assistance (130/174, 74.7%), lack of resources available in the health care system (126/174, 72.4%), financial costs associated with services (118/174, 67.8%), and feeling that one should be able to do it alone (113/174, 64.9%). Information needs that were rated highly included: parenting/infant care (52.9-81.6%), supporting (121/174, 69.5%) and improving (124/174, 71.3%) relationship with their partner, work-family balance (120/174, 69.0%), improving sleep (100/174, 57.5%), and managing stress (98/174, 56.3%). Perceiving the website as personally relevant (151/174, 86.8%), credible (141/174, 81.0%), effective (140/145, 80.5%), and having an easy navigation structure (141/174, 81.0%) were identified as important factors related to a first website visit. Providing useful (134/174, 77.0%) and easy to understand (158/174, 90.8%) information, which was also free of charge (156/174, 89.7%), were considered important for deciding to prolong a website visit. Providing the possibility to post questions to a health professional (133/174, 76.4%), adding new content regularly (119/174, 68.4%), and personal motivation (111/174, 63.8%) were factors identified that would encourage a revisit. CONCLUSIONS: Our findings demonstrate that there is substantial interest among expectant and new fathers for using Internet-delivered strategies to prepare for the transition to parenthood and support their mental health. Specific user and website features were identified to optimize the use of father-focused websites.

Provoked Vestibulodynia: Does Pain Intensity Correlate With Sexual Dysfunction and Dissatisfaction?

INTRODUCTION: Provoked vestibulodynia (PVD) is suspected to be the most frequent cause of vulvodynia in premenopausal women. Previous research has been inconclusive as to whether higher vulvovaginal pain ratings are associated with lower sexual function and satisfaction in women with PVD. Whether pain intensity correlates with sexual impairment is an important question given its implications for treatment recommendations. AIM: To examine the associations among self-reported and objective pain measurements, sexual function, and sexual satisfaction in a large combined clinical and community sample of premenopausal women diagnosed with PVD. METHODS: Ninety-eight women with PVD underwent a cotton-swab test, a vestibular friction pain measurement, and a vestibular pressure-pain threshold measurement. In addition to sociodemographics, participants completed measurements of pain, sexual function, and sexual satisfaction. MAIN OUTCOME MEASURES: Self-report measurements were the pain numerical rating scale (0-10), the McGill-Melzack Pain Questionnaire, the Female Sexual Function Index, and the Global Measure of Sexual Satisfaction. Objective measurements were pain during a cotton-swab test, pain during a vestibular friction procedure, and the vestibular pressure-pain threshold measurement. RESULTS: Age and relationship duration were significantly correlated with the Female Sexual Function Index total score (r = -0.31, P < .01; and r = -0.22, P < .05, respectively). When controlling for age, intercourse-related pain intensity, pain during the cotton-swab test, pain during vestibular friction, the vestibular pressure-pain threshold, and the McGill-Melzack Pain Questionnaire sensory and affective subscale scores were not significantly associated with sexual function and satisfaction in women with PVD. CONCLUSION: The findings show that in women with PVD, self-report and objective pain ratings are not associated with sexual function and satisfaction. The results support the biopsychosocial nature of PVD and underscore the importance of a patient-focused multidisciplinary treatment approach for PVD.

Can Fear, Pain, and Muscle Tension Discriminate Vaginismus from Dyspareunia/Provoked Vestibulodynia? Implications for the New DSM-5 Diagnosis of Genito-Pelvic Pain/Penetration Disorder.

Fear has been suggested as the crucial diagnostic variable that may distinguish vaginismus from dyspareunia. Unfortunately, this has not been systematically investigated. The primary purpose of this study, therefore, was to investigate whether fear as evaluated by subjective, behavioral, and psychophysiological measures could differentiate women with vaginismus from those with dyspareunia/provoked vestibulodynia (PVD) and controls. A second aim was to re-examine whether genital pain and pelvic floor muscle tension differed between vaginismus and dyspareunia/PVD sufferers. Fifty women with vaginismus, 50 women with dyspareunia/PVD, and 43 controls participated in an experimental session comprising a structured interview, pain sensitivity testing, a filmed gynecological examination, and several self-report measures. Results demonstrated that fear and vaginal muscle tension were significantly greater in the vaginismus group as compared to the dyspareunia/PVD and no-pain control groups. Moreover, behavioral measures of fear and vaginal muscle tension were found to discriminate the vaginismus group from the dyspareunia/PVD and no-pain control groups. Genital pain did not differ significantly between the vaginismus and dyspareunia/PVD groups; however, genital pain was found to discriminate both clinical groups from controls. Despite significant statistical differences on fear and vaginal muscle tension variables between women suffering from vaginismus and dyspareunia/PVD, a large overlap was observed between these conditions. These findings may explain the great difficulty health professionals experience in attempting to reliably differentiate vaginismus from dyspareunia/PVD. The implications of these data for the new DSM-5 diagnosis of Genito-Pelvic Pain/Penetration Disorder are discussed.

Morphometry of the pelvic floor muscles in women with and without provoked vestibulodynia using 4D ultrasound.

INTRODUCTION: It has been suggested that pelvic floor muscles (PFMs) play an important role in provoked vestibulodynia (PVD) pathophysiology. Controversy in determining their exact contribution may be explained by methodological limitations related to the PFM assessment tools, specifically the pain elicited by the measurement itself, which may trigger a PFM reaction and introduce a strong bias. AIM: The aim of this study was to compare PFM morphometry in women suffering from PVD to asymptomatic healthy control women using a pain-free methodology, transperineal four-dimensional (4D) ultrasound. METHODS: Fifty-one asymptomatic women and 49 women suffering from PVD were recruited. Diagnosis of PVD was confirmed by a gynecologist following a standardized examination. All the participants were nulliparous and had no other urogynecological conditions. The women were evaluated in a supine position at rest and during PFM maximal contraction. MAIN OUTCOME MEASURES: Transperineal 4D ultrasound, which consists of a probe applied on the surface of the perineum without any vaginal insertion, was used to assess PFM morphometry. Different parameters were assessed in sagittal and axial planes: anorectal angle, levator plate angle, displacement of the bladder neck, and levator hiatus area. The investigator analyzing the data was blinded to the clinical data. RESULTS: Women with PVD showed a significantly smaller levator hiatus area, a smaller anorectal angle, and a larger levator plate angle at rest compared with asymptomatic women, suggesting an increase in PFM tone. During PFM maximal contraction, smaller changes in levator hiatus area narrowing, displacement of the bladder neck, and changes of the anorectal and of the levator plate angles were found in women with PVD compared with controls, which may indicate poorer PFM strength and control. CONCLUSION: Using a reliable and pain-free methodology, this research provides sound evidence that women with PVD display differences in PFM morphometry suggesting increased tone and reduced strength.

Biopsychosocial predictors of postmenopausal dyspareunia: the role of steroid hormones, vulvovaginal atrophy, cognitive-emotional factors, and dyadic adjustment.

INTRODUCTION: Although dyspareunia experienced after menopause is widely attributed to declining estrogen levels and vulvovaginal atrophy, critical reviews of the literature have suggested that these factors are incomplete as explanatory mechanisms. Little is known about psychosocial factors that may also be implicated in postmenopausal dyspareunic pain. AIM: To determine the extent to which levels of estrogens and progesterone, vulvovaginal atrophy, cognitive-emotional factors, and dyadic adjustment are predictive of postmenopausal dyspareunic pain intensity. METHODS: A total of 182 postmenopausal dyspareunia sufferers underwent a structured interview concerning sociodemographic status as well as medical and pain histories, gynecological examination, cytological evaluation, a blood draw, and answered a series of self-report questionnaires. Given the large number of genital and pelvic pain variables measured, a principal components analysis was undertaken to identify a smaller number of components representing meaningful dimensions of genital and pelvic pain. MAIN OUTCOME MEASURES: Pain severity ratings during intercourse were obtained using the McGill Pain Questionnaire. Pain ratings were also obtained during gynecological assessment. Serum estrone, estradiol, and progesterone levels were measured via immunoassay. The Vaginal Atrophy Index and maturation value were used to determine vulvovaginal atrophy severity. Participants completed the Pain Catastrophizing Scale, State-Trait Anxiety Inventory, The Beck Depression Inventory-II, and Dyadic Adjustment Scale. RESULTS: Hormone levels were not found to be consistent predictors of pain severity. Maturation value and cognitive-emotional variables (e.g., catastrophization, depression, anxiety) were significant predictors of vestibular pain, which affected over 90% of our sample. Relationship adjustment variables were inversely associated with pain severity within several genital locations. CONCLUSIONS: Results suggest that the traditional hypoestrogen and vulvovaginal atrophy conceptualization of postmenopausal dyspareunia is an insufficient explanatory model, and that pain is also influenced by cognitive, affective, and dyadic factors.

Challenging atrophied perspectives on postmenopausal dyspareunia: a systematic description and synthesis of clinical pain characteristics.

This study investigated the clinical attributes of postmenopausal dyspareunia. The authors obtained a systematic description of pain symptomatology from 182 postmenopausal dyspareunia sufferers using a structured interview, quantitative sensory testing, a standardized pain measure, and gynecological examination. The authors conducted a cluster analysis to examine whether sufferers could be categorized using clinical pain and gynecological factors. The authors delineated 6 subgroups, each exhibiting distinct combinations of pain and gynecological characteristics. The results support the hypothesis that, similarly to premenopausal dyspareunia, postmenopausal dyspareunia is a heterogeneous condition.

Use of pelvic floor ultrasound to assess pelvic floor muscle function in Urological Chronic Pelvic Pain Syndrome in men.

INTRODUCTION: An important cause or maintaining factor for pain in Urological Chronic Pelvic Pain Syndrome (UCPPS) may be pelvic floor muscle (PFM) dysfunction, which may also be implicated in sexual dysfunction and influenced by psychosocial factors. Pelvic floor ultrasound is a noninvasive, reliable, and relatively simple method to assess PFM morphology and function and can be assessed by the anorectal angle (ARA) and levator plate angle (LPA). AIMS: The aim of the present study was to examine PFM morphology in men with UCPPS as compared with controls and to examine the correlation with pain and psychosocial measures. METHODS: Our participants were 24 men with UCPPS and 26 controls. A GE Voluson E8 ultrasound probe was placed on the perineum, and three-dimensional images were taken at rest and during PFM contraction. MAIN OUTCOME MEASURES: The main outcomes were ARA and LPA at rest and contraction. Participants also completed the National Institute of Health (NIH) Chronic Prostatitis Symptom Index, Male Sexual Health Questionnaire, State Anxiety Inventory, and Pain Catastrophizing Scale. RESULTS: Men with UCPPS had more acute ARAs than controls both at rest and during contraction. The two groups did not differ in LPA at rest; however, men with UCPPS had significantly more acute angles during contraction and LP excursion. Acute ARAs were positively correlated with greater pain report and sexual dysfunction. Anxiety was correlated with more acute ARAs and more obtuse LPAs. CONCLUSIONS: Three implications can be drawn from the findings. First, ARA at rest and during contraction as well as LP angle during contraction and LPA excursion separates men with UCPPS from controls. Second, ARA at rest and during contraction was correlated with pain and sexual dysfunction, while LPA at rest was related to anxiety. Third, pelvic floor ultrasound has the potential to be a useful and objective method of assessing PFM morphology in UCPPS.

Attributions about pain as predictors of psychological symptomatology, sexual function, and dyadic adjustment in women with vestibulodynia.

The present study examined whether attributions for vulvo-vaginal pain predicted pain intensity, sexual function, as well as psychological and dyadic adjustment in women with vestibulodynia. Women with vestibulodynia (N = 77) completed measures of attributions, pain, psychological distress, sexual functioning, and dyadic adjustment. They also took part in a structured interview and a gynaecological examination for diagnostic purposes. Attributions are represented by: (1) internality (personal responsibility) or externality (cause lies in an external situation); (2) globality (entire life affected by the problem) or specificity (problem affecting only a specific situation); (3) stability (problem will still remain in the future) or instability (weak probability that the problem will be maintained with time); and (4) partner responsibility (partner responsible or not for the problem). Results indicated that attributions were not significantly correlated with pain outcomes. However, after controlling for pain intensity and relationship duration, internal attributions predicted higher dyadic adjustment, both global and stable attributions predicted lower dyadic adjustment and higher psychological distress, whereas global attributions also predicted increased sexual impairment. Findings suggest that cognitive factors, such as attributions, may be related to psychological distress, sexual functioning, and dyadic adjustment in women with vestibulodynia. Results also highlight the importance of adhering to a biopsychosocial perspective focusing on pain reduction, sexual rehabilitation, and relationship enhancement in the treatment of dyspareunia.

History of sexual and physical abuse in women with dyspareunia: association with pain, psychosocial adjustment, and sexual functioning.

AIM: Dyspareunia is a women's sexual health problem that still often goes undiagnosed despite its high prevalence and its detrimental impact on sexual, relationship, and psychological adjustment. Although sexual and physical abuse may constitute risk factors for the development of dyspareunia, the effects of past abuse on current pain and associated sexual and psychosocial impairments have never been examined. Thus, the aim of this study is to determine the relation between a history of sexual and physical abuse and a series of pain, psychological, dyadic, and sexual functioning variables in a sample of women with dyspareunia. METHODS: A hundred and fifty-one women took part in the study via health professional referrals and advertisements in local newspapers. Each participant underwent a standardized gynecological examination and a structured interview in order to confirm the diagnosis of dyspareunia. They also completed self-report questionnaires investigating past sexual and physical abuse, in addition to current pain, psychosocial adjustment, and sexual functioning. Dependent measures included: (i) The Brief Symptom Inventory; (ii) the Sexual History Form; and (iii) the Locke-Wallace Marital Adjustment Scale. Pain was assessed via the McGill Pain Questionnaire and a visual analogue scale. RESULTS: Results revealed that a history of sexual abuse involving penetration was associated with poorer psychological adjustment and sexual functioning. Additionally, findings showed that women who perceived a link between their dyspareunia and their past sexual abuse reported worse sexual functioning than those who did not. Finally, the experience of sexual abuse was not associated with pain intensity and physical abuse was not associated with any of the outcome measures. CONCLUSIONS: Findings suggest that the presence of a sexual abuse history in women with dyspareunia is associated with increased psychological distress and sexual impairment, although there is no relation between a history of physical abuse and these outcomes.

Sleep problems and depressed mood negatively impact health-related quality of life during pregnancy.

The objectives of this study were to evaluate and identify determinants of health related quality of life (HRQoL) during pregnancy. Pregnant women (n = 245) completed questionnaires measuring: HRQoL (Short Form Health Survey SF-36), life stress, social support, sleep, and depressed mood in the third trimester. Demographics and medical variables were also collected. Compared to Canadian normative data, our sample scored significantly poorer on the following HRQoL domains: physical functioning, role limitations due to physical health problems, bodily pain, vitality, and social functioning. Multivariate linear regressions were used to model each of the SF-36 subscales. Experiencing sleep problems emerged as a significant determinant of poorer HRQoL in all domains, with the exception of emotional role. Higher depressed mood scores was independently associated with lower HRQoL in six of the eight domains, including bodily pain, general health, vitality, social functioning, emotional role, and mental health. Greater pregnancy-related anxiety was independently associated with lower scores on physical functioning and role limitations due to physical health problems. Women experience lower HRQoL during pregnancy, particularly in the physical domains. The importance of identifying and managing modifiable determinants early in pregnancy to enhance maternal health status is discussed.

Persistent genital and pelvic pain after childbirth.

INTRODUCTION: Although genital pain and pelvic pain are common and well-documented problems in the early postpartum period, little is known about their course. The few published studies of such pain beyond 1 year postpartum have focused primarily on the perineum and have not assessed pain onset. AIM: To investigate the prevalence and characteristics of all types of genital and pelvic pain in the second year postpartum, and to explore risk factors for their persistence. METHODS: Over a 6-month period, a questionnaire on genital/pelvic pain, sociodemographic and childbirth variables, breastfeeding, and chronic pain history was mailed to patients of the collaborating obstetrician at 12 months postpartum. MAIN OUTCOME MEASURES: The prevalence, characteristics, and correlates of persistent genital/pelvic pain with postpartum onset. RESULTS: Almost half of the 114 participants (82% response rate; M = 14 months postpartum) reported a current (18%) or resolved (26%) episode of genital or pelvic pain lasting 3 or more months. Just under one in 10 (9%) mothers continued to experience pain that had begun after they last gave birth. This pain was described at various locations (e.g., vaginal opening and pelvic area), as moderate in intensity and unpleasantness, and most often as burning, cutting, or radiating. Although it was triggered by both sexual and nonsexual activities, none of the mothers affected were receiving treatment. Univariate analyses revealed that only past diagnosis with a nongenital chronic pain condition (e.g., migraine headache) was significantly correlated with (i) any history of chronic genital/pelvic pain or (ii) the persistence of pregnancy- or postpartum-onset genital or pelvic pain. CONCLUSIONS: Postpartum genital and pelvic pain persists for longer than a year for a significant percentage of mothers. Women with a history of other chronic pain appear to be particularly vulnerable to developing persistent genital or pelvic pain.

Pelvic floor muscle training as a treatment for genitourinary syndrome of menopause: A single-arm feasibility study.

OBJECTIVES: Treatments for genitourinary syndrome of menopause (GSM) may not be suitable for all women, may not be completely effective, and may cause adverse effects. Therefore, there is a need to explore new treatment approaches. The objectives were to evaluate the feasibility of using a pelvic floor muscle training (PFMT) program in postmenopausal women with GSM, and to investigate its effect on symptoms, signs, activities of daily living (ADL), quality of life (QoL) and sexual function. STUDY DESIGN: Postmenopausal women with GSM participated in a single-arm feasibility study embedded in a randomized controlled trial (RCT) on PFMT for urinary incontinence. This substudy was composed of two pre-intervention evaluations, a 12-week PFMT program and a post-intervention evaluation. MAIN OUTCOME MEASURES: Feasibility was defined as study completion and participation in physiotherapy sessions and in-home exercises. The effects of the PFMT program were assessed by measuring GSM symptoms ('Most Bothersome Symptom' approach, ICIQ-UI SF), GSM signs (Vaginal Health assessment scale), GSM's impact on ADL (Atrophy Symptom questionnaire), QoL and sexual function (ICIQ-VS, ICIQ-FLUTSsex) and leakage episodes. RESULTS: Thirty-two women participated. The study completion rate was high (91%), as was participation in treatment sessions (96%) and in-home exercises (95%). Post-intervention, there were significant reductions in GSM symptoms and signs (p < 0.01) as well as in its impacts on ADL, QoL and sexual function (p < 0.05). CONCLUSIONS: A study including a PFMT program is feasible, and the outcomes indicate PFMT to be an effective treatment approach for postmenopausal women with GSM and urinary incontinence. This intervention should be assessed through a RCT.

Surgical and behavioral treatments for vestibulodynia: two-and-one-half year follow-up and predictors of outcome.

OBJECTIVE: To estimate whether treatment gains for provoked vestibulodynia participants randomly assigned to vestibulectomy, biofeedback, and cognitive-behavioral therapy in a previous study would be maintained from the last assessment-a 6-month follow-up-to the present 2.5-year follow-up. Although all three treatments yielded significant improvements at 6-month follow-up, vestibulectomy resulted in approximately twice the pain reduction as compared with the two other treatments. A second goal of the present study was to identify predictors of outcome. METHODS: In a university hospital, 51 of the 78 women from the original study were reassessed 2.5 years after the end of their treatment. They completed 1) a gynecologic examination involving the cotton-swab test, 2) a structured interview, and 3) validated pain and sexual functioning measures. RESULTS: Results from the multivariate analysis of variance conducted on the pain measures showed a significant time main effect (P<.05) and a significant treatment main effect (P<.01), indicating that participants had less pain at the 2.5-year follow-up than at the previous 6-month follow-up. Results from the multivariate analysis of variance conducted on sexual functioning measures showed that participants remained unchanged between the 6-month and 2.5-year follow-up and that there were no group differences. Higher pretreatment pain intensity predicted poorer outcomes at the 2.5-year follow-up for vestibulectomy (P<.01), biofeedback (P<.05), and cognitive-behavioral therapy (P<.01). Erotophobia also predicted a poorer outcome for vestibulectomy (P<.001). CONCLUSION: Treatment gains were maintained at the 2.5-year follow-up. Outcome was predicted by pretreatment pain and psychosexual factors. LEVEL OF EVIDENCE: II.

Male partners of women with provoked vestibulodynia: attributions for pain and their implications for dyadic adjustment, sexual satisfaction, and psychological distress.

INTRODUCTION: Provoked vestibulodynia is a female genital pain condition that results in sexual dysfunction and impacts negatively on the couple. Although patients' causal attributions have been linked to worse psychosexual outcomes, no study has documented the male partners' perspective of this distressing problem and its potential influence on their psychosexual adaptation. AIM: To identify whether male partners' attributions for vestibulodynia are possible predictors of their dyadic adjustment, sexual functioning, sexual satisfaction, and psychological distress, as well as of women's pain and sexual functioning. METHODS: Thirty-eight women with vestibulodynia first completed measures of pain intensity and sexual functioning. Male partners responded to mailed questionnaires assessing their own attributions for genital pain as well as their psychological distress, relationship adjustment, sexual functioning, and sexual satisfaction. MAIN OUTCOME MEASURES: Women completed the McGill-Melzack Pain Questionnaire (MPQ) and the Female Sexual Function Index (FSFI). Attributions of male partners were measured using an adapted version of the Attributional Style Questionnaire (ASQ)-Partner Version. Men also filled out the Brief Symptom Inventory (BSI), the Dyadic Adjustment Scale (DAS), the Sexual History Form (SHF), and the Global Measure of Sexual Satisfaction (GMSEX). RESULTS: All four negative attribution dimensions and higher levels of women's pain intensity successfully predicted increased psychological distress in male partners. Higher levels of both internal and global attributions were associated with men's poorer dyadic adjustment, whereas global and stable attributions were related to their lower sexual satisfaction. Attributions failed to significantly predict sexual functioning in male partners and women's pain and sexual functioning. CONCLUSIONS: Evaluation and treatment of sexual pain problems should involve both partners and should explore the role of negative attributions.