An Investigation of Descending Pain Modulation in Women With Provoked Vestibulodynia: Alterations of Brain Connectivity.

Provoked Vestibulodynia (PVD) is the most common vulvodynia subtype (idiopathic chronic vulvar pain). Functional magnetic resonance imaging (fMRI) studies indicate that women with PVD exhibit altered function in a number of pain modulatory regions in response to noxious stimulation, such as in the secondary somatosensory cortex, insula, dorsal midcingulate, posterior cingulate, and thalamus. However, previous neuroimaging studies of PVD have not examined periods of time before and after noxious stimulation or investigated functional connectivity among pain modulatory regions. Fourteen women with PVD and 14 matched Control participants underwent five fMRI runs with no painful stimuli interleaved randomly with five runs with calibrated, moderately painful heat stimuli applied to the thenar eminence. As recent findings indicate that pain processing begins before and continues after painful stimulation, 2-min periods were included in each run before and after the stimulus. Functional brain connectivity was assessed during both trials of Pain and No Pain stimulation for each group using structural equation modeling (SEM). Analyses of variance (ANOVAs) on connectivity values demonstrated significant main effects of study condition, and group, for connectivity among pain modulatory regions. Most of the differences between the Pain and No Pain conditions found only in the PVD group take place before (i.e., thalamus to INS, ACC to S1, thalamus to S1, and thalamus to S2) and after pain stimulation (i.e., INS to amygdala, PPC to S1, and thalamus to S2). Such differences were not observed in the Control group. These findings further support previous results indicating that women with PVD have altered pain processing compared to pain-free women.

An Investigation of Descending Pain Modulation in Women With Provoked Vestibulodynia (PVD): Alterations of Spinal Cord and Brainstem Connectivity.

The most common subtype of vulvodynia (idiopathic chronic vulvar pain) is provoked vestibulodynia (PVD). Previous imaging studies have shown that women with vulvodynia exhibit increased neural activity in pain-related brain regions (e.g., the secondary somatosensory cortex, insula, dorsal midcingulate, posterior cingulate, and thalamus). However, despite the recognized role of the spinal cord/brainstem in pain modulation, no previous neuroimaging studies of vulvodynia have examined the spinal cord/brainstem. Sixteen women with PVD and sixteen matched Control women underwent a spinal cord/brainstem functional magnetic resonance imaging (fMRI) session consisting of five runs with no painful thermal stimuli (No Pain), interleaved randomly with five runs with calibrated, moderately painful heat stimulation (Pain). Functional connectivity was also assessed in periods before, during, and after, pain stimulation to investigate dynamic variations in pain processing throughout the stimulation paradigm. Functional connectivity in the brainstem and spinal cord for each group was examined using structural equation modeling (SEM) for both Pain and No Pain conditions. Significant connectivity differences during stimulation were identified between PVD and Control groups within pain modulatory regions. Comparisons of Pain and No Pain conditions identified a larger number of connections in the Control group than in the PVD group, both before and during stimulation. The results suggest that women with PVD exhibit altered pain processing and indicate an insufficient response of the pain modulation system. This study is the first to examine the spinal cord/brainstem functional connectivity in women with PVD, and it demonstrates altered connectivity related to pain modulation in the spinal cord/brainstem.

Exploring the neural correlates of touch and pain in women with provoked vestibulodynia.

Group differences in touch and pain thresholds-and their neural correlates-were studied in women with provoked vestibulodynia (PVD; N = 15), a common subtype of vulvodynia (chronic vulvar pain), and pain-free control women (N = 15). Results from quantitative sensory testing and self-report measures indicated that, as compared with control participants, women with PVD exhibited allodynia (ie, pain in response to a normally nonpainful stimulus) and hyperalgesia (ie, an increased response to a normally painful stimulus) at vulvar and nonvulvar sites. In addition, brain imaging analyses demonstrated reduced difference scores between touch and pain in the S2 area in women with PVD compared with control participants, supporting previous findings of allodynia in women with PVD. There were no significant reductions in difference scores between touch and pain for regions related to cognitive and affective processing of painful stimuli. The results of this study contribute important information to the general pain and vulvodynia literatures in elucidating the specific sensorimotor neural mechanisms that underlie hyperalgesia in a chronic pain population. These results have implications for differentiating neural processing of touch and pain for women with and without PVD. Future research should attempt to examine alterations related to hyperalgesia in commonly comorbid conditions of PVD.

Is Mode of Delivery Associated With Sexual Response? A Pilot Study of Genital and Subjective Sexual Arousal in Primiparous Women With Vaginal or Cesarean Section Births.

INTRODUCTION: Although postpartum sexual concerns are common, limited data exist on postpartum sexual response. Furthermore, the physiological process of vaginal birth may negatively impact genital response compared with unlabored cesarean section (C-section), but this hypothesis has yet to be tested. AIM: To (i) compare genital and subjective sexual response and sexual concordance by mode of delivery with inclusion of a control group, (ii) compare groups on self-reported sexual function over the past month, (iii) examine the relationship between laboratory measurement of sexual response and self-reported sexual function, and (iv) investigate association between obstetrical factors and breastfeeding and between sexual response and self-reported sexual function. METHODS: 3 groups of cisgender women were recruited from the community: primiparous women who delivered via vaginal birth within the past 2 years (VB group; n = 16), primiparous women who delivered via unlabored C-section within the past 2 years (CS group, n = 15), and age-matched nulliparous women (NP group, n = 18). Laser Doppler imaging was used to assess genital response while participants watched a neutral and erotic film. MAIN OUTCOME MEASURES: The main outcome measures were change in flux units from neural to erotic video as a measure of genital response, subjective sexual arousal rated continuously throughout films, perceived genital response rated after films, and Female Sexual Function Index (FSFI). RESULTS: Women in the VB group had significantly lower change in flux units than women in the CS (P = .005, d = 1.39) and NP (P < .001, d = 1.80) groups. Groups did not differ on their subjective indices of sexual response or in sexual concordance. Women in both postpartum groups reported lower FSFI scores than women in the NP group. No relationship was determined between FSFI scores and sexual response in the laboratory. Results suggested that genital trauma and breastfeeding may negatively impact FSFI scores, but they were not related to genital response or subjective sexual arousal as measured in the laboratory. CLINICAL IMPLICATIONS: Results underscore the importance of balancing objective and subjective indices of sexual response and function, especially considering the biopsychosocial nature of postpartum sexuality. STRENGTHS & LIMITATIONS: The present study is the first to apply modern sexual psychophysiological methodology to the study of postpartum sexuality. Cross-sectional methodology limits the ability to make causal inferences, and the strict inclusion criteria limits generalizability. CONCLUSION: Physiological changes as a result of labor and delivery may have a detrimental impact on genital response; however, these physiological differences may not impact women's subjective experience of postpartum sexuality. Cappell J, Bouchard KN, Chamberlain SM, et al. Is Mode of Delivery Associated With Sexual Response? A Pilot Study of Genital and Subjective Sexual Arousal in Primiparous Women With Vaginal or Cesarean Section Births. J Sex Med 2020; 17:257-272.

Genital Sensations in Persistent Genital Arousal Disorder: A Case for an Overarching Nosology of Genitopelvic Dysesthesias?

INTRODUCTION: Persistent genital arousal disorder (PGAD) is a highly distressing and poorly understood condition characterized by unwanted sensations of genital arousal in the absence of subjective sexual desire. Research has shown that some individuals with PGAD also report orgasm, urinary, and pain symptoms, with 1 recent study specifically comparing a "painful persistent genital arousal symptom" group to a "non-painful persistent genital arousal symptom" group on various indicators given the highly frequent report of comorbid genitopelvic pain in their sample. AIM: To review literature on PGAD focusing on the presence of pain symptoms. METHODS: A literature review through May 2018 was undertaken to identify articles that discuss pain characteristics in individuals with persistent sexual arousal syndrome, persistent genital arousal disorder, symptoms of persistent genital arousal, and restless genital syndrome. MAIN OUTCOME MEASURE: A review of pain/discomfort associated with persistent genital arousal, and the proposal of a new theoretical framework of genitopelvic dysesthesias. RESULTS: PGAD is a distressing condition that is associated with a significant, negative impacts on psychosocial and daily functioning. Although it is clear that unwanted and persistent genital arousal is the hallmark symptom of PGAD, symptoms of pain and discomfort are also frequently reported. Based on the results of this review, a model of genitopelvic dysesthesias is proposed, with subcategories of unpleasant sensations that are based on patients' primary complaint: arousal, arousal and pain, or pain (and other sensations). CONCLUSION: The proposed model can provide an important framework for conceptualizing conditions characterized by unpleasant genitopelvic sensations. A model such as this one can benefit highly misunderstood conditions that are questioned in terms of their legitimacy and severity-such as PGAD-by conceptualizing them as sensory disorders, which in turn can reduce stigma, unify research efforts, and potentially improve access to care. Pukall CF, Jackowich R, Mooney K, et al. Genital Sensations in Persistent Genital Arousal Disorder: A Case for an Overarching Nosology of Genitopelvic Dysesthesias? Sex Med Rev 2019;7:2-12.

Provoked Vestibulodynia: Diagnosis, Self-Reported Pain, and Presentation During Gynaecological Examinations.

OBJECTIVE: To explore factors associated with the diagnosis of provoked vestibulodynia (PVD) through (1) self-reported pain characteristics and (2) Friedrich's criteria (vestibular pain during sexual activity/gynaecological examination). We also identified cases in which incorrect diagnoses were assigned and explored group differences in gynaecological examination presentation and associations with self-reported pain. METHODS: Data were extracted from nine studies conducted in our research laboratory. Information obtained during a telephone interview and a standardized gynaecological examination was compiled for 106 participants with vulvar pain and 106 pain-free control participants, matched for age, hormonal contraceptive use, and parity. RESULTS: Cohen's kappa (0.78) indicated substantial agreement (87.3%) between the telephone interview group categorization and diagnosis after the gynaecological examination. A discriminant function analysis yielded one significant function: Friedrich's first two criteria correctly classified 84.2% of cases, accounting for 76.0% of group membership variance. Of note, those in the other genital pain group were most likely to have received an incorrect diagnosis following the telephone interview (P < 0.001). Paired-samples t tests showed that those with pain reported lower pain intensity during the gynaecological examination than during intercourse (P < 0.001) and that intercourse pain was not necessarily related to pain during the examination. However, many participants (72.8%) indicated that the pain elicited during the cotton swab test was similar to the pain they felt with intercourse. CONCLUSION: These results support the use of a targeted clinical interview and the evaluation of vestibular pain during sexual activity and the gynaecological examination for diagnosing PVD. Caution should be exercised when a patient presents with genital pain symptoms other than those typically observed in PVD. Furthermore, the cotton swab test may underestimate the degree of pain regularly experienced.

Sexual and relationship satisfaction and vestibular pain sensitivity among women with provoked vestibulodynia.

INTRODUCTION: Provoked vestibulodynia (PVD) is a common cause of painful intercourse. Despite the fact that PVD is associated with high levels of pain and negative impact on women's sexuality, research has not examined associations between affected women's pain sensitivity and their sexual and relationship satisfaction. AIMS: This study aimed to examine sexual and relationship functioning/satisfaction and vestibular pain sensitivity among PVD-affected women, and potential associations between these variables. METHODS: Participants were 17 women with PVD and 17 matched controls. Women were assessed via a gynecological examination, structured interview, and the Female Sexual Function Index (FSFI), Golombok Rust Inventory of Sexual Satisfaction (GRISS), and Dyadic Adjustment Scale (DAS). Additionally, women completed a quantitative sensory testing session to assess vestibular pain thresholds and associated pain ratings; specifically, vestibular pressure-pain and heat pain thresholds were measured. MAIN OUTCOME MEASURES: Gynecological and intercourse pain ratings; FSFI; GRISS; DAS; vestibular pressure-pain threshold; and vestibular heat pain thresholds. RESULTS: PVD-affected women reported significantly decreased sexual function in comparison with controls. While no differences in relationship satisfaction were found between groups, women with PVD did report less sexual satisfaction on the FSFI. PVD-affected women also reported significantly higher vestibular pain ratings associated with the gynecological examination and heat pain tolerance procedures, and lower pressure-pain threshold, heat pain threshold, and heat pain tolerance at the vestibule in comparison with controls. Among women with PVD, lower heat pain threshold was associated with less sexual satisfaction, and higher pain ratings related to intercourse and heat pain tolerance, respectively, were associated with lower sexual function and satisfaction. CONCLUSIONS: The results indicate that women with PVD experience negative sexual effects and increased pain sensitivity. This study also suggests that some aspects of pain may be related to lower levels of sexual function and satisfaction among affected women.

Sexual arousal in women with provoked vestibulodynia: the application of laser Doppler imaging to sexual pain.

Introduction. Women with provoked vestibulodynia (PVD) report lower sexual arousal than nonaffected women, however, laboratory studies of arousal have reported contradictory results about whether group differences exist in genital and subjective arousal. Aim. To examine genital and subjective sexual arousal in women with and without PVD. Methods. Eligible women with and without PVD (N = 42) attended a laboratory session that included an interview, questionnaire completion, and genital imaging. A direct measure of superficial blood flow-laser Doppler imaging-was used to assess vulvar blood flow levels while participants watched three films, including an erotic film. Participants answered questions about their level of sexual arousal before, during, and after the erotic film. Main Outcome Measures. Average vulvar blood flow levels during the baseline and erotic films, numerical ratings of subjective sexual arousal and anxiety, as well as questionnaire measures of arousal. Results. There was a significant group difference in genital arousal, whereby the PVD group showed a lower genital response to the erotic film, as well as a significant interaction between baseline blood flow and group membership. Separate group regression analyses demonstrated that baseline blood flow explained a substantial amount of the variance in erotic film blood flow in the control group (70%), while only 27% was explained by this variable in the PVD group. There were no differences in subjective sexual arousal or anxiety between the groups. Across questionnaire measures, women with PVD reported lower sexual arousal than the control group. Conclusions. The results suggest that women with PVD show lower genital responsiveness than nonaffected women to sexual stimuli in a laboratory setting and that their genital arousal is likely impacted by a number of biopsychosocial factors. Boyer SC, Pukall CF, and Chamberlain SM. Sexual arousal in women with provoked vestibulodynia: The application of laser Doppler imaging to sexual pain. J Sex Med **;**:**-**.

"Just relax": physicians' experiences with women who are difficult or impossible to examine gynecologically.

INTRODUCTION: The internal pelvic exam is a critical component of women's reproductive health care; however, it can be perceived as uncomfortable, embarrassing, and painful, which may lead some women to avoid this procedure. AIMS: The purpose of this study was to survey physicians with respect to their experiences with female patients who are difficult or impossible to examine gynecologically. METHODS: Six hundred and fifty-eight obstetrician-gynecologist and family physicians were sent a 15-item questionnaire by mail and 424 participants responded (64% response rate). The survey consisted of questions pertaining to demographic variables, professional training and practice information, the frequency with which they encounter female patients who are difficult or impossible to examine, and the strategies employed with and beliefs surrounding such patients. MAIN OUTCOME MEASURES: The main outcome measures were the frequency of patients who are difficult or impossible to examine, strategies used to manage such patients, and beliefs as to why these patients are difficult or impossible to examine. RESULTS: The results, based on a final sample size of 401, indicated that most respondents have had some experience with patients who are difficult or impossible to examine. In such cases, most physicians (87%) reported attempting to address their patients' lack of relaxation. The majority of physicians in this study believed that a previous negative experience with (87%), and heightened anxiety about (79%), the exam were to blame. Twelve percent of respondents specifically reported that a previous history of sexual abuse was an important factor. CONCLUSIONS: This study reinforces the importance of being aware of patient discomfort during pelvic exams and of developing strategies that fit the individual patient and her needs. Future research should examine women's perceptions of their reproductive care, particularly correlates of pain and anxiety during pelvic exams, prevalence of negative experiences, and doctor-patient interactions in this context.

Provoked vestibulodynia.

Vulvodynia, or chronic vulvar pain, is a common but poorly understood condition. Affected women report negative impacts in terms of sexual functioning, relationship adjustment, psychological well-being and overall quality of life. Although the etiology of vulvodynia is not well understood, it appears as if different levels of pathophysiology are implicated. Accordingly, therapeutic options are targeted at a variety of mechanisms. Unfortunately, few randomized, controlled trials exist, and few combination therapies have been examined; however, the quality and breadth of the treatment literature is improving. Further studies are needed to more fully investigate the mechanisms involved in the development and maintenance of vulvodynia, and more research in the area of treatment outcome is needed.

Women's views on elective primary caesarean section.

OBJECTIVE: Elective primary Caesarean section (EPCS), Caesarean section performed at a woman's request in the absence of a recognized obstetrical indication, is becoming increasingly common. Recent articles and opinions in both the medical and lay press have polarized this issue. The purpose of this study was to determine the opinions and choices of nulliparous and multiparous women with respect to mode of delivery. METHODS: All women attending antenatal clinics at Kingston General Hospital from May to August 2005 were invited to participate in a confidential survey. Basic demographic data including maternal age, level of education, parity, and previous mode of delivery were collected. Respondents who had had a previous Caesarean section were excluded from data analysis. The questionnaire provided a written statement of potential benefits and risks of an EPCS compared with vaginal delivery; no other counselling was provided. Respondents were asked if EPCS should be offered to all women and whether they would choose EPCS if given the choice. Respondents were also asked to indicate the most and least influential factors in their decision. RESULTS: Responses were received from 107 nulliparous women and 103 multiparous women. Thirteen percent of nulliparas (14/107) stated that they would choose EPCS if given the option, compared with 5% of multiparas (5/103). Fifty-one percent of nulliparas (55/107) and 28% of multiparas (29/103) believed that EPCS should be offered to all women receiving antenatal care. The most and least important reasons, chosen from a list, for requesting or declining EPCS varied between nulliparas and multiparas. The convenience of scheduling permitted by Caesarean section was not important for either multiparas or nulliparas. The perceived risks of vaginal delivery were commonly cited by both nulliparas and multiparas as reasons for requesting EPCS, whereas the risks of Caesarean section for the baby or for future pregnancies were the most commonly cited reasons to decline EPCS in both groups. Regardless of the decision to request or decline EPCS, cost to the health care system was not an important factor for either nulliparas or multiparas. CONCLUSION: The majority of pregnant women surveyed would not request an EPCS. However, a significant number of pregnant women, both nulliparous and multiparous, felt that women should be given the option of undergoing EPCS.