The Biopsychosocial Puzzle of Painful Sex.

Genital pain associated with sex is a prevalent and distressing problem with a complex research and clinical profile. This article reviews the historical context of the "sexual pain disorders" and the circuitous trajectory that has led from the first mention of painful sex in ancient documents to the latest diagnostic category of genito-pelvic pain penetration disorder in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders as well as in other existing and proposed nomenclatures. Prominent etiologic research and emergent theoretical models are critically assessed, as is the latest treatment outcome research of note. Finally, the review points to a number of extant needs in the research and clinical effort, including an integrated biopsychosocial and multidisciplinary approach, randomized clinical trials, targeting of treatment barriers, and expansion of the entire enterprise to include populations that have not been considered.

Psychometric properties of vaginal penetration cognition questionnaire (VPCQ) in Iranian women with sexual pain disorders.

AIM: The aim of this study was to investigate the psychometric properties of the Persian version of the Vaginal Penetration Cognition Questionnaire (VPCQ). DESIGN: Cross-sectional study. METHODS: This research was conducted in two phases from June 2019 to February 2020. PHASE I: The World Health Organization Protocol of forward-backward translation and an expert panel in order to determine face and content validity. PHASE II: Survey development with 352 eligible women with sexual pain disorders, construct validity, internal consistency and construct reliability were evaluated. RESULTS: The exploratory factor analysis showed that the Persian version of VPCQ has three factors that explained 53.94% of the total variance. Confirmatory factor analysis also confirmed the fit of the three-factor model. Convergent and divergent validity were confirmed for all factors. The average measure ICC was 0.99 (95% CI 0.98 to 0.99). The absolute reliability with estimated SEM of 2.67 and MDC% of 28% approved the reliability of the questionnaire.

Dispareunia y vaginismo, trastornos sexuales por dolor / Dispareunia and vaginism, sexual disorders due to pain

Introducción: Dentro de los trastornos sexuales por dolor, se estudian la dispareunia y el vaginismo. El Manual diagnóstico y estadístico de los trastornos mentales V, los engloba bajo la categoría trastorno de dolor génito-pélvico y penetración. En Cuba, no existen muchos referentes teóricos de estas enfermedades. Objetivo: Sistematizar y actualizar los referentes teóricos relacionados con la dispareunia y el vaginismo, desde un enfoque sexológico. Métodos: Se realizó una revisión de la literatura publicada sobre el tema, de los últimos diez años, a texto completo, en las bases de datos SciELO y desde la búsqueda con Google académico con las palabras claves: trastornos sexuales por dolor, dispareunia y vaginismo. Desarrollo: La dispareunia y el vaginismo presentan una etiología multifactorial y variables grados de afectación del disfrute sexual de las parejas. Se presentan los aspectos esenciales de ambas entidades, fundamentalmente la clasificación, etiología, caracterización clínica, evaluación y el tratamiento. Conclusiones: La dispareunia y el vaginismo, son dos afecciones que afectan la vida sexual plena y satisfactoria y requieren de conocimientos, orientación y tratamiento especializado para que los resultados sean satisfactorios(AU)

Introduction: Within sexual disorders due to pain, dyspareunia and vaginismus are studied. The Diagnostic and Statistical Manual of Mental Disorders V encompasses them under the category of pelvic pain and penetration disorder. In Cuba, there are not many theoretical references of these diseases. Objective: Systematize and update the theoretical references related to dyspareunia and vaginismus, from a sexological approach Methods: A review of the literature published on the subject, of the last ten years, in full text, in the SciELO databases and from the search with academic Google with the keywords: sexual disorders due to pain, dyspareunia and vaginismus. Development: Dyspareunia and vaginismus have a multifactorial etiology and varying degrees of impairment of sexual enjoyment of couples. The essential aspects of both entities are presented, fundamentally the classification, etiology, clinical characterization, evaluation and treatment. Conclusions: Dyspareunia and vaginismus are two conditions that affect full and satisfactory sex life and require specialized knowledge, guidance and treatment for the results to be satisfactory(AU)

Pelvic Floor Biometric Changes Assessed by 4D Translabial Ultrassound in Women With Vulvodynia Submitted to Physical Therapy: A Pilot Study of a Randomized Controlled Trial.

BACKGROUND: Vulvodynia is a disabling condition in which pelvic floor muscles' (PFM) hypertonicity plays an important role. AIM: To evaluate biometric changes in PFM in women with vulvodynia undergoing kinesiotherapy treatment protocol (KTP). METHODS: A single-blinded randomized controlled trial of 57 women with vulvodynia randomly assigned to either KTP + amitriptyline or amitriptyline alone (controls) for treatment. Four-dimensional translabial ultrasound assessed PFM regarding symphysis-levator distance at rest, anorectal angle at rest, excursion of the levator plate angle, and levator hiatal narrowing. Volunteers underwent a vaginal examination for a cotton swab test (CST), fulfillment of Friedrich criteria score and PFM power of contraction, and completed a diary of sexual pain and frequency of vaginal intercourse. Outcomes were assessed at baseline and after 8 weeks of treatment. OUTCOMES: Primary outcomes were differences in biometric parameters assessed by four-dimensional translabial ultrasound after treatment, between groups. Secondary outcomes were changes in clinical variables (CST, Friedrich criteria, PFM power of contraction, frequency of intercourse, and intensity of sexual pain) between groups and correlation analysis between biometric parameters and clinical variables. RESULTS: Only the KTP group had statistically significant changes in biometric parameters after treatment (symphysis-levator distance: 0.22 ± 0.2, 95% CI = 0.1-0.4, P = .008; levator hiatal narrowing: -0.33 ± 0.2, 95% CI = -1 to -0.2, P = .04). Comparisons between groups showed that symphysis-levator distance (0.3, 95% CI = 0.2-0.6, P = .005) and excursion of levator plate angle (4.9, 95% CI = -0.4 to 10.1, P = .02) improved significantly after KTP treatment. Clinical variables showed greater improvement in the group treated with KTP for CST (difference of -3.7, 95% CI = -7 to -0.4, P = .01), Friedrich criteria (difference of -1.9, 95% CI = -3.2 to -0.6, P = .003), PFM power of contraction (0.3, 95% CI = 0.1-0.6, P = .05) and intensity of sexual pain (reduction of 1.7, 95% CI = -3.1 to -0.2, P = .01). Some clinical and biometric variables correlated positively, for example, frequency of vaginal intercourse and anorectal angle (P = .04; r = 0.25), or inversely, for example, pain intensity at CST and anorectal angle (P = .004, r = -0.31). CLINICAL IMPLICATIONS: This study provides evidence on efficiency of a physical therapy protocol for improvement of symptoms of vulvodynia and hypertonicity changes. CONCLUSION: This pilot study suggests that KTP for women with vulvodynia promoted significant changes in PFM biometric measures, consistent with alterations in hypertonicity and clinical improvement. Bardin MG, Giraldo PC, Martinho N. Pelvic Floor Biometric Changes Assessed by 4D Translabial Ultrassound in Women With Vulvodynia Submitted to Physical Therapy: A Pilot Study of a Randomized Controlled Trial. J Sex Med 2020;17:2236-2246.

Outcome of Medical and Psychosexual Interventions for Vaginismus: A Systematic Review and Meta-Analysis.

INTRODUCTION: Although vaginismus is a condition with a great impact on psychosexual well-being, the evidence on the efficacy of interventions is lacking. AIM: To review all information on vaginismus treatment, including data from randomized clinical trials (RCTs) and observational studies. METHODS: A systematic search was conducted of MEDLINE, EMBASE, PsycINFO, and ClinicalTrials.gov. 2 Independent meta-analyses of RCTs and observational studies were performed. For RCTs, only those having no treatment as the comparator were considered eligible. MAIN OUTCOME MEASURE: The primary outcome was the success rate (number of successes/total sample) in the completion of sexual intercourse. RESULTS: 43 Observational studies (n = 1,660) and 3 RCTs (n = 264) were included in the final analyses, respectively. In the meta-analysis of RCTs, the use of psychological interventions showed a trend toward a significantly better result vs waiting list control (OR 10.27 [95% CI 0.79-133.5], P = .075). The combination of the results obtained from the observational studies showed that treating vaginismus is associated with the completion of sexual penetrative intercourse in 79% of cases, independently of the therapy used (success rate 0.79 [0.74-0.83]). When only moderate- or strong-quality studies were considered, the success rate was 0.82 (0.73-0.89). As for the different definitions of vaginismus, studies with unconsummated marriage as the inclusion criterion showed the worst success rate (0.68). The origin of vaginismus (primary, secondary, or both), its duration, the mean age of the participants, the involvement of the partner in the intervention, or the geographic setting did not exert a significant effect on the outcome. Studies enrolling women with unconsummated marriage showed a significantly worse success rate. CLINICAL IMPLICATIONS: No approach is superior to the others in allowing the achievement of penetrative intercourse in women with vaginismus. STRENGTH & LIMITATIONS: Only studies specifically enrolling patients with vaginismus were selected, and analyses were performed on an intention-to-treat approach. The main limitations are the small number of trials in the meta-analysis of RCTs and the lack of a comparison group in the meta-analysis of observational studies, which cannot rule out a placebo effect. Due to the limited evidence available, great caution is required in the interpretation of results. Further well-designed trials, with more appropriate outcomes than penetrative sex, are required. CONCLUSION: The meta-analysis of RCTs documented a trend toward higher efficacy of active treatment vs controls, whereas the meta-analysis of observational studies indicated that women with vaginismus benefit from a range of treatments in almost 80% of cases. Maseroli E, Scavello I, Rastrelli G, et al. Outcome of Medical and Psychosexual Interventions for Vaginismus: A Systematic Review and Meta-Analysis. J Sex Med 2018;15:1752-1764.

Female sexual dysfunction: Assessment.

Female sexual dysfunction (FSD) is a common complex clinical condition, with multiple etiologies, association and pathophysiologic correlations. This review includes the definition, etiology, and diagnosis of FSD. It calls for a bio psychosocial approach to FSD management, which incorporates, but is not limited to, only the psychological aspects of FSD.

Transcutaneous electrical nerve stimulation as an additional treatment for women suffering from therapy-resistant provoked vestibulodynia: a feasibility study.

INTRODUCTION: The current approach to women with provoked vestibulodynia (PVD) comprises a multidimensional, multidisciplinary therapeutic protocol. As PVD is considered to be a chronic pain disorder, transcutaneous electrical nerve stimulation (TENS) can be used as an additional therapy for women with otherwise therapy-resistant PVD. AIMS: The aims of this study were to evaluate whether TENS has a beneficial effect on vulvar pain, sexual functioning, and sexually-related personal distress in women with therapy-resistant PVD and to assess the effect of TENS on the need for vestibulectomy. METHODS: A longitudinal prospective follow-up study was performed on women with therapy-resistant PVD who received additional domiciliary TENS. Self-report questionnaires and visual analog scales (VASs) were completed at baseline (T1), post-TENS (T2), and follow-up (T3). MAIN OUTCOME MEASURES: Vulvar pain, sexual functioning, and sexually-related personal distress were the main outcome measures. RESULTS: Thirty-nine women with therapy-resistant PVD were included. Mean age was 27 ± 5.6 years (range: 19 to 41); mean duration between TENS and T3 follow-up was 10.1 ± 10.7 months (range: 2 to 32). Vulvar pain VAS scores directly post-TENS (median 3.4) and at follow-up (median 3.2) were significantly (P < 0.01) lower than at baseline (median 8.0). Post-TENS, sexual functioning scores on the Female Sexual Functioning Index questionnaire had improved significantly (P = 0.2); these scores remained stable at follow-up. Sexually-related personal distress scores had improved significantly post-TENS (P = 0.01). Only 4% of the women who received TENS needed to undergo vestibulectomy vs. 23% in our previous patient population. CONCLUSION: The addition of self-administered TENS to multidimensional treatment significantly reduced the level of vulvar pain and the need for vestibulectomy. The long-term effect was stable. These results not only support our hypothesis that TENS constitutes a feasible and beneficial addition to multidimensional treatment for therapy-resistant PVD, but also the notion that PVD can be considered as a chronic pain syndrome.

Dynamic clinical measurements of voluntary vaginal contractions and autonomic vaginal reflexes.

INTRODUCTION: The vaginal canal is an active and responsive canal. It has pressure variations along its length and shows reflex activity. At present, the prevailing idea is that the vaginal canal does not have a sphincter mechanism. It is hypothesized that an active vaginal muscular mechanism exists and might be involved in the pathophysiology of genito-pelvic pain/penetration disorder. AIM: The aim of this study was to detect the presence of a canalicular vaginal "sphincter mechanism" by measuring intravaginal pressure at different levels of the vaginal canal during voluntary pelvic floor contractions and during induced reflexive contractions. METHODS: Sixteen nulliparous women, without sexual dysfunction and pelvic floor trauma, were included in the study. High-resolution solid-state circumferential catheters were used to measure intravaginal pressures and vaginal contractions at different levels in the vaginal canal. Voluntary intravaginal pressure measurements were performed in the left lateral recumbent position only, while reflexive intravaginal pressure measurements during slow inflation of a vaginal balloon were performed in the left lateral recumbent position and in the sitting position. MAIN OUTCOME MEASURES: Intravaginal pressures and vaginal contractions were the main outcome measures. In addition, a general demographic and medical history questionnaire was administered to gain insight into the characteristics of the study population. RESULTS: Fifteen out of the sixteen women had deep and superficial vaginal high-pressure zones. In one woman, no superficial high-pressure zone was found. The basal and maximum pressures, as well as the duration of the autonomic reflexive contractions significantly exceeded the pressures and the duration of the voluntary contractions. There were no significant differences between the reflexive measurements obtained in the left lateral recumbent and the sitting position. CONCLUSION: The two high-pressure zones found in this study, as a result of voluntary contractions and, even more pronounced, as a result of reflexive contractions on intravaginal stimulation, support the hypothesis that the vaginal canal has an active and passive canalicular sphincter mechanism. Further investigation of this sphincter mechanism is required to identify its role in the sexual response and genito-pelvic pain/penetration disorder.

Predictors of task-persistent and fear-avoiding behaviors in women with sexual pain disorders.

INTRODUCTION: Dyspareunia and vaginismus are the most common sexual pain disorders (SPDs). Literature suggests that many women with dyspareunia continue with intercourse despite pain (task persistence), whereas many women with vaginismus avoid penetrative activities that may cause pain (fear avoidance). Both forms of sexual pain behavior may maintain or aggravate complaints. AIM: This study examined (i) whether women with SPD differ from pain-free controls in motives for sexual intercourse, sexual autonomy, maladaptive beliefs regarding vaginal penetration, and partner responses to pain; and (ii) which of these factors best predict whether women with SPD stop or continue painful intercourse (attempts). METHODS: Women with superficial dyspareunia (n = 50), women with lifelong vaginismus (n = 20), and pain-free controls (n = 45) completed questionnaires. MAIN OUTCOME MEASURES: For Aim 1, the main outcome measures were (i) motives for intercourse; (ii) sexual autonomy; (iii) maladaptive beliefs regarding vaginal penetration; and (iv) partner responses to pain. For Aim 2, sexual pain behavior (to continue or discontinue with painful intercourse) was the outcome measure. RESULTS: (i) Women with dyspareunia exhibited more mate guarding and duty/pressure motives for intercourse and were less sexually autonomous than controls. (ii) Symptomatic women had more maladaptive penetration-related beliefs than controls, with women with vaginismus reporting the strongest maladaptive beliefs. (iii) Partners of women with dyspareunia self-reported more negative responses to pain than those of women with vaginismus. (iv) The factors that best predicted sexual pain behavior were the partner responses to pain and the woman's maladaptive beliefs regarding vaginal penetration. CONCLUSIONS: Our findings reveal support for task persistence in women with dyspareunia and fear avoidance in women with lifelong vaginismus. As such, it is important to consider these distinct types of responding to sexual pain when treating SPD.