Genito-Pelvic Pain Penetration Disorder

Genito pelvic pain/penetration disorder combines what were previously called dyspareunia and vaginismus. Symptoms last at least 6 months, cause significant distress, and are not better explained by another mental disorder, medical condition (such as lichen sclerosus), relationship distress, or substance effect.

It is persistent or recurrent difficulty with one or more of:

• Vaginal penetration during intercourse.
• Marked vulvovaginal or pelvic pain during intercourse or penetration attempts.
• Marked fear or anxiety about vulvovaginal or pelvic pain in anticipation of, during, or after penetration.
• Marked tensing or tightening of the pelvic floor muscles during attempted penetration.

Prevalence is about 10 to 15 percent of women for dyspareunia (up to 20 to 30 percent in some groups), peaking in younger women and in the perimenopausal years. The pain may be lifelong or acquired, superficial (entry pain) or deep (thrusting pain), situational or generalised.

Causes and contributing factors:

• provoked vestibulodynia (a common cause of entry pain)
• genitourinary syndrome of menopause and lactational atrophy
• vulvovaginitis (candidiasis, trichomoniasis, bacterial vaginosis)
• lichen sclerosus and lichen planus
• post-childbirth scarring and episiotomy
• hypertonic pelvic floor
• endometriosis
• adenomyosis
• pelvic inflammatory disease
• adhesions
• retroverted uterus
• ovarian masses
• interstitial cystitis
• irritable bowel syndrome
• hormonal contraception (reduced ovarian androgens)
• radiotherapy scarring
• sexual abuse
• anxiety
• relationship difficulty
• vaginismus

• Entry pain (burning, stinging, tearing, rawness at penetration or tampon insertion), deep pain (aching or stabbing pain with thrusting, positional), or pain that persists for hours to days after intercourse.
• Fear and avoidance of intercourse, inability to have intercourse or to undergo speculum examination, and reflex tightening of the thighs and pelvic floor.
• Secondary effects: reduced desire and arousal, relationship strain, anxiety and depression.
• Examination: vulvar erythema at the vestibule and tenderness to cotton swab touch at the 4 to 8 o'clock positions of the hymenal ring (provoked vestibulodynia), vaginal dryness or atrophy, skin changes of lichen sclerosus, fissures, scarring, pelvic floor muscle tenderness and hypertonicity (levator ani, obturator internus), uterine retroversion with fixed tenderness, nodularity of the uterosacral ligaments, adnexal tenderness.

• Detailed sexual and pain history: location (entry versus deep), timing, onset, character, associated factors, relationship to menses and childbirth, sexual function domains, trauma, mood, medications and previous treatments; use of a pain diary and questionnaires (Female Sexual Function Index, visual analogue pain scale).
• Examination with consent and control by the woman: cotton swab test of the vulva and vestibule (pain scored 0 to 10), assessment of skin, vaginal pH (above 4.5 indicates atrophy or infection), pelvic floor muscle tone and tenderness by single digit palpation, then bimanual examination for deep pain; if intolerable, defer or use examination under anaesthesia.
• Tests: vaginal swabs for candidiasis, bacterial vaginosis and trichomoniasis, chlamydia and gonorrhoea testing, and pregnancy test when relevant; biopsy of suspicious skin lesions; transvaginal ultrasound or MRI for deep pain when endometriosis, adenomyosis or masses are suspected; laparoscopy if indicated.
• Screening for depression, anxiety, post-traumatic stress and history of abuse.

Treat identified causes and apply multimodal therapy, as for chronic pain.

• Education and reassurance; avoid painful penetration (non-penetrative intimacy); gradual re-introduction; use of generous lubricants (water based or silicone) and positional changes for deep pain (woman on top, lateral positions).
• Treat causes:
  • Infection:
    • Fluconazole 150 mg orally, repeated at 72 hours in recurrent candidiasis, then weekly for 6 months.
    • Metronidazole 400 mg twice daily for 7 days for bacterial vaginosis.
    • Metronidazole 2 g stat or 400 to 500 mg twice daily for 7 days for trichomoniasis.
  • Atrophy: vaginal estradiol 10 microgram tablet daily for 2 weeks then twice weekly, prasterone 6.5 mg nightly, or ospemifene 60 mg daily.
  • Lichen sclerosus: clobetasol propionate 0.05 percent ointment nightly for 4 weeks, alternate nights for 4 weeks, then twice weekly.
  • Endometriosis and adenomyosis: hormonal suppression or surgery.
  • Pelvic inflammatory disease.
• Provoked vestibulodynia:
  • Topical lidocaine 5 percent ointment applied to the vestibule 20 to 30 minutes before intercourse (use a condom for partner protection), or overnight application for 6 to 8 weeks.
  • Amitriptyline 10 to 75 mg at night (or nortriptyline), gabapentin, compounded topical amitriptyline 2 percent with baclofen 2 percent twice daily.
  • Botulinum toxin A injections (50 units into the bulbospongiosus).
  • Vestibulectomy (excision of the painful vestibule, success 60 to 90 percent) for refractory localised disease after conservative failure.
• Pelvic floor physical therapy: manual therapy, trigger point release, biofeedback, relaxation, stretches, and graded vaginal dilators (progressing through sizes with lubricant, 10 to 20 minutes daily), which improve pain and function in most patients.
• Cognitive behavioural and sex therapy: pain coping, desensitisation, graded exposure to penetration, mindfulness; couples therapy to include the partner and improve communication.
• Neuropathic agents for persistent pain: duloxetine 30 to 60 mg daily, gabapentin 300 to 1,800 mg daily, or pregabalin; nerve blocks (pudendal) and neuromodulation in refractory cases.
• Treat comorbid depression, anxiety and trauma. Referral for pelvic pain assessment or specialist vulvar clinics when needed.
• Hormonal contraceptive related vestibulodynia: consider stopping the pill, switching to a non-hormonal method or a levonorgestrel intrauterine system.
• Prognosis is good with multidisciplinary therapy, with 60 to 80 percent improving.