Urinary and sexual impact of pelvic reconstructive surgery for genital prolapse by surgical route. A randomized controlled trial

INTRODUCTION AND HYPOTHESIS

The main objective of the study was to evaluate the rates of de novo stress urinary (SUI) and postoperative dyspareunia after both sacrocolpopexy/hysteropexy (SCP) and vaginal mesh surgery.

METHODS

A prospective, multicenter, randomized, open-label study with two parallel groups treated by either SCP or Uphold Lite vaginal mesh was carried out. Study participants were ≥ 50 and < 80 years old patients with Pelvic Organ Prolapse Quantification (POP-Q) stage ≥2 who were considered eligible for reconstructive surgery and who were sexually active with no dyspareunia and free from bothersome SUI at presentation. Women were assessed before surgery and at 4-8 weeks and 11-13 months after using validated measures including POP-Q, Pelvic Floor Disability Index (PFDI-20), Pelvic Floor Impact Questionnaire (PFIQ-7), Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire, IUGA-Revised (PISQ-IR), and Patient Global Impression of Improvement (PGI-I). Data were also collected for health economics evaluation.

RESULTS

Of the required sample of 156 women, 42 women (19 SCP and 23 vaginal mesh) were only recruited owing to the discontinuation of vaginal mesh worldwide. The median follow-up was 376 days. The rates of bothersome de novo SUI were similar in the SCP and Uphold vaginal mesh groups (15.79 vs 15.00%, OR 0.95 [95% CI 0.22-4.14]). Among 30 sexually active patients at follow-up, the rates of women reporting de novo dyspareunia "usually or always" were 6.7% after SCP vs 13.3% after vaginal mesh (p = 1). Health economics evaluation showed a cost saving of 280€ in favor of the Uphold vaginal mesh technique, but no significant difference in the total cost (2,934.97€ for SCP vs 3,053.26€ for Uphold vaginal mesh).

CONCLUSIONS

Bothersome de novo SUI and de novo dyspareunia occurred in approximately 15% and 23% of our study cohorts, with no significant difference between sacrocolpopexy/hysteropexy and anterior/apical vaginal mesh surgery. However, these results should be interpreted with caution owing to the small sample size.

Interactions between vulvovaginal disorders and urinary disorders: The case for an integrated view of the pelvis

Lower urinary tract symptomatology is often difficult to categorize if history and investigation focus only on the urinary tract. Disease and dysfunction in organs more posteriorly can often cause or influence such bladder and urethral symptoms. Vulvovaginal skin diseases are an important but often missed influence on lower urinary tract symptomatology.

Sexual function in primiparous women: a prospective study

INTRODUCTION AND HYPOTHESIS

The aim of this prospective study was to examine the impact of sociodemographic, pregnancy and obstetric characteristics on sexual function 12 months postpartum in primiparous women. We hypothesized that sexual function would decrease after childbirth.

METHODS

Between 1 October 2014 and 1 October 2017, all nulliparous women in early pregnancy registering for maternity health care in Region Örebro County, Sweden, were invited to participate in this prospective study. A total of 958 women were included. Sexual activity and function were measured at early pregnancy, 8 weeks postpartum and 12 months postpartum using the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ-12). The associations between sociodemographic, pregnancy and obstetric characteristics and sexual activity and function from early pregnancy to 12 months postpartum were examined using linear and logistic models based on generalized estimating equations.

RESULTS

We found that the prevalence of sexually active women decreased from 98.0% in early pregnancy to 66.7% at 8 weeks postpartum, but increased to 90.0% at 12 months postpartum. Age ≥ 35 years, second-degree perineal tear and current breastfeeding were statistically significant risk factors for sexual inactivity at 12 months postpartum. Poor self-reported health in early pregnancy was statistically significantly associated with decreased sexual function at 12 months postpartum.

CONCLUSIONS

A majority of women resumed sexual activity at 8 weeks postpartum and most women at 12 months postpartum; the decrease in sexual function at 12 months postpartum was small and few risk factors were observed.

Circumferential Acquired Macropenis: Definition, Literature Review and Proposal of Geometrically-Based Reduction Corporoplasty

Introduction

Over the years, scattered cases of acquired penile girth increase have been published with different terms, the common clinical feature being a mechanically hampered penetration.

Aim

To search for all published cases of acquired penile girth increase, and to propose a geometrically-based reduction corporoplasty.

Methods

A case of acquired penile bilateral albuginea herniation prompted us to a PubMed, EMBASE and Google Scholar literature review from 1970 to 2021, in search for similar conditions.

Main Outcome Measure

We identified 7 cases of acquired penile girth increase; the geometric approach used to surgically correct bilateral corporal herniation proved successful in our case.

Results

In 5 of the 7 cases of acquired penile girth increase, priapistic episodes were deemed the causal factor; in the remaining 2 and in ours, a clear etiology could not be identified.

Conclusion

“Circumferential acquired macropenis” describes the unusual syndrome of acquired penile girth increase, that encompasses 2 distinct etiologies: post-priapistic cases, characterized by penile girth increase both in flaccidity and erection, and idiopathic cases, characterized by girth increase in erection only, and at surgery by a thinned albuginea in the affected area.

Pescatori ES, Drei B, Rabito S Circumferential Acquired Macropenis: Definition, Literature Review and Proposal of Geometrically-Based Reduction Corporoplasty. Sex Med 2022;10:100460.

Improvement in dyspareunia after vaginal mesh removal measured by a validated questionnaire

INTRODUCTION AND HYPOTHESIS

The objective was to examine the effect of the surgical removal of vaginally placed prolapse and incontinence mesh on sexual function. We hypothesize that patients with painful complications of mesh will experience improvement in dyspareunia and sexual function after mesh removal.

METHODS

The eligible cohort consisted of 133 women who presented with a new onset of pain attributed to mesh-augmented incontinence or prolapse surgery and who elected to undergo mesh removal between 1 August 2012 and 1 July 2013. Sexual function symptoms were assessed before and after mesh removal surgery using the Pelvic Organ Prolapse and Urinary Incontinence Sexual Function Questionnaire short form (PISQ-12). Multivariate analysis was performed to identify predictors of improvement in dyspareunia.

RESULTS

Ninety-four patients undergoing mesh removal completed a pre-operative questionnaire, 63 of whom also completed a post-operative questionnaire. After mesh removal, there was a nearly 50% reduction in the proportion of women reporting always experiencing post-operative pain with intercourse among those experiencing pre-operative pain. There was a statistically significant quantitative improvement in pain with intercourse after mesh removal based on mean change score of PISQ-12 question 5 "How often do you experience pain with intercourse?". In multivariate analysis, only history of vaginal delivery was associated with symptom improvement.

CONCLUSION

Removal of transvaginal prolapse mesh is associated with improvement in self-reported dyspareunia based on a standardized question on a validated instrument in a small cohort of women. Although larger studies are needed to confirm the relationship between mesh-augmented surgeries and post-procedural dyspareunia, these data suggest that consideration of mesh removal is a reasonable step for patients with painful intercourse attributed to mesh-augmented prolapse and incontinence surgeries.

Transcranial direct current stimulation for provoked vestibulodynia: What roles do psychosexual factors play in treatment response?

There is growing evidence that provoked vestibulodynia (PVD), a frequent and debilitating condition, is characterized by central sensitization. This study aimed to examine predictive factors of transcranial direct current stimulation (tDCS) efficacy in this chronic pain population. Exploratory analysis derived from a randomized controlled trial was performed to assess predictors of pain reduction among 39 women with PVD who received 10 daily sessions of either active or sham tDCS. Clinical characteristics (e.g. pain intensity, duration and pain sensitivity) and psychosexual factors (e.g. pain catastrophizing, pain-related fear, anxiety, depressive symptoms and vaginal penetration cognitions) were assessed at baseline and used to predict tDCS response at 3-month follow-up. Analysis revealed that higher depressive symptoms and lower negative self-image cognitions were significant predictors of pain reduction at follow-up and accounted for 62.3% of the variance in the active tDCS group. Higher genital incompatibility cognitions were related to poorer response, regardless of treatment group. These findings suggest that women with PVD presenting higher depressive symptoms and lower levels of negative self-image cognitions could derive greater benefits from tDCS. These results suggest that tDCS could be effective in a subgroup of women with PVD - a possibility worth exploring with future prospective larger studies.

Temporal Relationships Between Pain During Intercourse (PDI), Loneliness, and Depressive Symptoms Among Women

Background

Painful sex can lead to increased psychological distress, including major depressive disorder, and the experience of loneliness may explain this association.

Aims

We aimed to investigate loneliness as a mediator between painful sex and depressive symptoms and hypothesized that women who experienced greater pain during intercourse (ie, more severe and more frequent pain) would endorse higher rates of loneliness and, in turn, higher rates of depressive symptoms at a 6-month follow-up.

Methods

Participants were 148 adults who were assigned female at birth (78.4% white, 77% partnered, 31.14 ± 10.9 years old) and completed an online, anonymous survey including the Female Sexual Function Index (FSFI), UCLA Loneliness Scale-3 (ULS), and demographic information.

Main Outcome Measure

Depressive symptoms, measured via the Patient Health Questionnaire-8 (PHQ8) at baseline (T1) and 6-month follow-up (T2) were used as the outcomes of the present study.

Results

Painful sex and ULS at T1 were significantly correlated with each other and with PHQ8 at T1 (r = 0.590). However, change in PHQ8 from T1 to T2 was not significantly correlated with ULS (r = 0.024) or any other key study variables, indicating that that ULS was not a significant mediator of the relationship between painful sex at T1 and change in PHQ8 (standardized indirect effect = 0.011; 99% CI = −0.114 to 0.188).

Conclusion

These findings are consistent with previous studies highlighting that painful sex is related to depressive symptoms through loneliness cross-sectionally, suggesting that future treatments for depressive symptoms among women who experience painful sex might target loneliness.

Stout ME, Hawkins MAW. Temporal Relationships Between Pain During Intercourse (PDI), Loneliness, and Depressive Symptoms Among Women. Sex Med 2021;9:100444.

Sexual Health

Women's sexual health is a frequently ignored area of geriatric medicine. There are clearly defined criteria for sexual dysfunction that are organized by phase of sexual function, including desire, arousal, orgasm, and pain. The menopause transition and comorbid medical conditions (as well as their treatments) can contribute to alterations in sexual function. The partner must be included and involved in the evaluation and management to achieve a better intimate relationship in an established couple. A variety of effective and evidence-based treatments are available to women for sexual concerns in the geriatric population.

Microablative Erbium: YAG Laser Therapy for Vulvodynia - A Report on Efficacy, Safety, and Treatment Satisfaction

Introduction

Treatment for vulvodynia is challenging and a multidisciplinary approach is recommended.

Aim

To examine the effectiveness, safety and treatment satisfaction of vulvovaginal microablative laser treatment for vulvodynia.

Methods

Case study of women who received laser treatment as part of a multidisciplinary treatment program for vulvodynia. Subjective improvement was compared to a retrospective cohort of women treated for vulvodynia without LASER therapy. LASER treatment was offered to women with vulvodynia presenting to a gynecologic pain clinic of a tertiary university hospital. LASER treatments were performed with a microablative 2,940 nm Er:YAG LASER and potentially repeated after 1 month.

Main outcome measures

Change in local vulvar pain was assessed with cotton-swab tests and rated on a numeric rating scale (NRS). Treatment discomfort and short-term adverse events were recorded. The Freiburg Index of Patient Satisfaction was used to assess treatment satisfaction. Subjective symptom improvement was assessed with the Patient Global Impression of Improvement questionnaire.

Results

35 women received at least 1 laser treatment, with overall mild treatment adverse effects (mean pain NRS 2.4 ± 1.9) and good treatment satisfaction (mean total score of 27.6 ±5.1; potential range 8–32). One month after last LASER treatment the pain NRS on vulvar cotton swab test improved from 6.1 ± 2.6 at baseline to 3.1 ± 2.6 (P < .001), and 74% of women (n = 26) reported symptom improvement. At 9–12 months follow-up 66% reported ongoing symptom improvement, with no significant difference to the control group of 32 women.

Conclusion

Microablative Er:YAG vulvovaginal LASER therapy appears safe and well accepted among vulvodynia patients, but there was no significant difference in symptom improvement compared to a control group.

Trutnovsky G, Bliem B, Greimel E, et al. Microablative Erbium: YAG Laser Therapy for Vulvodynia – A Report on Efficacy, Safety, and Treatment Satisfaction. Sex Med 2021;9:100432.

Chronic Vulvar Pain After Female Genital Mutilation/Cutting: A Retrospective Study

INTRODUCTION

Chronic vulvar pain is a condition that affects many women during their lifetime, including women with Female Genital Mutilation/Cutting (FGM/C).

AIM

To study the prevalence and possible etiologies of chronic vulvar pain among women living with FGM/C.

METHODS

We conducted a retrospective review of consecutive medical files of 506 women who consulted our specialized clinic for women with FGM/C between April 1, 2010 and December 31, 2017. We collected sociodemographic and clinical data including information on the type of FGM/C and its complications. We focused on studying the prevalence, etiologies and characteristics of chronic vulvar pain.

MAIN OUTCOME MEASURES

Prevalence and etiologies of vulvar pain in women with FGM/C.

RESULTS

Chronic vulvar pain was present in 14 women (2.8%). Pain was unprovoked in one case (7.1%) and provoked in the 13 other cases (92.9%). In most of the cases, women presented vulvar pain related to scar complications such as clitoral or peri-clitoral adhesions or scar tissue (n = 3, 21.4%), bridle scars (n = 1, 7.1%), post-traumatic neuromas (n = 2, 14.3%) and vulvar cysts (n = 6, 42.9%), the latter being found more frequently in women with FGM/C type III. In 2 cases (14.3%) of chronic vulvar pain, no lesions other than FGM/C were visible at clinical examination. Among these 14 women, 12 suffered from superficial dyspareunia as well. The remaining ones had not had any sexual contact for several years. Dyspareunia was present in 126 women (24.9%), among which 75 patients (14.8%) suffered from superficial dyspareunia and 25 patients (4.9%) complained of deep dyspareunia. Fourteen women (2.8%) reported both superficial and deep dyspareunia. Twelve women (2.3%) reported dyspareunia with no specified localization documented in the medical charts. Dyspareunia was significantly more frequent among infibulated women compared to women with FGM/C different from type III (P = .014).

CONCLUSION

Chronic vulvar pain after FGM/C is probably associated with scar complications and FGM/C type III (infibulation). Dyspareunia is more frequent in women with FGM/C type III. Bazzoun Y, Aerts L, Abdulcadir J. Chronic Vulvar Pain After Female Genital Mutilation/Cutting: A Retrospective Study. Sex Med 2021;9:100425.

Evaluation of the effect of multipoint intra-mucosal vaginal injection of a specific cross-linked hyaluronic acid for vulvovaginal atrophy: a prospective bi-centric pilot study

Background

Vulvo-vaginal atrophy (VVA) is one of the common consequences of estrogen deficiency especially after the menopause. Several studies have assessed the effects of Hyaluronic acid (HA) on physical and sexual symptoms associated with VVA with promising results. However, most of these studies have focused on subjective assessment of symptom response to topically administered preparations. Nonetheless, HA is an endogenous molecule and it is logical that its effects are best realized if injected in the superficial epithelial layers. Desirial® is the first crosslinked HA that is administered by injection in the vaginal mucosa. The aim of this study was to explore the effect of multipoint vaginal intra-mucosal injections of specific cross-linked hyaluronic acid (DESIRIAL®, Laboratoires VIVACY) on several clinical and patient reported core outcomes.

Methods

A cohort bi-centric pilot study. The chosen outcomes included change in vaginal mucosa thickness, biological markers for collagen formation, vaginal flora, vaginal pH, vaginal health index, vulvo-vaginal atrophy symptoms and sexual function 8 weeks post Desirial® injection. Patients’ satisfaction was also assessed using the patient global impression of improvement (PGI-I) scale.

Results

A total of 20 participants were recruited between 19/06/2017 and 05/07/2018. At the end of the study, there was no difference in the median total thickness of the vaginal mucosa or in procollagen I, III or Ki67 fluorescence. However, there was a statistically significant increase in COL1A1 and COL3A1 gene expression (p = 0.0002 and p = 0.0010 respectively). There was also a significant reduction in reported dyspareunia, vaginal dryness, vulvar pruritus, vaginal chafing and significant improvement in all female sexual function index dimensions. Based on PGI-I, 19 patients (95%) reported varying degrees of improvement where, 4 (20%) felt slightly better; 7 (35%) better and 8 (40%) much better.

Conclusions

Multi-point vaginal intra-mucosal injections, of Desirial® (a crosslinked HA) was significantly associated with the expression of CoL1A1 and CoL3A1 suggesting stimulation of collagen formation. Furthermore, there was a significant reduction in VVA symptomatology and a significant improvement in patient satisfaction and sexual function scores. However, there was no demonstrable change in the total vaginal mucosal thickness.

Study registration ID-RCB: 2016-A00124-47, Protocol code number: LOCAL/2016/PM-001.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12905-021-01435-w.

Sexual Function After Pelvic Reconstructive Surgery

Improvement in sexual function is an important goal for many women undergoing surgery for pelvic organ prolapse, and patient counseling regarding changes in sexual function and activity is necessary prior to pelvic reconstructive surgery. Based on validated questionnaires, sexual function either remains unchanged or improves after pelvic reconstructive surgery for prolapse, while dyspareunia prevalence is reduced. De novo dyspareunia ranges from 0% to 9% after various types of prolapse surgery, with the exception of posterior repair.

Secondary dysmenorrhea and dyspareunia associated with pelvic girdle dysfunction: A case report and review of literature

Secondary dysmenorrhea is frequently associated with dyspareunia. When the diagnostic workup is negative, its clinical management could be complex and a cause for concerned for the patient. We reported a case of a young woman who suffered from dyspareunia, dysmenorrhea and chronic pelvic pain. After symptoms progression and pharmacological therapy unresponsiveness, the gynaecologist referred the patient to an osteopath for the functional evaluation of the abdominal pevic area. The examination revealed the presence of pelvic, lumbosacral, and sacrococcygeal dysfunctions which, once treated, significatively reduced the severity of dysmenorrhea and dyspareunia. A multidisciplinary approach might be considered in case of suspected functional impairment. This should be carefully evaluated, considering the previous trauma history and the somatic dysfunctions on abdominal-pelvic fascia.

Epidemiology and aetiology of male and female sexual dysfunctions related to pelvic ring injuries: a systematic review

Introduction

Pelvic ring injuries, frequently caused by high energy trauma, are associated with high rates of morbidity and mortality (5–33%), often due to significant blood loss and disruption of the lumbosacral plexus, genitourinary system, and gastrointestinal system. The aim of the present study is to perform a systematic literature review on male and female sexual dysfunctions related to traumatic lesions of the pelvic ring.

Methods

Scopus, Cochrane Library MEDLINE via PubMed, and Embase were searched using the keywords: “Pelvic fracture,” “Pelvic Ring Fracture,” “Pelvic Ring Trauma,” “Pelvic Ring injury,” “Sexual dysfunction,” “Erectile dysfunction,” “dyspareunia,” and their MeSH terms in any possible combination. The following questions were formulated according to the PICO (population (P), intervention (I), comparison (C), and outcome (O)) scheme: Do patients suffering from pelvic fracture (P) report worse clinical outcomes (C), in terms of sexual function (O), when urological injury occurs (I)? Is the sexual function (O) influenced by the type of fracture (I)?

Results

After screening 268 articles by title and abstract, 77 were considered eligible for the full-text analysis. Finally 17 studies that met inclusion criteria were included in the review. Overall, 1364 patients (902 males and 462 females, M/F ratio: 1.9) suffering from pelvic fractures were collected.

Discussion

Pelvic fractures represent challenging entities, often concomitant with systemic injuries and subsequent morbidity. Anatomical consideration, etiology, correlation between sexual dysfunction and genitourinary lesions, or pelvic fracture type were investigated.

Conclusion

There are evidences in the literature that the gravity and frequency of SD are related with the pelvic ring fracture type. In fact, patients with APC, VS (according Young-Burgess), or C (according Tile) fracture pattern reported higher incidence and gravity of SD. Only a week association could be found between GUI and incidence and gravity of SD, and relationship between surgical treatment and SD. Electrophysiological tests should be routinely used in patient suffering from SD after pelvic ring injuries.

Which symptoms of pelvic floor dysfunction does physiotherapy improve after an OASI?

OBJECTIVES

Obstetric Anal Sphincter Injury (OASI) is associated with significant morbidity in the form of pelvic floor dysfunction, both in the immediate period of healing and long term. The aim of this study was to determine the prevalence of urinary, anorectal and sexual symptoms arising from OASI within 6 weeks after delivery at their first physiotherapy appointment (immediate postnatal) and 3-6 months after delivery following completion of physiotherapy (intermediate postnatal). Symptom prevalence were compared between the two time periods and the impact of pelvic floor physiotherapy analysed to determine any changes in symptomology.

STUDY DESIGN

This prospective observational study, conducted at a tertiary teaching hospital, involved completion of a paper questionnaire by pelvic floor physiotherapists at the immediate postnatal review and by consultant gynaecologists at the intermediate postnatal review. Data were then compared to determine changes in symptoms using Fisher Exact tests and Mann Whitney U tests.

RESULTS

Of the 131 women seen within 6 weeks of delivery, follow-up data at 3-6 months were collected for 96. There was a significant improvement in pain on defecation (P = 0.008), rectal bleeding on wiping (P = 0.0233) and women's ability to defer a bowel motion (P = 0.0001) however faecal incontinence did not improve significantly even with supervised physiotherapy. Urinary symptoms including stress incontinence, urgency and nocturia also significantly improved at P = 0.0097, P = 0.0045 and P < 0.0001, respectively. For the sexual domain, significantly more women had resumed intercourse (P < 0.0001) and started using contraception (P < 0.0001) by the follow up appointment.

CONCLUSION

This study shows that physiotherapy is valuable in the treatment of urinary symptoms after delivery but does not have the same impact on faecal incontinence. Further investigation is required to confirm if early anal symptomology may be a predictor of long-term adverse outcomes.

Vaginismus, Dyspareunia and Abuse History: A Systematic Review and Meta-analysis

BACKGROUND

Genito-pelvic pain/penetration disorder, which consists of a combination of vaginismus and dyspareunia, is considered a new diagnosis in the latest version of the Diagnostic and Statistical Manual of Mental Disorders. Although the etiology of this diagnosis is not well known, a history of abuse has been suggested to be a primary factor in the emergence of this disorder.

AIM

This systematic review and meta-analysis aimed to determine the association of abuse history with vaginismus and dyspareunia diagnosis.

METHODS

Related keywords were used to search articles in PubMed, PsycArticles, PsycINFO, Scopus, Web of Science, and the Turkish scientific information database (TRDizin). All articles published in English and Turkish until August 2020 were systematically reviewed. A total of 14 case-control studies, including 1428 participants, were included in the final analysis. The fixed-effects model was used to pool odd ratios (ORs) and 95% confidence intervals (CIs) of the studies. Heterogeneity was evaluated using the I² statistic.

OUTCOMES

Case-control studies that reported vaginismus or dyspareunia outcomes in individuals with or without a history of abuse.

RESULTS

A significant relationship was found between a history of sexual (1.55 OR; 95% CI, 1.14-2.10; 12 studies) and emotional abuse (1.89 OR; 95% CI, 1.24-2.88; 3 studies) and the diagnosis of vaginismus. A significant relationship was found between sexual abuse and dyspareunia (1.53 OR; 95% CI, 1.03-2.27; 6 studies). No statistically significant relationship was observed between physical abuse, vaginismus, and dyspareunia. No significant difference was found between sexual or physical abuse in terms of assessment methods for the diagnosis of vaginismus and dyspareunia.

CLINICAL IMPLICATIONS

This systematic review and meta-analysis points out that in the assessment of vaginismus patients, the risk of sexual and emotional abuse and in the assessment for dyspareunia patients, the risk of sexual abuse should be questioned and addressed in its treatment.

STRENGHT AND LIMITATIONS

The strength of the current meta-analysis is the inclusion of all forms of abuse, and studies published in Turkish and English with a broad and reproducible search strategy. The limitations of this meta-analysis are the exclusion of sources and design other than journal articles and case-control studies, including studies both childhood and adult abuse, which in some studies were not differentiated, having potential language and recall bias.

CONCLUSION

The study analysis suggests an association of vaginismus with sexual and emotional abuse and dyspareunia with sexual abuse. However, both disorders showed no association with physical abuse. S. Tetik, ÖY. Alkar, Vaginismus, Dyspareunia, and Abuse History: A Systematic Review and Meta-analysis. J Sex Med 2021;18:1555-1570.

Use of Botulinum Toxin (Botox®) in Cases of Refractory Pelvic Floor Muscle Dysfunction

INTRODUCTION

Pelvic floor muscle (PFM) dysfunction is a sexual pain disorder characterized by involuntary spasm of pelvic floor muscles (PFMs) around the vagina that interferes with intercourse or any kind of vaginal penetration, making it impossible or extremely painful. Recently, researchers have shown increased interest in botulinum toxin (BoNTA) as an alternative option for refractory cases of PFM dysfunction, especially those that fail first-line treatments. Questions have been raised about the efficacy of BoNTA for the treatment of PFM dysfunction.

OBJECTIVES

To provide an updated and comprehensive review on the role of BoNTA in the management of refractory PFM dysfunction.

METHODS

We reviewed the literature using a systematic search strategy via PubMed and Google Scholar databases, to identify articles investigating the use of BoNTA in PFM dysfunction. We included studies that explored its indications, mechanism of action, injection dosing and technique, success rate, side effects, and contraindications.

RESULTS

We identified 20 relevant articles. Of these, 12 were original studies: 7 clinical trials, 1 retrospective cohort study and 4 case reports or case series. Doses of BoNTA that were used in these studies ranged between 20 and 500 units. The most commonly injected sites were levator ani muscles. Success rates varied between 62 and 100 %. Most studies showed no recurrence within 1 year after treatment. The majority of these studies used BoNTA after conventional first-line treatments have failed.

CONCLUSION

PFM dysfunction is a debilitating condition that adversely affects quality of life. There is promising evidence to support the use of BoNTA in cases of refractory PFM dysfunction. Further randomized controlled trials are warranted to standardize the use of BoNTA as a treatment option for these cases. Gari R, Alyafi M, Gadi RU, et al. Use of Botulinum Toxin (Botox) in Cases of Refractory Pelvic Floor Muscle Dysfunction. Sex Med Rev 2021;XX:XXX-XXX.

Coping with dyspareunia, the importance of inter and intrapersonal context on women's sexual distress: a population-based study

BACKGROUND

Recently known as the genito-pelvic pain/penetration disorder (GPPPD), Dyspareunia is considered a negative factor affecting a couple's sexual health. This paper analyzes pain in Dyspareunia cases and determines protective factors causing lower levels of sexual distress among patients.

METHODS

In a population-based cross-sectional study conducted in 2017, the cluster quota sampling technique was adopted to randomly select 590 Iranian married women aged 18-70 years from 30 health centers. The research tools included demographic data, a sexual distress scale, and Binik's GPPPD questionnaire.

RESULTS

In this study, the prevalence of self-report Dyspareunia, confirmed moderate Dyspareunia, and confirmed severe Dyspareunia (based on Binik's proposed criteria) were 33 %, 25.8 %, and 10.5 %, respectively. Interestingly, 32 (34 %) out of 94 women who experienced severe pain based on Binik's criteria reported no sexual distress. Compared to women with distress, they also had more positive body images, higher self-confidence, higher levels of sexual satisfaction, and more intimacy in their relationships (P = 0.000). In contrast, 8.5 % of the participants reported significant sexual distress even without confirmed Dyspareunia.

CONCLUSIONS

Improving intrapersonal characteristics such as self-confidence and body image as well as interpersonal factors such as sexual satisfaction and intimacy with a spouse can effectively treat Dyspareunia by alleviating sexual distress. The partner's role in female pain and distress management would be more critical than previously thought.

Extracorporeal shock wave therapy for treating dyspareunia: A prospective, randomized, double-blind, placebo-controlled study

BACKGROUND

Dyspareunia is a genital pain during or after penile-vaginal sexual intercourse. It is a painful spasm of the pelvic muscles that partly or entirely disables vaginal penetration.

OBJECTIVES

We examined the effect of extracorporeal shock wave therapy (ESWT) on idiopathic non-organic dyspareunia in women. A prospective, randomized, double-blind, placebo-controlled study was conducted.

METHODS

The study included 62 women who reported dyspareunia. Patients in the treatment and placebo groups received ESWT perineally weekly for 4 consecutive weeks; placebo patients received placebo stand-off treatment. The grade of dyspareunia was estimated by using the Marinoff Dyspareunia Scale and subjective pain intensity on a visual analog scale (VAS) before and after treatment. Follow-ups were conducted 1, 4 and 12 weeks after the final ESWT session.

RESULTS

The study included 61 women. The treatment but not placebo group differed by the Marinoff Dyspareunia Scale and VAS. Differences before and after treatment within groups were all P<0.001 and between groups, P<0.001. Pain reduction was always>30%. The effect sizes were both large: Marinoff 0.825 and VAS 0.883.

CONCLUSIONS

ESWT significantly reduced subjective pain in our women treated for dyspareunia.

The association of mode of delivery and dyspareunia: a systematic review and meta-analysis

This meta-analysis aimed to examine the association between the mode of delivery and dyspareunia worldwide. Epidemiologic studies evaluating the link between the mode of delivery and dyspareunia (published up to July 2019) were included in this research. These studies were selected by searching several databases such as MEDLINE, ClinicalTraial.gov, PubMed, Web of Science, Scopus and Google Scholar and considering the list of selected articles extracted from references. Then, meta-analyses, subgroup analyses and meta-regressions of the studies were conducted to evaluate the association between the mode of delivery and dyspareunia. In this study, 23 out of 1099 articles were identified and used in the final analysis. Dyspareunia differed according to the mode of delivery although this difference was not statistically significant. In terms of the mode of delivery, a difference was found between instrumental vaginal delivery and caesarean section, but it was not significant. It seems that more studies with a larger sample size should be considered to determine the difference.

A cross-sectional study of traditional Chinese medicine practitioner's knowledge, treatment strategies and integration of practice of chronic pelvic pain in women

BACKGROUND

Chronic pelvic pain (CPP) in women is persistent, intermittent cyclical and non-cyclical lower abdominal pain, lasting for more than 6 months. Traditional Chinese Medicine (TCM) is a popular treatment option for women's health conditions, but little is known about how treatment for CPP is delivered by TCM practitioners. The aim of this survey was to explore practitioners understanding and treatment of women with CPP, and how they integrate their management and care into the health care system.

METHOD

An online cross-sectional survey of registered TCM practitioners in Australia and New Zealand between May and October 2018. Survey domains included treatment characteristics (e.g. frequency), evaluation of treatment efficacy, referral networks, and sources of information that informed clinical decision making.

RESULTS

One hundred and twenty-two registered TCM practitioners responded to this survey, 91.7% reported regular treatment of women with CPP. Treatment decisions were most-often guided by a combination of biomedical and TCM diagnosis (77.6%), and once per week was the most common treatment frequency (66.7%) for acupuncture. Meditation (63.7%) and dietary changes (57.8%) were other commonly used approaches to management. The effectiveness of treatment was assessed using multiple approaches, most commonly pain scales, (such as the numeric rating scale) and any change in use of analgesic medications. Limitations to TCM treatment were reported by over three quarters (83.7%) of practitioners, most commonly due to cost (56.5%) and inconvenience (40.2%) rather than safety or lack of efficacy. Sources informing practice were most often Integration within the wider healthcare system was common with over two thirds (67.9%) receiving referrals from health care providers.

CONCLUSION

TCM practitioners seeing women with various CPP symptoms, commonly incorporate both traditional and modern diagnostic methods to inform their treatment plan, monitor treatment progress using commonly accepted approaches and measures and often as a part of multidisciplinary healthcare for women with CPP.

Reductions in endometriosis-associated pain among women treated with elagolix are consistent across a range of baseline characteristics reflective of real-world patients

Background

Elagolix is an oral, gonadotropin-releasing hormone (GnRH) receptor antagonist, that significantly reduces dysmenorrhea and non-menstrual pelvic pain (NMPP) in women with moderate to severe endometriosis-associated pain.

Methods

Data were pooled from two 6-month, placebo-controlled, phase 3 studies (Elaris Endometriosis [EM]-I and II) in which 2 doses of elagolix were evaluated (150 mg once daily and 200 mg twice daily). Pooled data from > 1600 women, aged 18–49, were used to evaluate the efficacy of elagolix and health-related quality of life (HRQoL) in prespecified subgroups of women with various baseline characteristics.

Results

Of the 1686 women treated, 1285 (76.2%) completed the studies. The percentages of women with clinically meaningful reductions in dysmenorrhea and NMPP were generally consistent by subgroup. Significant treatment by subgroup interaction was demonstrated for dysmenorrhea response in baseline analgesic use (p < 0.01) and previous history of pregnancy (p < 0.05) subgroups, and for NMPP response in the baseline NMPP score (p < 0.05) and history of pregnancy (p < 0.05) subgroups. Patient-reported reduction in pain at month 3 was significant across all subgroups taking elagolix 200 mg BID, and significant across most subgroups with elagolix 150 mg QD. Women across subgroups experienced improvement within each domain of the Endometriosis Health Profile-30 (EHP-30), although significant treatment by subgroup interactions were observed in several categories.

Conclusions

Elagolix was effective in reducing dysmenorrhea and NMPP, and improving HRQoL, compared with placebo across numerous subgroups of women with various baseline characteristics, covering a broad segment of the endometriosis disease and patient types.

Clinical trial registration: ClinicalTrials.gov: https://www.clinicaltrials.gov/ct2/show/NCT01620528; https://www.clinicaltrials.gov/ct2/show/NCT01931670.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12905-021-01385-3.

Relationship of postoperative vaginal anatomy and sexual function: a systematic review with meta-analysis

INTRODUCTION AND HYPOTHESIS

This was a planned secondary analysis of a systematic review that described sexual function outcomes following pelvic organ prolapse (POP) surgery. We aimed to describe the relationship of pre- and postoperative vaginal anatomic measures with sexual function outcomes. Data Sources included the Medline, Embase, and clinicaltrials.gov databases from inception to April 2018.

METHODS

The original systematic review included prospective, comparative studies that reported sexual function outcomes before and following POP surgery. Studies were extracted for population characteristics, sexual function outcomes, and vaginal anatomy, including total vaginal length (TVL) and genital hiatus. By meta-regression, we analyzed associations across studies between vaginal anatomic measurements and sexual function using the Pelvic Organ Prolapse/Urinary Incontinence Sexual Function Questionnaire-12 (PISQ-12) and dyspareunia outcomes.

RESULTS

We screened 3124 abstracts and identified 74 papers representing 67 original studies. Among these, 14 studies reported TVL and PISQ-12 outcomes. Nine studies reported TVL and dyspareunia outcomes, eight studies reported GH and PISQ-12 outcomes, and seven studies reported GH and dyspareunia outcomes. We found no associations between anatomic measures and PISQ-12 or dyspareunia, although, we found a statistically significant association found between preoperative TVL and change in PISQ-12.

CONCLUSION

Across studies, the evidence does not support an association between vaginal anatomy and either validated, condition-specific sexual function questionnaires or dyspareunia. However, no study has directly analyzed these associations in the setting of pelvic floor reconstructive surgery.

Low Dose, High Frequency Movement Based Dilator Therapy for Dyspareunia: Retrospective Analysis of 26 Cases

INTRODUCTION

While two-thirds of women will experience dyspareunia and vaginal dilators are often used to treat dyspareunia, outside of a single case report, no study has investigated the potential of low-dose, high frequency movement-based dilator therapy for dyspareunia in premenopausal female patients.

AIM

To determine the utility of low-dose, high frequency movement-based dilator use for dyspareunia in premenopausal female patients.

METHODS

Retrospective study of women presenting to outpatient hospital-based pelvic floor physical therapy office in a tertiary care center. All adult premenopausal female patients who were referred to pelvic floor physical therapy for dyspareunia and completed movement-based dilator therapy (MBDT) and met study criteria (n = 26) were included for analysis.

MAIN OUTCOME MEASURE

Patient change in pain level status using Numeric Pain Rating Scale with intercourse was compared between initial evaluation and time of discharge from pelvic floor physical therapy.

RESULTS

Among the 26 women who met criteria for this study, the average pain score decreased from 8.3 (SD 2.2) before treatment to 1.3 (SD 2.0) after treatment and was statistically significant (P< .001). Complete resolution of dyspareunia was reported in 58% of patients. Patients completed between 2 and 6 total pelvic floor physical therapy visits (average 3.7, SD1.5), over 0-44 weeks (mean 9.6 weeks, SD 8.3).

CONCLUSION

Low-dose, high frequency, movement-based dilator therapy significantly reduced or resolved the experience of pain with penetrative vaginal intercourse with dyspareunia. Future prospective studies with larger samples and the inclusion of sexual functional status should be considered to explore the full potential of this modality in treatment of premenopausal patients with dyspareunia. Miles K, Miles S. Low Dose, High Frequency Movement Based Dilator Treatment for Dyspareunia: Retrospective Analysis of 26 Cases. Sex Med 2021;9:100344.