Efficacy of vaginal therapies alternative to vaginal estrogens on sexual function and orgasm of menopausal women: A systematic review and meta-analysis of randomized controlled trials

Genitourinary syndrome of menopause (GSM) increases the probability of female sexual dysfunction (FSD). The aim of the current study is to systematically assess data regarding sexual function and use of vaginal therapies, alternative to vaginal estrogens (VE), in menopausal women with GSM. PubMed, Scopus and Cochrane Library were searched (May-September 2017) using combination keywords: "dyspareunia and vaginal therapy", "sexual function and vaginal therapy", "orgasm and vaginal therapy", "vaginal atrophy" and "genitourinary syndrome of menopause". Eligible studies were RCTs focusing on the use of vaginal therapies, alternative to VE, in menopausal women. These studies were written in English language and published in peer-reviewed journals with impact factor. Assessment of risk of bias was performed using the Cochrane Risk of Bias Tool. Outcomes involved dyspareunia, vaginal dryness, orgasm and all parameters of sexual function. Twenty-nine RCTs including 3689 menopausal women, were included. Vaginal therapies, alternative to VE included non-hormonal (vaginal laser, lubricants/moisturizers, phytoestrogens and lidocaine) and hormonal ones (Dehyadroapiandrosterone (DHEA), testosterone and oxytocin). Dyspareunia and/or vaginal dryness were assessed in 72% of the articles, while the FSD and orgasm in 45% and 28% of articles, respectively. Dyspareunia and vaginal dryness improved in all relevant studies. Sexuality scores of lubricants were inferior to estrogens [3 studies, n = 138, standardized mean difference (smd) -0.64, (95%CI -1.1, -0.2)]. Orgasm domain was the same for the DHEA 0.5% and placebo (2 studies, n = 663, smd 1.29 (95% -0.47, 3.05), I²:90%). Sexual satisfaction and sexuality score were the same when testosterone was compared or added to estrogen therapy (2 studies, n = 99, smd 0.16 (95%CI-0.23,0.56), I²:12% and 2 studies (n = 87), smd 0.20 (95%CI-0.23,0.62), I²:0%, respectively. Available data are not adequate to provide counseling by the physicians in menopausal women regarding the efficacy of vaginal therapies as an alternative to estrogens, on all parameters of sexual function.

Loneliness Mediates the Relationship Between Pain During Intercourse and Depressive Symptoms Among Young Women

Previous research suggests that women who experience pain during intercourse also experience higher rates of depressive symptoms. Loneliness might be one factor that contributes to this relationship. We hypothesized that women who experience more severe and interfering pain during intercourse would report higher rates of loneliness and higher rates of depressive symptoms. Further, we hypothesized that loneliness would mediate the relationship between pain during intercourse and depressive symptoms. A total of 104 female participants (85.6% white, 74.03% partnered, 20.9 [3.01] years old) completed an online survey including demographic information, PROMIS Vaginal Discomfort Measure, PROMIS Depression Measure, and Revised UCLA Loneliness Scale. Pearson correlations and bootstrapped mediation analysis examined the relationships among pain during intercourse, loneliness, and depressive symptoms. Pain during intercourse, loneliness, and depressive symptoms were all significantly correlated (p < .05). Results of the mediation analysis indicated that loneliness was a significant mediator of the relationship between pain during intercourse and depressive symptoms (indirect effect = 0.077; 95% CI 0.05-0.19). After accounting for loneliness, pain during intercourse was not significantly related to depressive symptoms, suggesting that loneliness fully mediated the relationship between pain during intercourse and depressive symptoms. These findings are consistent with previous studies highlighting that pain during intercourse is related to depressive symptoms. The current study adds to that literature and suggests that more frequent and severe pain during intercourse leads to more loneliness, which then leads to increased depressive symptoms. This line of work has important implications for treating women who experience depressive symptoms and pain during intercourse.

Vulvar vestibular effects of ospemifene: a pilot study

The study aimed to assess the effects of ospemifene on vulvar vestibule in postmenopausal women with vulvar pain and dyspareunia. Fifty-five postmenopausal women used oral ospemifene 60 mg/d for 60 d. Symptoms of dryness, burning, and dyspareunia were evaluated on a 10 cm visual analog scale. Visual examination of the vulvar vestibule was also conducted. Patients also underwent current perception threshold (CPT) testing obtained from the vulvar vestibule. Fifty-five patients (94.6%) completed the treatment. Hot flashes were the most frequent adverse effects, but this led to a discontinuation of therapy in three patients (5.4%). After therapy, there was a statistically significant decrease from the baseline in the mean scores for dryness, burning, and dyspareunia and reduction of vestibular trophic score (baseline value of 11.2-4.2 after the therapy, p ≤ 002) and cotton swab test scores (2.81 compared with 1.25, p = .001). There was a difference in CPT values for all nerve fibers and more consistent for C fibers (-38% of sensitivity). These results confirm the efficacy of ospemifene on postmenopausal vestibular symptoms and signs; moreover, the drug was effective in normalizing vestibular innervation sensitivity.

Vaginal diazepam plus transcutaneous electrical nerve stimulation to treat vestibulodynia: A randomized controlled trial

OBJECTIVE

To assess the effectiveness of vaginal diazepam in addition to transcutaneous electrical nerve stimulation (TENS) in the treatment of vestibulodynia (VBD).

STUDY DESIGN

This study was a randomized, double-blind, placebo-controlled trial. Forty-two patients with VBD were randomized, 21 underwent diazepam and TENS (diazepam group) and 21 received placebo and TENS (placebo group). Vulvar pain was assessed on a on a 10-cm visual analogue scale (VAS) and dyspareunia according to the Marinoff dyspareunia scale. Vaginal surface electromyography (EMG) and vestibular current perception threshold (CPT) testing were performed at baseline and 60 days after treatment. The primary endpoints included the change in pain and dyspareunia from baseline to 60 days of pain and dyspareunia. The secondary endpoints was the variation in objectivity of pelvic floor muscle (PFM) function and vestibular nerve fiber current perception threshold (CPT).

RESULTS

The VAS scores for pain from basal values of 7.5 and 7.2 for the diazepam and placebo, respectively, showed significant (p 0.01) decreases from 4.7 to 4.3, but this difference was not statistically significant. The Marinoff dyspareunia scores in the diazepam group showed a significant difference (p 0.05) from values measured in the placebo group. The ability to relax the PFM after contraction (difference between maximal contraction and rest tone) was significantly greater for the diazepam group versus the placebo group (3.8 μv and 2.4 μv, respectively, p 0.01). The CPT values for all of the nerve fibers increased after the treatment, but this increase was significant in the diazepam group only for the values at a 5-Hz stimulation (C fibers) with a change of 47.8% vs 26.9% (p < 0.05). Only two patients reported a mild drowsiness in the diazepam group.

CONCLUSIONS

The present study provided indications that vaginal diazepam plus TENS is useful to improve pain and PFM instability in women with VBD.

A Rare Case Report of a Tail-Gut Cyst from a Gynecological Point of View

A tail-gut cyst can be often a misleading clinical entity. In half of the patients there is no presenting symptom. On the other half, the patients most commonly present with a variety of symptoms such as rectal pain, constipation, lower back pain, dysuria or dyspareunia. The recommended treatment of choice for the tail-gut cyst is complete surgical excision without rupture of the cyst. We present the case of a 29-year-old female with history of dyspareunia over a 5-month period, who discovered an "ovarian" cyst during an annual scheduled ultrasound appointment. However, the intraoperative findings were surprising. The bottomline is always to keep in mind the Pandora's Box of the retrorectal space.

Prevalence of and risk factors associated with sexual health issues in primiparous women at 6 and 12 months postpartum; a longitudinal prospective cohort study (the MAMMI study)

BACKGROUND

Many women are not prepared for changes to their sexual health after childbirth. The aim of this paper is to report on the prevalence of and the potential risk factors (pre-pregnancy dyspareunia, mode of birth, perineal trauma and breastfeeding) for sexual health issues (dyspareunia, lack of vaginal lubrication and a loss of interest in sexual activity) at 6 and 12 months postpartum.

METHODS

A longitudinal cohort study of 832 first-time mothers who were recruited in early pregnancy and returned postnatal surveys at 3, 6, 9 and 12 months postpartum were assessed for sexual health issues and associated risk factors.

RESULTS

Nearly half of the women (46.3%) reported a lack of interest in sexual activity, 43% experienced a lack of vaginal lubrication and 37.5% of included women had dyspareunia 6 months after birth. On univariate analysis, vacuum-assisted birth, 2nd degree perineal tears, 3rd degree perineal tears and episiotomy were all associated with dyspareunia 6 months postpartum, but, of these only 3rd degree tears, in association with breastfeeding and pre-existing dyspareunia, remained significant on multivariable analysis. Breastfeeding, in combination, with other significant factors, was associated with dyspareunia, a lack of vaginal lubrication and a loss of interest in sexual activity 6 months postpartum, and, dissatisfaction with body image emerged as a significant factor associated with lack of interest in sexual activity at 12 months postpartum. Pre-pregnancy dyspareunia and breastfeeding emerged as common factors associated with all three outcomes of dyspareunia, a lack of vaginal lubrication and a loss of interest in sexual activity at 6 months postpartum.

CONCLUSION

Breastfeeding and pre-existing dyspareunia are associated with sexual health issues at 6 months postpartum. Pre-existing dyspareunia is associated with a lack of vaginal lubrication at 12 months postpartum and breastfeeding is associated with dissatisfaction with body image. Preparing women and their partners during the antenatal period and advising on simple measures, such as use of lubrication to avoid or minimise sexual health issues, could potentially remove stress, anxiety and fears regarding intimacy after birth. Introducing the topic of pre-existing sexual health issues antenatally may facilitate appropriate support, treatment or counselling for women.

Pelvic Floor Physical Therapy for Vulvodynia: A Clinician's Guide

Vulvar pain affects up to 20% of women at some point in their lives, and most women with vulvar pain have associated pelvic floor impairments. Pelvic floor dysfunction is associated with significant functional limitations in women by causing painful intercourse and urinary, bowel, and sexual dysfunction. A quick screening of the pelvic floor muscles can be performed in the gynecology office and should be used when patients report symptoms of pelvic pain. It is now known the vulvar pain syndromes are heterogeneous in origin; therefore, successful treatment plans are multimodal and include physical therapy.

A Rare Case of Rectovaginal Fistula Due to Consensual Sexual Intercourse

Rectovaginal fistulae after sexual intercourse are rare. We report a healthy recently married 21-year-old woman who presented to the Jordan Healthcare Centre, Amman, Jordan in 2014 with a five-week history of passing flatus and stool from the vagina. Six weeks prior, she had sustained a rectovaginal injury during initial consensual sexual intercourse, leading to the development of a distal rectovaginal fistula. A successful transvaginal repair was performed nine weeks after presentation which resulted in the complete resolution of her symptoms.

Improvements to the Vulva, Vestibule, Urethral Meatus, and Vagina in Women Treated With Ospemifene for Moderate to Severe Dyspareunia: A Prospective Vulvoscopic Pilot Study

Introduction

Ospemifene, an oral selective estrogen receptor modulator approved for the treatment of mild to moderate dyspareunia from menopause, has been shown to moderate sexual pain and vaginal epithelial cell characteristics. However, no prospective vulvoscopic studies have been performed.

Aim

To examine, in menopausal women taking ospemifene 60 mg daily, changes to the vulva, vestibule, urethral meatus, and vaginal region over 20 weeks using vulvoscopy in a prospective open-label pilot study.

Methods

Vulvoscopic photographs taken at screening and the end of therapy assessed for changes in the appearance of the vulva, vestibule, urethral meatus, and vagina rated by a single reviewer using a 10-parameter Likert rating scale, the Vulvoscopic Genital Tissue Appearance Scale (VGTA). In addition, the cotton-tipped swab test and subject diary scores were assessed over the 20-week treatment period and compared before and after the intervention using Wilcoxon signed-rank test.

Main Outcome Measure

Changes in VGTA score from baseline to end of study.

Results

8 subjects (age = 59 ± 4.7 years) completed all visits and were included in the analysis of vulvoscopic photographs (n = 258). There were significant changes during the study period for urethral meatal prominence, introital stenosis, vestibular pallor, vestibular erythema, mucosal moisture, vaginal rugation, and anterior wall prominence (P < .05). Total pain score during cotton-tipped swab testing decreased from 11 (interquartile range = 10–16) before the intervention to 1 (interquartile range = 0–3) at the end of the study. Quantitative diary analysis indicated an increase in the number of sexual events, decrease in rates of pain during foreplay and intercourse, and decrease in use of lubricant at study completion (P < .05).

Conclusions

Ospemifene 60 mg daily for 20 weeks showed improvement in physical examination findings in this prospective study of menopausal women with dyspareunia, as documented on vulvoscopic photography. These changes were consistent with improvements in subject-reported pain and sexual function.

Goldstein SW, Winter AG, Goldstein I. Improvements to the Vulva, Vestibule, Urethral Meatus, and Vagina in Women Treated With Ospemifene for Moderate to Severe Dyspareunia: A Prospective Vulvoscopic Pilot Study. Sex Med 2018;6:154–161.

Female Sexual Dysfunction Among Muslim Women: Increasing Awareness to Improve Overall Evaluation and Treatment

INTRODUCTION

Muslim women are an increasingly underserved population in the United States and worldwide. Diagnosis and treatment of female sexual dysfunction bring unique challenges because of the conservative nature of those practicing the religion. Several cultural and religious codes of conduct affect sexual behavior and the dysfunction that can ensue.

AIM

To assess and describe the types of sexual dysfunction that have been found in Muslim women internationally and encourage a better understanding of their issues to enhance health care delivery.

METHODS

A comprehensive review of the literature through Ovid and PubMed was performed in search of articles reviewing female sexual dysfunction, Muslim women, and Islam.

MAIN OUTCOME MEASURES

A brief explanation and review of the interpretations of sexuality within Islam are discussed. The link is made between conservative sexual relations and interpretations and the types of sexual dysfunction experienced. Female sexual dysfunction is explored in relation to how female chastity is extolled and how cultural procedures continue despite the ethical and health concerns related to them.

RESULTS

Most Muslim women experience sexual dysfunction similar to other women, including arousal, desire, and orgasmic disorders related to organic and psychologic factors. Sexual pain disorders might be more prevalent in this population, particularly concerning unconsummated marriage. There are special concerns related to maintaining virginity and preserving the hymen until marriage. Female genital cutting, practiced by some Muslim countries, has potential sexual consequences.

CONCLUSION

Understanding Islamic views on sexuality and how they can affect sexual dysfunction in Muslim women is critical in opening lines of communication with patients and approaching female sexual dysfunction impartially. Although some issues that arise might introduce ethical dilemmas for the provider, having the cultural competence to address these issues will facilitate improved health care delivery. Rahman S. Female Sexual Dysfunction Among Muslim Women: Increasing Awareness to Improve Overall Evaluation and Treatment. Sex Med Rev 2018;6:535-547.

Patterns in Vulvodynia Treatments and 6-Month Outcomes for Women Enrolled in the National Vulvodynia Registry-An Exploratory Prospective Study

BACKGROUND

Vulvodynia is a poorly characterized condition with multiple treatment options that have been described as largely ineffective in research settings.

AIM

To describe treatment patterns in women enrolled in the National Vulvodynia Registry and determine if there is an association between selected treatments and patient-reported outcomes such as pain, sexual function, and psychological distress after 6 months of treatment.

METHODS

Participants completed questionnaires on general medical history and patient-reported outcomes using the short-form McGill Pain Questionnaire, the Female Sexual Function Index, the Short Form-12 quality-of-life questionnaire, the Coping Strategies Questionnaire, and the State-Trait Anxiety Inventory. The evaluation also included pain sensitivity assessment of the vaginal mucosa using a cotton-tipped applicator and the vaginal muscles using a single-digit. In this prospective cohort study, all measurements were collected at baseline and again at 6 months after treatment.

OUTCOMES

Type of treatment, number of treatments, self-reported pain intensity, dyspareunia, and pain-related psychological distress measures are reported at baseline and 6 months.

RESULTS

Of 344 women enrolled, 282 received treatment; 78 different treatments were identified and categorized by type (eg, topical, oral, physical therapy) and number. The most commonly used treatments were topical (85%, n = 241), physical therapy (52%, n = 147), and oral medications (45%, n = 128). Notably, 73% of participants received ≥2 treatments. There was no association between type or number of treatments and patient characteristics. At 6 months, women reported improvements in general pain (P = .001), pain during intercourse (P = .001), catastrophizing (P = .000), and anxiety (P = .000). The Short Form-12 quality-of-life questionnaire showed improvements in physical limitations (P = .024), emotional limitations (P = .003), well-being (P = .025), and social function (P = .010). However, all domains of the Female Sexual Function Index indicated worsening in sexual function (P = .000) except for pain.

CLINICAL TRANSLATION

Multi-modal treatments were most commonly used in clinical practice and improvements in patient-reported outcomes such as quality of life, distress, and pain were noted; however, participants who returned at 6 months continued to report poor sexual function.

CONCLUSIONS

Strengths include a prospective and long-term study design that evaluated women in clinical settings. Limitations include a high rate of loss to follow-up for certain measures and inability to evaluate efficacy of individual treatments. In a setting where women were receiving highly specialized care, we found wide variation in the type and number of treatments used to treat vulvodynia. Despite this heterogeneity in treatment selection, women reported significant improvements in all study measures except sexual function. Lamvu G, Alappattu M, Witzeman K, et al. Patterns in Vulvodynia Treatments and 6-Month Outcomes for Women Enrolled in the National Vulvodynia Registry-An Exploratory Prospective Study. J Sex Med 2018;15:705-715.

[Epidemiology and diagnosis strategy: CNGOF-HAS Endometriosis Guidelines]

Based on the best evidence available, we have provided guidelines for clinical practice to target the nature of endometriosis as a disease, the consequences of its natural history on management, and the clinical and imaging evaluation of the disease according to the level of care (primary care, specialized or referral). The frequency of endometriosis is unknown in the general population; endometriosis requires management when it causes symptoms (pain, infertility) or when it affect the function of an organ. In the absence of symptom, there is no need for follow-up or screening of the disease. Endometriosis may be responsible for various pain symptoms such as severe dysmenorrhea, deep dyspareunia, painful bowel movements or low urinary tract signs increasing with menstruation, or infertility. A careful evaluation of the symptoms and their impact on the quality of life should be made. The first-line examinations for the diagnosis of endometriosis are: digital examination and pelvic ultrasound. The second-line examinations are: the pelvic exam by an expert clinician, the pelvic MRI and/or the transvaginal ultrasound by an expert. MRI and ultrasound carrying different and complementary information. Other examinations may be considered as part of the pre-therapeutic assessment of the disease in case of specialized care. Diagnostic laparoscopy may be suggested in case of clinical suspicion of endometriosis whereas preoperative examinations have not proved the disease, it must be part of a management plan of endometriosis-related pain or infertility. During management, it is recommended to give comprehensive information on the different therapeutic alternatives, the benefits and risks expected from each treatment, the risk of recurrence, fertility, especially before surgery. The information must be personalized and take into account the expectations and preferences of the patient, and accompanied by an information notice given to the patient.

The Manchester procedure: anatomical, subjective and sexual outcomes

INTRODUCTION AND HYPOTHESIS

Classical native-tissue techniques for pelvic organ prolapse (POP) repairs, such as the Manchester procedure (MP), have been revitalized because of vaginal mesh complications. However, there are conflicting opinions regarding sufficient apical (mid-compartment) support by the MP and concerns about the risk of dyspareunia. The aims of this study were therefore to investigate anatomical and patient-reported outcomes 1 year after MP.

METHODS

Prospective cohort study of 153 females undergoing an MP for anterior compartment POP between October 2014 and June 2016. Pre- and 1-year postoperative evaluations included POP-Q measurements and the questionnaires Pelvic Floor Distress Inventory Short Form 20 (PFDI-20) and POP/Urinary Incontinence Sexual Questionnaire (PISQ-12).

RESULTS

At 1 year, 97% (148/153) attended the follow-up. Significant anatomical improvements (p < 0.01) were obtained in all compartments. Mean Ba was -1.1 (± 1.4), mean C -5.9 (± 1.7) and mean D -7.0 (± 1.2) at follow-up. Point C ≤ -5 was present in 81.1%. POP-Q stage 0-1 was obtained in 99.3% in the mid-compartment (C < -1), but only in 48.6% in the anterior compartment (Ba < -1). A significant reduction in symptom scores was obtained for PFDI-20 (p < 0.01) and PISQ-12 (p = 0.01). No significant changes were seen in dyspareunia rates (q.5, PISQ-12), but 5.6% reported de novo dyspareunia. Concerning POP symptoms, 96.0% reported being cured or significantly improved.

CONCLUSIONS

The Manchester procedure provides adequate apical support, albeit inferior anatomical anterior compartment results, and 96.0% reported being subjectively cured or substantially better at 1-year follow-up, with no significant change in dyspareunia.

The Vulvar Pain Assessment Questionnaire: Factor Structure, Preliminary Norms, Internal Consistency, and Test-Retest Reliability

BACKGROUND

The Vulvar Pain Assessment Questionnaire (VPAQ) was developed to assist in the assessment and diagnosis of chronic vulvar pain (vulvodynia).

AIM

To further establish the psychometric properties of the VPAQ by examining factor structure, test-retest reliability, internal consistency, and scale normative data, and to gather feedback from those with vulvar pain about the usefulness and accessibility of the questionnaire.

METHODS

182 participants completed a confidential online study and 70 participated again at time 2 (4 weeks later).

OUTCOMES

Participants were asked to complete the full VPAQ, which assesses pain characteristics, effects on various parts of their lives, coping strategies used, and romantic partner factors. Additional questions captured sociodemographics and feedback about the instrument.

RESULTS

Exploratory structural equation modeling indicated that the previously established subscales, except the coping scale, had adequate model fit, and all items loaded significantly onto relevant factors. Pearson product moment correlations (r = 0.57-0.96) established strong 4-week test-retest reliability for most subscale scores, and Cronbach α indicated overall acceptable to high internal consistency (α = 0.56-0.95). Preliminary norms for the scales are supplied. Approximately half the participants reported an increase in their comfort level in discussing a range of topics after completing the VPAQ. Most participants reported that the length, readability, and range of VPAQ questions were "good" or "excellent."

CLINICAL IMPLICATIONS

The results of this study provide further justification for using the VPAQ scales in clinical and research settings, preliminary norms for a vulvar pain population, and suggestions for interpretation.

STRENGTHS AND LIMITATIONS

This study established the psychometric properties of the VPAQ scales using multiple methods at 2 time points and gathered feedback from participants. However, data were collected online so diagnoses could not be confirmed and more than half the initial sample did not complete the survey at time 2.

CONCLUSION

The results of this study suggest that most VPAQ subscales (except the coping subscale) have moderate to strong psychometric properties and that the VPAQ is user friendly. Dargie E, Holden RR, Pukall CF. The Vulvar Pain Assessment Questionnaire: Factor Structure, Preliminary Norms, Internal Consistency, and Test-Retest Reliability. J Sex Med 2017;14:1585-1596.

Physiotherapy for pelvic pain and female sexual dysfunction: an untapped resource

Introduction and hypothesis

Chronic pelvic pain (CPP) in women is a complex syndrome. Pain sensation and intensity often do not correspond with the identified lesion location but are felt elsewhere, leading to muskuloskeletal and myofascial disorders and sexual dysfunction (SD). Although physical aspects are prevalent, they are often underdiagnosed and undertreated due to lack of understanding regarding its origin and distribution. Frequently, patients experience pelvic pain as psychological distress resulting in physical complaints, leading clinicians to prescribe medication or surgical intervention to correct or alleviate these symptoms, often with insufficient results. Because pelvic floor muscle disorders contribute significantly to CPP and SD, there is rationale for physiotherapy. However, physiotherapy is a widely underused and untapped resource, which has its place in the multidisciplinary approach to these health problems.

Methods

Computer-aided and manual searches and methodological quality assessment were carried out for meta-analyses, systematic reviews, and randomized controlled trials (RCTs) published between 1990 and 2017 investigating classification, assessment, and (physiotherapeutic) treatment of pelvic pain and/or female SD defined by the keywords below. Expert opinions were sought via interviews.

Results

Due to a lack of sufficient relevant medical information, referral data, and test results, focused physiotherapy is difficult to administer adequately. However, recent quality studies indicate significant clinical effects of physiotherapy for CPP and female SD, and experts advocate a multidisciplinary approach that includes physiotherapy.

Conclusions

Because of its holistic approach, physiotherapy can contribute significantly to the multidisciplinary assessment and treatment of CPP and female SD.

Sexual Function Post-Breast Cancer

The consequences of estrogen deprivation and therapeutic interventions such as radiation, chemotherapy and surgery have a significant negative impact on libido, sexual arousal, orgasmic function and the ability to have pleasurable intercourse. Evaluation and treatment of female sexual dysfunction is a significant unmet need in the breast cancer survivor in spite of the availability of safe and effective treatments.

The development and validation of a new postpartum sexual function and dyspareunia assessment tool: The Carol Scale

OBJECTIVE

The aim is to develop a new tool to evaluate postpartum sexual function and dyspareunia which will facilitate better evaluation of perineal pain in woman after vaginal delivery.

DESIGN

The development and validation of the Carol Postpartum Sexual Function and Dyspareunia Assessment Scale.

SETTING

The Obstetrics and Gynecology Service of a University Hospital in central Spain.

PARTICIPANTS

102 women after being attended for vaginal birth, and 5 midwife assessors.

FINDINGS

81women reinitiated sexual activity (with vaginal intercourse) during the first three months postpartum. The Carol Postpartum Sexual Function and Dyspareunia Assessment Scale (Carol Scale) was internally reliable with a Cronbach-α value of 0.79 (95%CI0.72-0.85). Cronbach-α coefficients for Carol Scale domains were: preparation for the sexual activity 0.69 (95%CI0.55-0.79), pain or discomfort on caressing the vulval area 0.86 (95%CI0.79-0.91), pain or discomfort related to vaginal intercourse 0.93 (95%CI0.90-0.95) and pain or discomfort after vaginal intercourse 0.86 (95%CI0.78-0.91).

CONCLUSIONS

The Carol Postpartum Sexual Function and Dyspareunia Assessment Scale is valid and reliable for measuring sexual function and postpartum dyspareunia in women after being attended for vaginal birth.

IMPLICATIONS FOR PRACTICE

The Carol Scale could be used both clinically and in research to improve the quality of care for the mother after childbirth. The scale could help to identify problems in the reinitiation of postpartum sexual activity and, therefore, could contribute to widening the clinical information about these women and help in decision making.

[Endometriosis : An often unrecognized pain disorder]

Endometriosis is a chronic disease of women during their reproductive age. The most typical symptoms are dysmenorrhoea, dyspareunia, dysuria, cyclical and acyclical pelvic pain, bleeding disorders and infertility. These symptoms lead to significant impairment of the quality of life and economic burden. The prevalence is estimated to be 2-20 % of all women in this age and due to this fact, it is one of the most frequently benign gynecological diseases. Not all women suffer from severe symptoms, but more than 50 % require ongoing treatment. Beside the severe physical impairment due to the pain, the high recurrence rate of 50-80 % also after surgical and/or hormonal treatment is problematic. The interval between onset of symptoms and diagnosis is approximately 6-8 years. These problems are a consequence of lack of knowledge about the pathogenesis of the disease and the pain mechanisms as well as the lack of awareness of physicians in this field.

Martius' flap for recurrent perineal and rectovaginal fistulae in a patient with Crohn's disease, endometriosis and a mullerian anomaly

Background

Rectovaginal fistulas represent 5% of all anorectal fistulae and are a disastrous manifestation of Crohn’s disease that negatively affects patients’ social and sexual quality of life. Treatment remains challenging for colorectal surgeons, and the recurrence rate remains high despite the numerous available options.

Case presentation

We describe a 31-year-old female patient with a Crohn’s disease-related recurrent perineo-vaginal and recto-vaginal fistulae and a concomitant mullerian anomaly. She complained of severe dyspareunia associated with penetration difficulties. The patient’s medical history was also significant for a previous abdominal laparoscopic surgery for endometriosis for the removal of macroscopic nodules and a septate uterus with cervical duplication and a longitudinal vaginal septum. The patient was successfully treated using a Martius’ flap. The postoperative outcome was uneventful, and no recurrence of the fistula occurred at the last follow-up, eight months from the closure of the ileostomy.

Conclusion

Martius’ flap was first described in 1928, and it is considered a good option in cases of rectovaginal fistulas in patients with Crohn’s disease.

The patient should be referred to a colorectal centre with expertise in this disease to increase the surgical success rate.

How Big is Too Big? The Girth of Bestselling Insertive Sex Toys to Guide Maximal Neophallus Dimensions

BACKGROUND

In our practice we have encountered 4 female-to-male transgender patients seeking neophallus revision surgery for girth precluding penetrative vaginal or anal intercourse. Despite this, there is little evidence available to guide transitioning patients in neophallus sizing. In this work we examined the dimensions of bestselling realistic dildos, presuming that the most popular dimensions would reflect population preferences for penetrative toys and phalluses.

AIM

To determine a maximal upper limit for girth compatible with penetrative intercourse based on measurements of bestselling realistic dildos and published erect penile dimensions.

METHODS

We collected measurements for "realistic dildos" designated as bestsellers for the top 5 Alexa.com-rated online adult retailers in the United States and for Amazon.com. We compared these with measurements of dildos available at Good Vibrations in San Francisco and with studies of erect natal dimensions. We compared all data with measurements of 4 index patients whose neophallus girth prevented penetrative intercourse.

OUTCOMES

Length and circumference of overall bestselling and largest bestselling realistic dildos as reported on top websites and measured by investigators.

RESULTS

The average insertive length of the compiled dildos (16.7 ± 1.6 cm) was 1 SD longer than natal functional erect penile length as reported in the literature (15.7 ± 2.6 cm); however, their average circumference (12.7 ± 0.8 cm) mirrored natal erect penile girth (12.3 ± 1.3). The average girth of vendors' top 3 largest-girth dildos was 15.1 ± 0.9 cm, 2 SD wider than natal erect penile girth. Index patients had an average length of 16.3 ± 3.2 cm and an average girth of 17.6 ± 1.3 cm. Index patient girth was 4 to 5 SD wider than the average natal erect girth.

CLINICAL IMPLICATIONS

Based on our data, we suggest that a surgically created neophallus should have a girth no wider than 15.1 cm after implantation of an inflatable penile prosthesis. This corresponds to 2 SD wider than the average natal man's erect girth.

STRENGTHS AND LIMITATIONS

Strengths include in-person measurements of patients whose girth prevented penetrative intercourse, the large number of dildos assessed, and correlations with in-person measurements. Limitations include the inability to account for the pliability of different materials, whether dildos were used for vaginal and/or anal insertion, the limited sample of 4 transmen for in-person measurement, and the absence of implanted inflatable penile prostheses in index neophalluses.

CONCLUSIONS

Neophallus girth wider than 15.1 cm could lead to difficulty in penetrative intercourse for many individuals. A conservative recommendation for neophallus girth is 13 to 14 cm, or 0.5 to 1.5 SD wider than natal erect penile girth. Isaacson D, Aghili R, Wongwittavas N, Garcia M. How Big is Too Big? The Girth of Bestselling Insertive Sex Toys to Guide Maximal Neophallus Dimensions. J Sex Med 2017;14:1455-1461.

Comparison of intravaginal 6.5mg (0.50%) prasterone, 0.3mg conjugated estrogens and 10μg estradiol on symptoms of vulvovaginal atrophy

The objective is to compare the effect of intravaginal dehydroepiandrosterone (DHEA, prasterone), conjugated equine estrogens (CEE) and estradiol (E₂) on moderate to severe dyspareunia and/or vaginal dryness. In a review of available data, independent prospective, randomized, double-blind and placebo-controlled Phase III 12-week clinical trials involved daily administration of 6.5mg (0.50%) prasterone, daily (21days on/7days off) 0.3mg CEE, twice weekly 0.3mg CEE or 10μg E₂ daily for 2 weeks followed by twice weekly for 10 weeks. Vulvovaginal atrophy (VVA) symptoms were evaluated by questionnaires. The total severity score of dyspareunia decreased from baseline by 1.27 to 1.63 units with prasterone treatment, 1.4 with CEE and 1.23 in one statistically significant study with E₂ (combined symptoms). Decreases over placebo ranged from 0.35 to 1.21 with prasterone, 0.7 to 1.0 with CEE and 0.33 for the E₂ study. The total decreases in vaginal dryness severity ranged from 1.44 to 1.58 units for prasterone, 1.1 unit for CEE and 1.23 unit for E₂. The decreases over placebo of vaginal dryness intensity ranged from 0.30 to 0.43 unit for prasterone, 0.40 unit for CEE and 0.33 for the E₂ study with combined symptoms. Daily 6.5mg (0.50%) prasterone appears to be at least as efficacious as 0.3mg CEE or 10μg E₂ for treatment of the VVA symptoms. In summary, the beneficial effects on the VVA symptomatology can be obtained by the addition of a small amount of intravaginal prasterone to compensate for the low serum concentration of prasterone observed in the majority of women after menopause without concerns about systemic effects.

"That's Kind of One of Our Jobs": Sexual Activity as a Form of Care Work Among Women with Sexual Difficulties

Willing engagement in unwanted or undesired sexual activity, often associated with fulfilling a partner's needs or sustaining intimate relationships, is common. Acquiescence with undesired sexual activity can be conceptualized as sexual care work, that is, domestic "labor" that women undertake with the goal of caring for their partners' well-being. Drawing on interviews with 53 women with dyspareunia (pain experienced during intercourse) and low desire, the aim of this study was to examine how women with sexual difficulties engage in sexual care work, the implications of the inability to perform such work for gender identity, and the ways in which sexual care work may blur the lines between women's perceptions of coercion and consent. The women in this study engaged in sexual activity for a number of reasons, including the pursuit of intimacy, to care for their partner, and to fulfill their perceived sexual obligations. Sexual compliance was conceptualized as a form of work, similar to other forms of unpaid care work such as housework or childcare, which negatively affected women's gender identities when it could not be performed. For many women, sex was simultaneously wanted and unwanted, contributing to women's ambivalence regarding the meaning of consent. Further exploration of these issues may lead to a better understanding of how gender is achieved through normative sexuality.

Effects of Vaginal Lubricants on In-Vitro Progressive Spermatozoa Motility

Vaginal lubricants are used to solve intercourse difficulties or as sexual enhancers, but recent reports raise questions about their safety in terms of fertility. In this study, twenty semen samples were tested against commercially available vaginal lubricants for progressive spermatozoa motility and vitality with varying exposure time intervals. Results showed that the vaginal lubricant which least affected progressive spermatozoa motility was the oil-based vaginal lubricant, which kept the mean percentage of progressive spermatozoa motility within the minimum normal range of 32%, following 60 minutes of exposure. The silicone-based vaginal lubricant produced similar results to the oil-based vaginal lubricant, however the progressive spermatozoa motility dropped below the minimum normal range within 60 minutes of exposure. The fertility lubricant did not produce mean progressive motilities that were within the normal minimum range at any of the three time intervals, producing poor results overall. The vaginal lubricant which produced the poorest results was the water-based, which immobilized all of the spermatozoa within 5 minutes of exposure and killed on average 95.23% within 60 minutes. Although further assessment is required, these results highlight potential fertility issues related to the formulation of commercially available vaginal lubricants.

Ospemifene: A Novel Option for the Treatment of Vulvovaginal Atrophy

Ospemifene—a third-generation selective estrogen receptor modulator approved by the Food and Drug Administration in 2013—is an oral medication for the treatment of dyspareunia. In postmenopausal women with vulvovaginal atrophy, ospemifene significantly improves the structure and pH levels of the vagina, reducing dyspareunia. It is available as a 60-mg tablet; hence, women who may have had prior difficulty with vaginal administration or on-demand use of nonprescription lubricants and moisturizers would likely prefer this form of treatment. Preclinical studies demonstrated that ospemifene has an estrogen agonist action on the bone, reducing the cell proliferation of ductal carcinoma in an in situ model. Studies evaluating the safety of treatment for up to 52 weeks have shown that ospemifene is a safe medication with minimal impact on the endometrium. Further studies with larger number of subjects are necessary to better conclude its effects and long-term safety.

Microablative fractional CO2 laser for the genitourinary syndrome of menopause: power of 30 or 40 W?

This retrospective case-control study aimed to compare 30 versus 40 W power of CO₂ laser for the therapy of genitourinary syndrome of menopause (GSM). Postmenopausal women with severe intensity of dyspareunia and dryness were eligible to be included in this study. Primary outcomes were dyspareunia and dryness. Secondary outcomes were itching/burning, dysuria, frequency and urgency, Female Sexual Function Index (FSFI), vaginal maturation value (VMV), and Vaginal Health Index Score (VHIS). One laser therapy was applied every month for 3 months. Outcomes were evaluated at baseline and 1 month following the 3rd therapy. Fifty (25 per group) women were included in this study. In the 30-W group, mean improvement of dyspareunia, dryness, itching/burning, FSFI, VMV, and VHIS was 6.1 ± 1.7, 6.0 ± 1.9, 5.9 ± 2.0, 16.6 ± 6.7, 29.9 ± 13.0, and 11.0 ± 2.9, respectively (within group comparisons all p < 0.001). In the 40-W group, mean improvement of dyspareunia, dryness, itching/burning, FSFI, VMV, and VHIS was 6.1 ± 1.7, 6.5 ± 2.0, 5.2 ± 2.5, 14.8 ± 7.1, 25.0 ± 13.4, and 10.5 ± 4.1, respectively (within-group comparisons, all p ≤ 0.001). Comparison between 30 and 40 W revealed that mean improvement or presence of all GSM symptoms and clinical signs was not statistically significant different. CO₂ laser therapy may improve GSM symptoms and clinical signs. This improvement did not seem to associate to power of 30 or 40 W.

Anatomic Sites and Associated Clinical Factors for Deep Dyspareunia

Introduction

Deep dyspareunia negatively affects women’s sexual function. There is a known association between deep dyspareunia and endometriosis of the cul-de-sac or uterosacral ligaments in reproductive-age women; however, other factors are less clear in this population.

Aim

To identify anatomic sites and associated clinical factors for deep dyspareunia in reproductive-age women at a referral center.

Methods

This study involved the analysis of cross-sectional baseline data from a prospective database of 548 women (87% consent rate) recruited from December 2013 through April 2015 at a tertiary referral center for endometriosis and/or pelvic pain. Exclusion criteria included menopausal status, age at least 50 years, previous hysterectomy or oophorectomy, and not sexually active. We performed a standardized endovaginal ultrasound-assisted pelvic examination to palpate anatomic structures for tenderness and reproduce deep dyspareunia. Multivariable regression was used to determine which tender anatomic structures were independently associated with deep dyspareunia severity and to identify clinical factors independently associated with each tender anatomic site.

Main Outcome Measure

Severity of deep dyspareunia on a numeric pain rating scale of 0 to 10.

Results

Severity of deep dyspareunia (scale = 0–10) was independently associated with tenderness of the bladder (b = 0.88, P = .018), pelvic floor (levator ani) (b = 0.66, P = .038), cervix and uterus (b = 0.88, P = .008), and cul-de-sac or uterosacral ligaments (b = 1.39, P < .001), but not with the adnexa (b = −0.16, P = 0.87). The number of tender anatomic sites was significantly correlated with more severe deep dyspareunia (Spearman r = 0.34, P < .001). For associated clinical factors, greater depression symptom severity was specifically associated with tenderness of the bladder (b = 1.05, P = .008) and pelvic floor (b = 1.07, P < .001). A history of miscarriage was specifically associated with tenderness of the cervix and uterus (b = 2.24, P = .001). Endometriosis was specifically associated with tenderness of the cul-de-sac or uterosacral ligaments (b = 3.54, P < .001).

Conclusions

In reproductive-age women at a tertiary referral center, deep dyspareunia was independently associated not only with tenderness of the cul-de-sac and uterosacral ligaments but also with tenderness of the bladder, pelvic floor, and cervix and uterus.

Yong PJ, Williams C, Yosef A, et al. Anatomic Sites and Associated Clinical Factors for Deep Dyspareunia. Sex Med 2017;5:e184–e195.

Female sexual function following a novel transobturator sling procedure without paraurethral dissection (modified-TOT)

PURPOSE

To determine whether there is a difference in sexual function after modified and classical TOT procedures.

MATERIALS AND METHODS

Of the 80 sexually active women with SUI, 36 underwent na original outside-in TOT as described by Delorme, and 44 underwent modified TOT procedure, between 2011 and 2015. The severity of incontinence and sexual function were evaluated using International Consultation on Incontinence Questionnaire-Short Form (ICIQ-SF) and Female Sexual Function Index (FSFI) questionnaires preoperatively and 3 months after surgery.

RESULTS

The postoperative ICIQ-SF score was significantly lower than the preoperative ICIQ-SF score in both groups (p=0.004 for modified TOT and p=0.002 for classical TOT). There was no significant difference in the ICIQ-SF score reduction between the two groups (14.1±2.1 vs. 14.4±1.9; p=0.892). Complication rates according to the Clavien-Dindo classification were also similar in both groups. In both groups, difference between preoperative and postoperative FSFI scores revealed a statistically significant improvement in all domains. Comparison of postoperative 3-month FSFI scores of modified and classical TOT groups showed statistically significant differences in arousal, lubrication and orgasm domains. Desire, satisfaction, pain and total FSFI scores did not differ significantly between two groups.

CONCLUSION

The modified TOT technique is a simple, reliable and minimal invasive procedure. The cure rate of incontinence and complication rates are the same as those of the classical TOT technique. However, due to the positive effects of minimal tissue damage on sexual arousal and orgasmic function, modified TOT has an advantage over the classical TOT.

Periurethral Gland Calculus Discovered on Workup for Dyspareunia

A 55-year-old woman with a history of chronic dysuria in the absence of infection was found to have an unusual lesion below the urethral meatus. This was subsequently determined to be a periurethral gland containing a sizeable calculus. Pathologic analysis found the composition to be car bonate apatite (dahllite). Only one prior report of a female periurethral calculus has been noted in the English peer-reviewed literature.

Macro-regional variation in attitudes toward and experiences of vulvar and vaginal atrophy among Italian post-menopausal women: a post hoc analysis of REVIVE survey data

Italian participants in the European REVIVE survey reported that vaginal and vulvar atrophy (VVA) impaired various aspects of their lives, notably the ability to enjoy sex. The aim of the present study was to explore regional differences in knowledge, experiences, and treatment of VVA in the Italian REVIVE sample (n = 1000), which was analyzed according to region of residence. While many respondents were unfamiliar with the VVA condition, most could relate their VVA symptoms to the menopause. The rate of diagnosis of VVA was twice as high in Central Italy as in the North-East. For individual VVA symptoms, 25.4-41.6% of respondents judged that the symptom had worsened over time. There were no significant regional differences for symptoms in terms of reported rate, change in severity, impact on sexual activity, or health-care visits. Testosterone cream and OTC medication based on hyaluronic acid showed significant regional differences in lifetime rates of use. In Italy, there are modest regional differences in knowledge, diagnosis, and treatment of VVA, some of which may be explained by inter-regional differences in health care. Further efforts are needed to ensure that Italian women are properly informed about VVA and have access to appropriate health care and treatments.

Postpartum dyspareunia and sexual functioning: a prospective cohort study

OBJECTIVES

Sexual functioning is an important concern for women in the postpartum period. The aim of this research was to investigate the prevalence and determinants of dyspareunia and sexual dysfunction before and after childbirth.

METHODS

Between November 2013 and April 2014, 109 women in their third trimester of pregnancy were enrolled in a prospective cohort study at Ghent University Hospital. Dyspareunia, sexual functioning and quality of life (QOL) were evaluated at enrolment and again 6 weeks and 6 months postpartum. Sexual functioning and QOL were assessed using validated self-report questionnaires: the Female Sexual Function Index and the Short Form-36 health survey. Dyspareunia was evaluated by a specific self-developed questionnaire.

RESULTS

One hundred and nine women were enrolled; respectively, 71 (65.1%), 66 (60.6%) and 64 (58.7%) women returned the questionnaires prepartum, and 6 weeks and 6 months postpartum. Sexual functioning at 6 weeks was predictive of sexual functioning at 6 months postpartum (r_s = 0.345, p = .015). The prevalence of dyspareunia in the third trimester of pregnancy, and 6 weeks and 6 months postpartum was, respectively, 32.8%, 51.0% and 40.7%. The severity of pain decreased significantly between 6 weeks and 6 months postpartum (p = .003). In the first 6 weeks postpartum, the degree of dyspareunia was significantly associated with breastfeeding (p = .045) and primiparity (p = .020). At 6 months, only the association with primiparity remained significant (p = .022).

CONCLUSIONS

The impaired postpartum sexual functioning, the high prevalence of dyspareunia postpartum and their impact on QOL indicate the need for further investigation and extensive counselling of pregnant women, especially primiparous women, about sexuality after childbirth.

Systematic Review of the Effectiveness of Physical Therapy Modalities in Women With Provoked Vestibulodynia

INTRODUCTION

Pelvic floor muscle physical therapy is recommended in clinical guidelines for women with provoked vestibulodynia (PVD). Including isolated or combined treatment modalities, physical therapy is viewed as an effective first-line intervention, yet no systematic review concerning the effectiveness of physical therapy has been conducted.

AIM

To systematically appraise the current literature on the effectiveness of physical therapy modalities for decreasing pain during intercourse and improving sexual function in women with PVD.

METHODS

A systematic literature search using PubMed, Scopus, CINHAL, and PEDro was conducted until October 2016. Moreover, a manual search from reference lists of included articles was performed. Ongoing trials also were reviewed using clinicaltrial.gov and ISRCTNregistry. Randomized controlled trials, prospective and retrospective cohorts, and case reports evaluating the effect of isolated or combined physical therapy modalities in women with PVD were included in the review.

MAIN OUTCOME MEASURES

Main outcome measures were pain during intercourse, sexual function, and patient's perceived improvement.

RESULTS

The literature search resulted in 43 eligible studies including 7 randomized controlled trials, 20 prospective studies, 5 retrospective studies, 6 case reports, and 6 study protocols. Most studies had a high risk of bias mainly associated with the lack of a comparison group. Another common bias was related to insufficient sample size, non-validated outcomes, non-standardized intervention, and use of other ongoing treatment. The vast majority of studies showed that physical therapy modalities such as biofeedback, dilators, electrical stimulation, education, multimodal physical therapy, and multidisciplinary approaches were effective for decreasing pain during intercourse and improving sexual function.

CONCLUSION

The positive findings for the effectiveness of physical therapy modalities in women with PVD should be investigated further in robust and well-designed randomized controlled trials. Morin M, Carroll M-S, Bergeron S. Systematic Review of the Effectiveness of Physical Therapy Modalities in Women With Provoked Vestibulodynia. Sex Med Rev 2017;5:295-322.

Vaginismus Treatment: Clinical Trials Follow Up 241 Patients

Introduction

Vaginismus is mostly unknown among clinicians and women. Vaginismus causes women to have fear, anxiety, and pain with penetration attempts.

Aim

To present a large cohort of patients based on prior published studies approved by an institutional review board and the Food and Drug Administration using a comprehensive multimodal vaginismus treatment program to treat the physical and psychologic manifestations of women with vaginismus and to record successes, failures, and untoward effects of this treatment approach.

Methods

Assessment of vaginismus included a comprehensive pretreatment questionnaire, the Female Sexual Function Index (FSFI), and consultation. All patients signed a detailed informed consent. Treatment consisted of a multimodal approach including intravaginal injections of onabotulinumtoxinA (Botox) and bupivacaine, progressive dilation under conscious sedation, indwelling dilator, follow-up and support with office visits, phone calls, e-mails, dilation logs, and FSFI reports.

Main Outcome Measures

Logs noting dilation progression, pain and anxiety scores, time to achieve intercourse, setbacks, and untoward effects. Post-treatment FSFI scores were compared with preprocedure scores.

Results

One hundred seventy-one patients (71%) reported having pain-free intercourse at a mean of 5.1 weeks (median = 2.5). Six patients (2.5%) were unable to achieve intercourse within a 1-year period after treatment and 64 patients (26.6%) were lost to follow-up. The change in the overall FSFI score measured at baseline, 3 months, 6 months, and 1 year was statistically significant at the 0.05 level. Three patients developed mild temporary stress incontinence, two patients developed a short period of temporary blurred vision, and one patient developed temporary excessive vaginal dryness. All adverse events resolved by approximately 4 months. One patient required retreatment followed by successful coitus.

Conclusion

A multimodal program that treated the physical and psychologic aspects of vaginismus enabled women to achieve pain-free intercourse as noted by patient communications and serial female sexual function studies. Further studies are indicated to better understand the individual components of this multimodal treatment program.

Pacik PT, Geletta S. Vaginismus Treatment: Clinical Trials Follow Up 241 Patients. Sex Med 2017;5:e114–e123.

What Does Electromyography Tell Us About Dyspareunia?

INTRODUCTION

Emergent evidence suggests that pelvic floor muscle (PFM) dysfunction contributes to dyspareunia, the experience of pain on vaginal penetration. Electromyography (EMG) is a valuable tool for the assessment of neuromuscular control and could be very useful in enhancing our understanding of PFM involvement in sexual function and in conditions such as dyspareunia. However, PFM EMG must be interpreted within the context of the many factors that can influence findings.

AIM

To outline the main factors to consider when evaluating PFM EMG for female sexual function and dyspareunia and to synthesize the literature in which EMG has been acquired and interpreted appropriately in this context.

METHODS

Standards for the acquisition and interpretation of EMG were retrieved and consulted. An exhaustive search of four electronic databases (Embase, CINAHL, PubMed, and PsycLit) and hand searching references from relevant articles were performed to locate articles relevant to PFM involvement in sexual function and in dyspareunia in which EMG was used as a primary outcome. Study outcomes were evaluated within the context of the appropriate application and interpretation of EMG and their contribution to knowledge.

MAIN OUTCOME MEASURES

A synthesis of the evidence was used to present the current state of knowledge on PFM involvement in sexual function and in dyspareunia.

RESULTS

Few standards documents and no practice guidelines for the acquisition and interpretation of PFM EMG are available. Some cohort studies with small samples of women have described the role of the PFMs in female sexual function. The literature on PFM involvement in dyspareunia also is limited, with outcomes suggesting that higher than normal tonic activation and higher than normal reflex responses might be present in the superficial PFM layer and might be characteristic features of dyspareunia. The data are less clear on the involvement of the deep layer of the PFMs in dyspareunia.

CONCLUSION

Guidelines for the application and interpretation of PFM EMG in the context of sexual function and dyspareunia are needed. When interpreted within the context of their strengths and limitations, EMG data have contributed valuable information to our understanding of PFM involvement in dyspareunia. The literature to date suggests that the superficial PFMs might have higher than normal tone and exaggerated responses to tactile or penetrative provocation in at least some women with dyspareunia. McLean L, Brooks K. What Does Electromyography Tell Us About Dyspareunia? Sex Med Rev 2017;5:282-294.

A vaginal estradiol softgel capsule, TX-004HR, has negligible to very low systemic absorption of estradiol: Efficacy and pharmacokinetic data review

This paper reviews the efficacy, safety, and systemic absorption of estradiol with TX-004HR, an investigational, low-dose 17β-estradiol vaginal softgel capsule, designed to treat vulvar and vaginal atrophy (VVA) in postmenopausal women, with an improved user experience. In phase 2 (NCT02449902) and phase 3 REJOICE (NCT02253173) studies, TX-004HR significantly improved the proportions of vaginal superficial and parabasal cells and vaginal pH, and in the phase 3 study decreased the severity of dyspareunia, vaginal dryness, and vulvar and/or vaginal itching or irritation. In two randomized, phase 1 trials, estradiol C_max and AUC_0-24 were significantly lower with 10μg and 25μg TX-004HR than with the same doses of an approved vaginal estradiol tablet. A substudy (n=72) of the REJOICE trial showed that estradiol C_avg and AUC_0-24 with 4μg and 10μg TX-004HR were not different from placebo on days 1 and 14. While TX-004HR 25μg was associated with higher C_avg and AUC_0-24 versus placebo on days 1 and 14, these levels remained within the postmenopausal range. Estradiol day-84 values for all three doses were not different from placebo, demonstrating no estradiol accumulation. All TX-004HR doses were well tolerated and had an acceptable safety profile in all reviewed studies. The local vaginal efficacy of TX-004HR was significantly better than that of placebo, while the overall safety profile was similar to that of placebo. Negligible to very low systemic estradiol absorption was observed whether given at 4, 10, or 25μg. If approved, TX-004HR may be an alternative option for women with symptomatic VVA without increasing mean systemic estradiol absorption above postmenopausal levels.

Primary Sjögren's Syndrome Adversely Affects the Female Sexual Function Assessed by the Female Sexual Function Index: A Case-Control Study

Objectives

This study aims to evaluate the sexual function of females with primary Sjögren's syndrome (pSS) in comparison to healthy females by using the Female Sexual Function Index (FSFI).

Patients and methods

This case-control study included 31 female patients (mean age 46.0±10.2 years; range 30 to 68 years) with pSS and 27 healthy females (mean age 44.2±8.5 years; range 30 to 55 years) as control group. The sexual function of the participants was assessed by 19-item FSFI.

Results

Mean duration of pSS in the patient group was 35.9 months (range 3 to 264 months). Significantly higher number of pSS patients reported positive history for vaginal infection compared to controls (n=26, 83.9% vs. n=7, 25.9%, respectively; p<0.001) without any difference in endocervical culture result. Cervical smear assessment revealed more inflammation and atrophy in patient group compared to control group (p=0.001). Mean FSFI total score was significantly lower in patient group than control group (18.9±9.9 vs. 25.1±5.1, respectively; p=0.004). Similarly, five out of six domains of FSFI -arousal, lubrication, orgasm, satisfaction, and pain- were significantly lower in patient group. FSFI total and subscale scores, except for pain, were found to be negatively correlated with duration of pSS.

Conclusion

The pSS causes sexual dysfunction in female patients. Furthermore, as disease duration increases, female sexual function decreases. Clinical management of female patients with pSS should cover the assessment of their sexual functionality and taking the necessary precautions to maintain satisfactory quality of life and treatment outcome.

Bladder leiomyoma

Leiomyomas of the bladder constitute <0.5% of all bladder tumors, with about 250 cases reported. Most patients present with urinary frequency or obstructive urinary symptoms. There are rare cases with other presentations, such as dyspareunia. We report a 22-year-old female who presented with complaints of pelvic discomfort, dysuria, and dyspareunia. Imaging and cystoscopy showed a protruding bladder lesion, which was excised through a transurethral resection. The pathologic diagnosis was bladder leiomyoma. Although being a benign condition, they can cause several different symptoms and should be early diagnosed and treated.

Rectovaginal Splenosis: An Unexpected Cause of Dyspareunia Approached by Laparoscopy

STUDY OBJECTIVE

To demonstrate the technique of laparoscopic approach in a rare case of rectovaginal splenosis with severe dyspareunia and dyschesia.

DESIGN

A step-by-step explanation of the patient's condition, diagnosis, surgical technique, and postoperative results (Canadian Task Force classification II-3).

SETTING

Splenosis consists of ectopic functioning splenic tissue that can be located anywhere within the abdomen or pelvis. Fragments are often multiple and range in diameter from a few millimeters to a few centimeters. They are reddish-blue and are sessile or pedunculated. Their appearance can mimic that of neoplasms or endometriosis, which are the main differential diagnoses. Trauma and subsequent splenectomy is the cause in most cases. Splenosis is a benign condition usually found incidentally and is usually asymptomatic. The need for therapy is controversial, and treatment is suggested only in symptomatic cases, primarily those related to pelvic or abdominal lesions, as in our patient. The diagnosis of splenosis in a woman complaining of pelvic pain may present diagnostic difficulties. The splenic tissue has the macroscopic appearance of endometriosis, and its position in the pelvis also may suggest this diagnosis. Where excision of splenosis is considered necessary, the approach should be laparoscopic, unless this is considered too risky owing to the proximity of vital structures.

INTERVENTION

A 40-year-old woman was referred to our department for severe dyspareunia and dyschezia. The gynecologic examination revealed a painfull nodularity on the posterior vaginal cul de sac. Further evaluation with 2- and 3-dimensional ultrasound and magnetic resonance imaging revealed several soft tissue nodules in the pouch of Douglas (POD), which were enhanced on contrast administration. She had undergone a splenectomy 15 years earlier after a car accident. A laparoscopic approach to a rectovaginal nodularity was performed. Under general anesthesia, the patient was placed in the dorsal decubitus position with her arms alongside her body and her legs in abduction. Pneumoperitoneum was achieved using a Veres needle placed at the umbilicus. Four trocars were placed: a 10-mm trocar at the umbilicus for the 0-degree laparoscope; a 5-mm trocar at the right anterosuperior iliac spine; a 5-mm trocar in the midline between the umbilicus and the pubic symphysis, approximately 8 to 10 cm inferior to the umbilical trocar; and a 5-mm trocar at the left anterosuperior iliac spine. The entire pelvis was inspected for endometriotic lesions. In the pelvis, hypervascular and bluish nodules were visible with extension from the POD into the deep rectovaginal space. The macroscopic appearance was atypical for endometriotic implants. The nodularities were carefully dissected and excised, and histological assessment revealed splenic tissue. At the time of this report, the patient had been asymptomatic for 6 months after surgery.

CONCLUSION

Rectovaginal splenosis may mimic endometriosis. The laparoscopic approach to rectovaginal splenosis avoids an abdominal incision, with its associated pain and possible adhesion formation. It also provides a better view for dissection. In this patient, the splenosis was removed by laparoscopy, with no postoperative dyspareunia or dyschesia.

Coital pain in the elderly: could a low dose estriol gel thrill the vulvar vestibule?

OBJECTIVE

The aim of this study was to evaluate the effectiveness of the application of 0.005% estriol gel to the vulvar vestibule in the management of postmenopausal dyspareunia.

STUDY DESIGN

Postmenopausal women with dyspareunia were enrolled in this study. Patients were instructed to use a fingertip to apply 0.25g of vaginal gel containing 25μg of estriol to the vulvar vestibule daily for three weeks and then twice weekly for up to 12 weeks.

RESULTS

Assessment of symptoms (dyspareunia and cotton swab test) and signs of vestibular atrophy were performed, and changes between baseline and weeks 3 and 12 were assessed. Adverse events were recorded. A total of 63 women were included. Of the 63, 59 (93.6%) completed the 12-week treatment period, and four dropped out for vestibular burning. Dyspareunia improved or was cured (score ≤1) by week 12 in 81.4% of patients. The patients also showed a statistically significant reduction in vestibular atrophy and cotton swab test at the end of treatment.

CONCLUSIONS

Application of 0.005% estriol gel to the vulvar vestibule is effective in correcting menopausal coital pain. This suggests that reduction in sensory vestibular innervation sensitivity is likely to play a pivotal role in the relief of dyspareunia. One limitation of this study is the limited follow-up, but the therapy may be continued for as long as the patients are distressed by their symptoms without estrogen intervention.

Microablative fractional CO2-laser therapy and the genitourinary syndrome of menopause: An observational study

OBJECTIVES

This study aimed to assess the effect of the Microablative Fractional CO₂ Laser (CO₂-laser) therapy on vaginal pathophysiology and the symptoms of the Genitourinary Syndrome of Menopause (GSM).

METHODS

Postmenopausal women with moderate to severe symptoms of GSM underwent three sessions of CO₂-laser therapy at monthly intervals. Participants were evaluated at baseline and 4 weeks after the last treatment.

MAIN OUTCOME MEASURES

The primary outcomes were Vaginal Maturation Value (VMV) and Vaginal Health Index Score (VHIS). Secondary outcomes included symptoms of GSM, Female Sexual Function Index (FSFI), International Consultation on Incontinence Questionnaire of Female Urinary Tract Symptoms (ICIQ-FLUTS) and Urinary Incontinence Short Form (ICIQ-UI SF), Urogenital Distress Inventory (UDI-6) and King's Health Questionnaire (KHQ).

RESULTS

Fifty-three postmenopausal women completed this study. VMV, VHIS and FSFI increased significantly. Dyspareunia, dryness, burning, itching, dysuria, frequency, urgency, urgency incontinence, stress incontinence and scores on the ICIQ-FLUTS, ICIQ-UI SF, UDI-6 and KHQ decreased significantly. Factors predicting for which women the CO₂-laser therapy was more effective were not identified.

CONCLUSION

This study suggests that intravaginal CO₂-laser therapy for postmenopausal women with clinical signs and symptoms of GSM may be effective in improving both vaginal pathophysiology and reported symptoms.

What Do Patients Want? A Needs Assessment of Vulvodynia Patients Attending a Vulvar Diseases Clinic

INTRODUCTION

Vulvodynia is a chronic pain disorder that negatively impacts the quality of life of affected women.

AIM

The goal of this study was to identify unmet needs among localized provoked vulvodynia patients.

METHODS

A qualitative needs assessment was performed in a subspecialized vulvar clinic in a single academic institution in Canada. Semistructured interviews were conducted, recorded, and analyzed using the constant comparative method of grounded theory to identify common themes.

MAIN OUTCOME MEASURES

Interviews were conducted until theme saturation was achieved.

RESULTS

A diverse sample of 8 patients completed all components of the study. The most prominent unmet needs raised by patients in their interviews were categorized into 3 main themes: (1) challenges related to obtaining a diagnosis of vulvodynia and finding practitioners who are knowledgeable about vulvodynia; (2) challenges related to the current impact of the disease physically, emotionally, and in social relationships with patients' intimate partners; and (3) barriers to adherence with recommended therapy. Solutions recommended by patients include better education of physicians regarding vulvodynia and the development of multidisciplinary programs that provide access to physiotherapy, sex therapy, mindfulness and psychology services on-site, information classes for new patients, and the creation of peer support networks for patients and their partners.

CONCLUSION

A patient-focused needs assessment suggests optimal vulvodynia care requires better education of physicians and a multimodal approach to therapy, ideally with multiple services offered in 1 location.

Effects of low-dose combined drospirenone-ethinylestradiol on perimenstrual symptoms experienced by women with endometriosis

OBJECTIVE

To determine the effectiveness of a 24/4-day regimen of a low-dose combination drospirenone-ethinylestradiol oral contraceptive in alleviating perimenstrual symptoms among Japanese women with endometriosis.

METHODS

The present prospective, non-randomized study enrolled women diagnosed with endometriosis radiographically or surgically at the Kyoto Prefectural University of Medicine hospital, Japan, between December 1, 2010 and August 31, 2013. Patients received treatment with oral drospirenone-ethinylestradiol for six treatment cycles. Dysmenorrhea, chronic pelvic pain, and dyspareunia severity were assessed using visual analog scale scores after three and six treatment cycles, and changes in perimenstrual symptoms were assessed using the menstrual distress questionnaire (MDQ) scores.

RESULTS

In total, 46 patients were recruited for the study. Dysmenorrhea, chronic pelvic pain, and dyspareunia were all significantly reduced after both three and six treatment cycles in comparison with baseline (P<0.001 for all comparisons). After six treatment cycles, significant reductions were observed for all menstrual MDQ measures and for the premenstrual water retention and negative-effect MDQ measures (all P<0.05).

CONCLUSIONS

Combination drospirenone-ethinylestradiol was effective in the treatment of dysmenorrhea, chronic pelvic pain, dyspareunia, and somatic/psychological symptoms in Japanese women with endometriosis.

Active and Passive Components of Pelvic Floor Muscle Tone in Women with Provoked Vestibulodynia: A Perspective Based on a Review of the Literature

AIM

Pelvic floor muscle (PFM) dysfunctions, especially elevated tone or tension, are suggested to play an important role in the pathophysiology of provoked vestibulodynia (PVD). However, the involvement of the PFMs remains misunderstood as the assessment of muscle tone is complex and requires a thorough understanding of muscle physiology in relation to the characteristics and limitations of current PFM assessment tools. The aim of this review was to describe the structures and mechanisms involved in muscle tone in normally innervated muscle, and to discuss and relate these concepts to the PFM findings in women with PVD.

METHODS

A narrative overview of the literature retrieved from searches of electronic databases and hand searches.

RESULTS

Muscle tone in a normally innervated muscle comprises both active (contractile) and passive (viscoelastic) components. Current methods for evaluating PFM tone such as digital palpation, ultrasound imaging, pressure perineometry, dynamometry, and electromyography may evaluate different components. Research findings suggestive of PFM hypertonicity in women with PVD include elevated general PFM tone, changes in viscoelastic properties, and at least in some women, abnormal increases in electrogenic activity.

CONCLUSION

There is a growing body of evidence to support the involvement of PFM hypertonicity in the pathophysiology of PVD. Limitations of the instruments as well as their properties should be considered when evaluating PFM tone in order to obtain better insight into which component of PFM tone is assessed. Future research is required for further investigating the underlying mechanisms of PFM hypertonicity, and studying the specific effects of physiotherapeutic interventions on PFM tone in women with PVD.

Analysis of changes in sexual function in women undergoing pelvic organ prolapse repair with abdominal or vaginal approaches

INTRODUCTION AND HYPOTHESIS

To examine changes in sexual function after abdominal and transvaginal pelvic organ prolapse repair.

METHODS

Women enrolled in our prospective, longitudinal prolapse database with abdominal sacrocolpopexy (ASC) or transvaginal (TVR) pelvic organ prolapse (POP) repair with or without mesh, between 19 December 2008 through 4 June 2014. The Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ-12) and the Pelvic Floor Distress Inventory (PFDI -20) were mailed preoperatively, and at 6 and 12 months postoperatively. Patients completed Global Response Assessments to rate their overall satisfaction.

RESULTS

Two hundred and four of the 300 women met the inclusion criteria: 74 out of 204 (36 %) had ASC and 130 out of 204 (64 %) had TVR. Seventy-two out of seventy-four ASCs were performed robotically and 2 were open. Baseline demographics were similar except that the ASC patients were significantly younger (60 vs 63, P = 0.019) and had a higher rate of apical repair (77 % vs 55 %). Thirty-six out of seventy-four ASC (48.7 %) and 63 out of 128 TVR patients (49.2 %) were sexually active at baseline (P = 0.94). Sixteen out of thirty-eight ASC (42.1 %) and 18 out 63 TVR patients (28.6 %; P = 0.16) reported dyspareunia at baseline. Seventy-two out of seventy-four ASC (97 %) and 86 out of 130 TVR patients (66 %) had mesh-augmented repairs. There was no difference in sexual activity or dyspareunia between the groups at the 6- or 12-month follow-up. PISQ and PFDI scores improved significantly in both the ASC and TVR groups over time compared with the baseline (p < 0.0001). Most women in the ASC (77.5 %) and TVR (64.8 %) groups were satisfied with the results of prolapse surgery at 12 months.

CONCLUSIONS

Sexual function and pelvic floor symptoms improved in a similar manner in patients after abdominal and transvaginal POP surgery.

A randomized, double-blind, crossover trial comparing a silicone- versus water-based lubricant for sexual discomfort after breast cancer

Discomfort during sexual activity is common after breast cancer. Vaginal estrogens are effective but commonly avoided due to systemic absorption. Despite the large commercial market for vaginal lubricants, no randomized studies have compared products. We aimed to compare efficacy and acceptability of two major types of lubricant for discomfort during sexual activity in postmenopausal breast cancer patients. In a single-center, randomized, double-blind, AB/BA crossover design, sexually active postmenopausal breast cancer patients used each lubricant for 4 weeks. The primary patient-reported efficacy outcome was total discomfort related to sexual activity (Fallowfield Sexual Activity Questionnaire Discomfort subscale SAQ-D). Acceptability was measured by patient preference and reported intention to continue using the products. Of 38 women analyzed, over 90 % experienced clinically significant sexually related distress at baseline. Water- and silicone-based lubricants did not differ statistically in efficacy based on total sexual discomfort (difference 0.7, 95 % confidence interval (CI) 0-1.4, p = 0.06). In a post hoc analysis, pain/discomfort during penetration improved more during silicone-based lubricant use than during water-based lubricant use (odds ratio 5.4, 95 % CI 1.3-22.1, p = 0.02). All aspects of sexual discomfort measured with diaries were reported more commonly with water- than silicone-based lubricant. Almost twice as many women preferred silicone-based to water-based lubricant than the converse (n = 20, 65 %, vs. n = 11, 35 %). 88 % continued to experience clinically significant sexually related distress despite use of either lubricant. Total sexual discomfort was lower after use of silicone-based lubricant than water-based, but many women continue to experience sexually related distress.

Sexual activity and dyspareunia the first year postpartum in relation to degree of perineal trauma

INTRODUCTION AND HYPOTHESIS

Knowledge on sexual complaints and time to sexual resumption after obstetric anal sphincter injury (OASI) is scarce. The aim of the study was to investigate self-reported sexual activity and coital problems 1 year postpartum in relation to perineal trauma, in addition to delivery mode.

METHODS

Among 2,846 women recruited during pregnancy, all women who delivered with OASI (n = 42, all third-degree perineal tears), in addition to 20 randomly selected controls per OASI case, a total of 882 women, were sent a self-administered questionnaire addressing time to coital resumption after delivery and potential coital difficulty 1 year postpartum.

RESULTS

By 8 weeks, half of the 561 responders (51.4 %) had resumed intercourse, increasing to 75.2 % by 12 weeks and 94.7 % 1 year postpartum. In multivariate regression analysis OASI was the strongest predictor for postponed coital onset, defined as after 8 weeks (aOR 5.52, CI 1.59-19.16). OASI was also the only significant predictor for dyspareunia 1 year after delivery (aOR 3.57, CI 1.39-9.19). Episiotomy was neither a risk factor for postponed coital onset nor for dyspareunia. There were no differences between episiotomy and second-degree laceration injury groups regarding postponed coital onset (p = 0.45) or dyspareunia (p = 0.67) 1 year postpartum.

CONCLUSIONS

Obstetric anal sphincter injury was a strong and independent predictor for both postponed coital resumption after delivery and for dyspareunia 1 year postpartum, whereas episiotomy and spontaneous second-degree lacerations were not. Our main finding of affected sexual activity after OASI further supports the need to reduce the rates of this obstetric injury to a minimum.

Efficacy of transcranial direct-current stimulation (tDCS) in women with provoked vestibulodynia: study protocol for a randomized controlled trial

Background

Provoked vestibulodynia is the most common form of vulvodynia. Despite its high prevalence and deleterious sexual, conjugal, and psychological repercussions, effective evidence-based interventions for provoked vestibulodynia remain limited. For a high proportion of women, significant pain persists despite the currently available treatments. Growing evidence suggests that the central nervous system (CNS) could play a key role in provoked vestibulodynia; thus, treatment targeting the CNS, rather than localized dysfunctions, may be beneficial for women suffering from provoked vestibulodynia. In this study, we aim to build on the promising results of a previous case report and evaluate whether transcranial direct-current stimulation, a non-invasive brain stimulation technique targeting the CNS, could be an effective treatment option for women with provoked vestibulodynia.

Methods/design

This single-center, triple-blind, parallel group, randomized, controlled trial aims to compare the efficacy of transcranial direct-current stimulation with sham transcranial direct-current stimulation in women with provoked vestibulodynia. Forty women diagnosed with provoked vestibulodynia by a gynecologist, following a standardized treatment protocol, are randomized to either active transcranial direct-current stimulation treatment for ten sessions of 20 minutes at an intensity of 2 mA or sham transcranial direct-current stimulation over a 2-week period. Outcome measures are collected at baseline, 2 weeks after treatment and at 3-month follow-up. The primary outcome is pain during intercourse, assessed with a numerical rating scale. Secondary measurements focus on the sexual function, vestibular pain sensitivity, psychological distress, treatment satisfaction, and the patient’s global impression of change.

Discussion

To our knowledge, this study is the first randomized controlled trial to examine the efficacy of transcranial direct-current stimulation in women with provoked vestibulodynia. Findings from this trial are expected to provide significant information about a promising intervention targeting the centralization of pain in women with provoked vestibulodynia.

Trial registration

Clinicaltrials.gov, NCT02543593. Registered on September 4, 2015.

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-016-1366-5) contains supplementary material, which is available to authorized users.

Mediolateral versus lateral episiotomy and their effect on postpartum coital activity and dyspareunia rate 3 and 6 months postpartum

OBJECTIVES

Comparison of the effects of two episiotomy types on sexual activity, dyspareunia and overall satisfaction after childbirth.

STUDY DESIGN

A prospective follow-up study of a randomized comparative trial evaluating peripartum outcome of a vaginal delivery after mediolateral (MLE) or lateral (LE) episiotomy.

MAIN OUTCOME MEASURES

The participants completed questionnaires regarding sexual activity, dyspareunia, perineal pain, aesthetic appearance and overall satisfaction 3 (3M) and 6 months (6M) postpartum.

RESULTS

A total of 648 women were available for the analyses (306 MLE, 342 LE). The groups showed no difference regarding resumption and regularity of sex, timing of resumption, frequency and intensity of dyspareunia, perineal pain, aesthetic appearance or overall satisfaction 3M or 6M postpartum. 98.0% of women after MLE and 97.7% after LE resumed sexual intercourse within 6M after delivery (p = 0.74). In the same period 15.6% of women after MLE and 16.1% after LE suffered from considerable dyspareunia (p = 0.86).

CONCLUSIONS

Quality of sexual life and perception of perineal pain after MLE is equivalent to LE.

Role of ultrasound imaging in advancing treatment of female patients with pelvic floor mesh complications

Application of vaginal mesh for stress urinary incontinence has seen widespread use due to its relatively short operative time in combination with its efficacy in treatment. However, vaginal mesh is not without its drawbacks and can lead to mesh erosion or extrusion, infection, dyspareunia, and recurrence of incontinence. Vaginal mesh complications can lead to feelings of hopelessness, isolation, shame, and emotional distress. Furthermore, failure to identify and address these complications in a timely manner can be permanently damaging to patient health. It is vital to be able to identify mesh complications early. Various imaging methodologies exist to visualize vaginal mesh placement and complications, including ultrasound, magnetic resonance imaging (MRI), and computed tomography (CT). This invited review paper focuses on the role of ultrasound in mesh visualization, mesh complication identification, and operative planning in the event of subsequent surgical mesh revision. Polypropylene mesh is echogenic on ultrasound, making it a useful tool for visualizing post-operative mesh placement. Transperineal, translabial and endovaginal ultrasound technique use has been described in the pre- and peri-operative setting to identify mesh in complex cases. Efficacy and practicality of CT and MRI use in identifying mesh in these cases is limited.

Dyspareunia in a Teenager Reveals a Rare Occurrence: Retroperitoneal Cervical Leiomyoma of the Left Pararectal Space

BACKGROUND

Retroperitoneal uterine leiomyoma is a very rare occurrence and to discover it as a cause of female sexual dysfunction in a teen is unusual.

CASE

An 18-year-old black woman reported deep dyspareunia, resulting in severe distress. Gynecological and instrumental examinations showed a pelvic mass of 7 cm in diameter. The preoperative diagnosis was uterine fibroid, but the exact location of the leiomyoma was uncertain. Laparoscopic examination showed a pedunculated retroperitoneal cervical leiomyoma in the left pararectal space. After surgical excision of the mass, normal sexual activity was restored.

SUMMARY AND CONCLUSION

When a teen experiences pain with intercourse, pelvic masses should be part of differential diagnosis of dyspareunia.