Genital and sexual pain in women

Vulvodynia: Pain Management Strategies

Background: Vulvodynia is defined in this international consensus as persistent vulvar pain that occurs for >3 months without an identifiable cause and with several potential associated factors. At present there is no univocal consensus in the therapeutic treatment of vulvodynia. The methods of intervention are based on various aspects including, above all, the management of painful symptoms. Methods: a research on scientific database such as “Pubmed”, “Medline Plus”, “Medscape” was conducted, using the words “women’s genital pain” and “vulvodynia” for the review of the scientific evidence on the assessment and treatment of women’s genital pain. Results: Among the drugs with pain-relieving action, the most effective in the treatment of vulvodynia would seem to be those with antidepressant and anticonvulsant action, even if their mechanisms of action are not known and there are still insufficient studies able to demonstrate their real validity. Among the least effective are non-steroidal anti-inflammatory drugs (NSAIDs) and corticosteroids. However, the ideal would seem to use a combined treatment with multiple types of drugs. Conclusions: Future studies are needed to draw up a unique therapeutic action plan that considers the stratification of patients with vulvodynia and the variability of the symptom.

The Gynogram: A Multicentric Validation of a New Psychometric Tool to Assess Coital Pain Associated With VVA and Its Impact on Sexual Quality of Life in Menopausal Women

BACKGROUND

Vulvo-Vaginal Atrophy (VVA) affects about fifty percent of postmenopausal women, contributing more vulnerable sexual and psycho-relational equilibrium. To date, no psychometric instruments have been designed to assess the impact of coital pain associated with VVA on sexual quality of life.

AIM

To validate a new psychometric tool, the Gynogram, able to investigate coital pain and to quantify its impact on sexual well-being in menopause.

METHODS

214 sexually active postmenopausal women were enrolled in the study during clinical consultations in gynecological outpatient clinics in Italy. After gynecological examination and evaluation of the presence of VVA, the study sample was divided in a clinical group (103 women with certified diagnosis of VVA) and in a control group (111 women without certified diagnosis of VVA) according to the Vaginal Health Index (VHI) cut-off. Factor, Reliability and Receiving Operating Characteristics (ROC) analysis were performed in order to validate our newly created Gynogram.

OUTCOMES

A structured questionnaire, named Gynogram, to assess coital pain and its impact, and the Female Sexual Function Index (FSFI).

RESULTS

The factor analysis performed on the original form (80 items) reduced the Gynogram to 24 items. Reliability analysis conducted with Cronbach's Alpha coefficients showed high values in all the components (ranging from .813 to .972), both in the long and in the short form. The sensitivity analysis demonstrated that the Gynogram, with a cut-off ≤93, is able to recognize a clinically significant coital pain. With respect to the FSFI, statistically significant differences were found for all the domains. In addition, statistically significant differences were found for all the twelve factors of the Gynogram, showing that VVA profoundly affects the sexual quality of life of women in post-menopause.

CLINICAL TRANSLATION

The utility of this tool consists in the possibility to improve prognosis, compliance/adherence and treatment outcomes.

STRENGTHS AND LIMITATIONS

The Gynogram is able to evaluate and to quantify the impact of coital pain associated with VVA. Moreover, it can also recognize the areas of biopsychosocial functioning being more affected by this clinical condition. The main limit of the study is the impossibility to evaluate both mental health and partner's general and sexual health.

CONCLUSIONS

The Gynogram is a new and validated psychometric tool able to detect the impact of symptomatic VVA on sexual quality of life among post-menopausal women, with a specific focus on the different areas of sexual functioning. Nappi RE, Graziottin A, Mollaioli A, et al. The Gynogram: A Multicentric Validation of a New Psychometric Tool to Assess Coital Pain Associated With VVA and Its Impact on Sexual Quality of Life in Menopausal Women. J Sex Med 2021;18:955-965.

Comparing the effectiveness of functional electrical stimulation via sexual cognitive/behavioral therapy of pelvic floor muscles versus local injection of botulinum toxin on the sexual functioning of patients with primary vaginismus: a randomized clinical trial

INTRODUCTION AND HYPOTHESIS

Most patients suffering from vaginismus feel sinful, anxious, and incompetent, with reduced self-confidence. This study was aimed at comparing the effectiveness of the physiotherapy of pelvic floor muscles as a standard treatment and local injection of botulinum toxin on the sexual functioning of patients with primary vaginismus.

METHODS

In this randomized clinical trial (RCT), the study population included women with primary vaginismus referred to the Sexual Health and Gynecologic Clinics of Imam Khomeini Hospital during 2013-2014. They were diagnosed according to DSM-5 criteria and underwent treatments with botulinum injection (intervention group) and physiotherapy as the current treatment (control group). The participants' primary and secondary outcomes were measured based on successful intercourse and sexual functioning of each group.

RESULTS

The results indicated that the overall standard physiotherapy, along with other measurements, such as functional electrical stimulation and desensitization, could effectively improve the patients' Female Sexual Function Index compared with botulinum treatment. At the end of the study, it was found that 20 and 26 patients out of the 30 and 28 patients in the intervention and control groups managed to have successful intercourse respectively (P = 0.014). Also, sexual dysfunction frequencies were seen to be decreased by 26.6% and 50% in the mentioned groups respectively (p = 0.008 and p < 0.001).

CONCLUSIONS

Considering the higher efficacy of physiotherapy procedures compared with those of the desensitization and electrical stimulation techniques, this therapeutic method should be considered the first-line treatment of vaginismus (IRCT2016061828486N1).

Psychobiological Correlates of Vaginismus: An Exploratory Analysis

BACKGROUND

Evidence concerning the determinants of vaginismus (V), in particular medical conditions, is inconclusive.

AIM

To investigate, in a cohort of subjects consulting for female sexual dysfunction, whether there is a difference in medical and psychosocial parameters between women with V and women with other sexual complaints.

METHODS

A series of 255 women attending our clinic for female sexual dysfunction was consecutively recruited. V was diagnosed according to Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision criteria. Lifelong and acquired V cases were included.

OUTCOMES

Patients underwent a structured interview and physical, gynecologic, laboratory, and clitoral ultrasound examinations; they completed the Female Sexual Function Index (FSFI), the Middlesex Hospital Questionnaire, the Female Sexual Distress Scale-Revised (FSDS), and the Body Uneasiness Test.

RESULTS

V was diagnosed in 20 patients (7.8%). Women with V were significantly younger than the rest of the sample (P < .05). No differences were found for traditional risk factors such as a history of sexual abuse, relational parameters, or gynecologic diseases or for newly investigated parameters (ie, neurologic, hormonal, and metabolic alterations). Women with V showed significantly higher histrionic-hysterical symptoms and traits (as detected by MHQ-H score; P < .05) compared with subjects with other sexual complaints. When the scores of all MHQ subscales were simultaneously introduced in a logistic model, the association between V and MHQ-H score was confirmed (P = .013). Women with V also showed higher FSFI pain and FSDS total scores, even after adjusting for age (P < .05). In an age-adjusted model, FSDS total score increased as a function of the years of duration of V (P = .032) but not as a function of its severity. All observations were confirmed in a case-control study (ratio = 1:3).

CLINICAL IMPLICATIONS

Our data demonstrate that some novel contributors of V should be investigated, namely histrionic-hysterical traits. This psychological comorbidity could offer valuable insights for intervention and managing complications.

STRENGTHS AND LIMITATIONS

This is the first study to assess the role of many metabolic and hormonal parameters as potential determinants of V. The main limitation is its exploratory and cross-sectional nature; our data need to be confirmed in larger, more systematic analyses.

CONCLUSION

V was associated with histrionic-hysterical traits, FSFI pain domain, and sex-related distress. A history of abuse, relational parameters, gynecologic diseases, and hormonal and metabolic alterations do not seem to play a role in the development of V. Maseroli E, Scavello I, Cipriani S, et al. Psychobiological Correlates of Vaginismus: An Exploratory Analysis. J Sex Med 2017;14:1392-1402.

Women’s attitude toward gynecological pain in fertile age: Results from a cross-sectional study among Italian community pharmacies

Introduction:

Several epidemiological data on women afferent to clinics for medical treatment of pelvic pain are available, while few studies explored the general population. Thus, this study aimed to investigate women presenting with gynecological pain at the community pharmacy and to evaluate the relevance of pharmacist advice regarding medical treatment.

Methods:

A cross-sectional study was conducted in a sample of 10 Italian community pharmacies, by administering a structured questionnaire to fertile age women reporting pelvic pain during the last 3 months. Questions were concerning demographic information, pain characteristics, women’s behavior toward gynecological pain, and diagnosis possibly received from a physician.

Results:

A group of 290 women were interviewed. Severe pain was reported in 58.3%, with a mean ± SD of 4.4 ± 6.8 days of suffering, causing absenteeism from work in 45.3% of cases. Almost half of women reported that the onset of gynecological pain was before 15 years and 72.2% had consulted a physician in the past, with a mean delay of 2.5 ± 4.3 years between the onset of pain and medical consultation. However, only 28% of the overall population received a diagnosis. 51.0% received one treatment, while 39% received two or more. The first therapy was prescribed in 40.2% cases by the physician, while in the remaining it was recommended either by the pharmacist or it was a self-medication.

Conclusion:

Gynecological pelvic pain is a disabling problem, regardless of the underlying cause, with significant impact on social and working life and requiring a better medical management.

Vaginismus in Assisted Reproductive Technology Centers: an invisible population in need of care

Objective

Genital and sexual pain is still neglected. Consequences may be dramatic, since infertility and sexual dysfunction may be reciprocally linked. This is the first study to focus on the identification of cases of vaginismus in the ART scenario and on the introduction of intra-cycle interventions as part of a comprehensive, integrated and patient-centered perspective.

Methods

This observational prospective study looked into 425 IVF/ICSI cycles and 226 frozen embryo transfers carried out from January 1, 2015 to December 31, 2016, and found seven cases of vaginismus. Within a six-month period, a questionnaire placed on SurveyMonkey was sent twice to 228 ART centers in Latin America. The purpose was to learn how often cases of vaginismus were found in ART centers and the perceptions around the presence of this condition.

Results

The few centers that took the time to answer the questionnaire (24/10.5%) stated that the number of cases in which they had trouble performing control ultrasound examination or needed to perform transfers with patients under sedation was not significant. Although 81% agreed that the incidence of these conditions is low, no references were made to cases of vaginismus, dyspareunia or sexual dysfunction. Our multidisciplinary team found seven cases of vaginismus, involving women with higher education degrees with a mean age of 37.8 years and married for a mean of four years. Although two reported they were able to tolerate intercourse, all reported undergoing treatments such as using vaginal dilators (3), psychotherapy (4) and psychiatric care (1). The care provided by the staff was designed to mitigate patient suffering.

Conclusion

Gentle care and sensitive listening should be integral components in the work of multidisciplinary teams to identify women with vaginismus and offer couples better quality treatment.

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Zusammenfassung. Das Urethralsyndrom bei Frauen mit Schmerzen in der Harnröhre und Blasenentleerungsstörungen ist eine Ausschlussdiagnose. Zu den möglichen Ursachen zählen unter anderem Infektionen, Entzündungen der paraurethralen Drüsen, Verspannungen der Sphinkteren und/oder der Beckenbodenmuskulatur, Östrogenmangelerscheinungen, Traumata, Neuropathien, Allergien und psychosomatische Störungen. Patientinnen mit Urethralsyndrom müssen ganzheitlich betrachtet, abgeklärt und behandelt werden. Während der Abklärung und Behandlung benötigen diese Patientinnen viel Zeit und Aufmerksamkeit. Heute gilt als sicher, dass bei vielen somatischen Leiden psychosoziale Faktoren mitspielen, die den Verlauf der Erkrankung entscheidend beeinflussen können und im Behandlungsprozess berücksichtigt werden müssen.