Vaginismus Treatment: Clinical Trials Follow Up 241 Patients

Obstetric outcomes of nulliparous women with pelvic pain undergoing fertility treatment

RESEARCH QUESTION

Is there any association between pelvic pain and primary caesarean delivery for patients undergoing assisted reproductive technology (ART) treatment?

DESIGN

Retrospective cohort study of nulliparous patients with singleton pregnancies who underwent ART treatment and achieved a live birth between 2012 and 2020. Cases included patients diagnosed with pelvic pain. A 3:1 ratio propensity-score-matched population of patients without a history of pelvic pain was included as the control group. Comparative statistics were performed using chi-squared test and Student's t-test. A multivariate regression analysis was conducted to evaluate the association between pelvic pain and mode of delivery.

RESULTS

One hundred and seventy-four patients with pelvic pain were compared with 575 controls. Patients with pelvic pain reported a significantly longer duration of infertility compared with controls (18.98 ± 20.2 months versus 14.06 ± 14.06 months; P = 0.003). Patients with pelvic pain had a significantly higher rate of anxiety disorders (115 ± 21.9 versus 55 ± 31.6; P = 0.009) and use of anxiolytics at embryo transfer (17 ± 3.2 versus 12 ± 6.9; P = 0.03) compared with controls. In addition, patients with pelvic pain had a higher rate of primary caesarean delivery compared with controls (59.8% versus 49.0%; P = 0.01). After adjusting for multiple variables, a significant association was found between pelvic pain and increased odds of primary caesarean delivery (adjusted OR 1.48, 95% CI 1.02-2.1).

CONCLUSION

Patients with pelvic pain have significantly higher odds of primary caesarean delivery compared with patients without a history of pelvic pain. The infertility outpatient setting may be uniquely positioned to identify patients at risk for undergoing primary caesarean delivery, and could facilitate earlier intervention for pelvic floor physical therapy during the preconception and antepartum periods.

The interrelationship between women's help-seeking experiences for vaginismus and their sense of self: a qualitative study and abductive analysis

Objective

There is a lack of research on women's holistic experiences of vaginismus, also called sexual pain-penetration disorder, from their perspective. To address this gap, an abductive qualitative study aimed to examine women's help-seeking experiences for vaginismus, and its impact on their sense of self.

Methods

This study was informed by a feminist approach to the theory of self focused on participants' negotiation of dis/empowerment when help-seeking for vaginismus. Twenty-one participants aged 19-37 years (mean 27.6 years) and diagnosed with vaginismus in Australia participated in semi-structured interviews, which were thematically analysed.

Results

Three themes were developed: Interconnected constructions of womanhood and help-seeking, Elicit agency to move forward, Resilience to surmount challenges with subthemes. Participant's overall help-seeking experiences, within and outside the healthcare system, shaped their sense of self in ways that drove their approach/es to future help-seeking behaviours.

Conclusions

Positive help-seeking experiences for vaginismus strengthened participants' sense of self to persevere with treatment even when it was difficult. Conversely, negative help-seeking experiences led to participants' weakened sense of self which was often caused by a gap between their ideal and perceived self. This led to negative feelings and responses of demotivation or halting subsequent help-seeking. Recommendations are provided to improve health professional practice to support women help-seeking for vaginismus, and to help close the gap between their ideal and perceived selves. Such insight can help to empower women's sense of self and motivate them to persevere with help-seeking to experience improvement for their vaginismus and quality of life.

The effects of a real-time temperature monitoring non-ablative monopolar radiofrequency technology on vulvovaginal atrophy symptoms in postmenopausal Chinese women

BACKGROUND

Vulvovaginal atrophy (VVA) includes a wide range of conditions affecting the reproductive and urinary systems, often requiring careful evaluation and management for optimal health.

AIMS

This study aims to evaluate the symptom management effects of a real time temperature-monitored non-ablative RF device for the treatment of postmenopausal Chinese women with VVA symptoms.

METHODS

This pilot study involved 24 postmenopausal Chinese women with one or more VVA symptoms, who wished to remain sexually active. VHIS, VAS, and FSFI were used to track and evaluate various aspects of the patient's condition. Analyses were conducted at the end of the study to verify the statistical significance of the treatment's results.

RESULTS

All patients reported substantial, statistically significant, improvements on every VVA symptom tracked. Approximately 80% of the patients reported total symptom reversal at 12-week post-treatment follow-up.

CONCLUSION

This pilot study demonstrated that non-ablative, monopolar RF technology equipped with real time temperature monitoring is feasible and safe in the treatment of postmenopausal women with VVA symptoms, and efficacious at up to 12 weeks post-treatment.

Sequential administration of peripheral nerve blocks and onabotulinumtoxinA for the treatment of chronic migraine and other headache disorders-A retrospective tolerability and safety study

OBJECTIVE

To determine the tolerability and safety of concurrent peripheral nerve blocks and onabotulinumtoxinA treatment during a single outpatient clinic procedure visit.

BACKGROUND

Procedural interventions are available for the treatment of headache disorders. OnabotulinumtoxinA and peripheral nerve blocks are used as alternatives or in addition to oral therapies to reduce the frequency and intensity of migraine attacks. There is currently a lack of safety data focusing on the sequential administration of local anesthetic via peripheral nerve blocks and onabotulinumtoxinA during a single clinical encounter for the treatment of headache. The primary aim of the study was to determine the safety and tolerability of concurrent peripheral nerve blockade and onabotulinumtoxinA injections during a single outpatient clinic procedure visit. We hypothesized that the dual intervention would be safe and well tolerated by patients with chronic migraine and other headache disorders.

METHODS

A retrospective chart review was performed using clinical data from patients seen by multiple providers over a 16-month timeframe at one outpatient headache clinic. Patients were identified by procedure codes and those receiving peripheral nerve block(s) and onabotulinumtoxinA injections during a single encounter within the study period were eligible for inclusion. Inclusion criteria were (1) patients 18 years and older who were (2) receiving both peripheral nerve blocks and onabotulinumtoxinA injections for the treatment of chronic migraine. Patients were excluded if they were under age 18, received their procedure outside of the clinic (emergency room, inpatient ward), or were receiving sphenopalatine ganglion blocks. Age- and sex-matched patients who received one procedure, either peripheral nerve blocks or onabotulinumtoxinA, were used for control. The primary outcome of this safety study was the number of adverse events that occurred in the dual intervention group compared to the single intervention control arms. Information regarding adverse events was gathered via retrospective chart review. If an adverse event was recorded, it was then graded by the reviewer utilizing the Common Terminology Criteria for Adverse Events ranging from Grade 1 Mild Event to Grade 5 Death. Additionally, it was noted whether the adverse event led to treatment discontinuation.

RESULTS

In total, 375 patients were considered eligible for inclusion in the study. After age and sex matching of controls, 131 patients receiving dual intervention were able to be compared to 131 patients receiving onabotulinumtoxinA alone and 104 patients receiving dual intervention were able to be compared to 104 patients receiving peripheral nerve block(s) alone. The primary endpoint analysis showed no significant difference in total adverse events between dual intervention compared to nerve blocks alone or onabotulinumtoxinA alone. The number of adverse events that led to treatment discontinuation approached but did not reach statistical significance for those receiving dual intervention versus onabotulinumtoxinA alone in the number of adverse events that led to treatment termination (4.6%, 6/131 vs. 0.8%, 1/131, p = 0.065); however, the number of patients who discontinued therapy was not significantly different between those groups (2.3%, 3/131 vs. 0.8%, 1/131; p = 0.314; odds ratio 0.3 [0-3.2]; p = 0.338).

CONCLUSIONS

In this retrospective chart review, there was no significant difference in adverse events or therapy discontinuation between patients receiving sequential peripheral nerve block(s) and onabotulinumtoxinA injections versus those receiving either peripheral nerve block(s) or onabotulinumtoxinA injections alone. As a result, we concluded that the combination procedure is likely safe and well tolerated in routine clinical practice.

Patients' recommendations to improve help-seeking for vaginismus: a qualitative study

BACKGROUND

Research to improve healthcare experiences for women with vaginismus tends to be produced from the perspective of healthcare professionals or health-based researchers. There is lacking research on women's experiences and recommendations to improve help-seeking for vaginismus from their perspective. To address this research gap, this qualitative study aimed to identify the issues that women face when help-seeking for vaginismus and their recommendations to address it. This sought to support the wellbeing of patients to advocate for their healthcare needs which is often overlooked.

METHODS

Using a feminist theoretical approach, semi-structured interviews were conducted with 21 participants who sought help for their vaginismus. Thematic analysis was employed to analyse participants' recommendations.

RESULTS

Four main themes emerged: Increase awareness of vaginismus, Dismantle myths about sex, Destigmatise vaginismus, and Empower people with vaginismus during medical consultations. Subthemes were identified as actionable strategies that participants recommended to improve help-seeking and healthcare for vaginismus.

CONCLUSIONS

The findings from this study can inform healthcare practice and policy to foster better synchronicity between health professionals and their patients' perceptions and expectations of treating vaginismus. This can promote more acceptance of patients' advocacy of their needs and goals to improve the therapeutic alliance and treatment outcomes for vaginismus in healthcare practice. The strategies recommended to increase awareness of vaginismus and challenge its stigma should be considered in policy to incite a culture of change in healthcare practice and broader society.

Botulinum Toxin for the Management of Pelvic Floor Tension Myalgia and Persistent Pelvic Pain: A Systematic Review and Meta-analysis

OBJECTIVE

To systematically review the literature on use of botulinum toxin to treat pelvic floor tension myalgia and persistent pelvic pain.

DATA SOURCES

The ClinicalTrials.gov , PubMed, EMBASE, and Scopus databases were searched from inception to November 2022 by two independent assessors (B.L.K. and F.G.L.). Identified studies were screened by title and abstract and included after full-text review. Data extraction was subsequently performed and recorded in Microsoft Excel.

METHODS

This study was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines after registration in PROSPERO (CRD42022289132). All randomized studies, prospective studies with more than five participants, and retrospective studies with more than 10 participants published in English or French and assessing the use of botulinum toxin for the treatment of pelvic floor tension myalgia and persistent pelvic pain in women were included. Meta-analyses were performed on randomized data.

TABULATION, INTEGRATION, AND RESULTS

Of 4,722 articles identified, 24 satisfied inclusion criteria. A meta-analysis of five randomized controlled trials totaling 329 participants demonstrated no differences in patient- and clinician-reported outcome measures, including pain, dyspareunia, sexual function, and vaginal manometry. Mean duration of follow-up was 6 months. A qualitative analysis of 14 prospective and four retrospective studies including 804 participants is supportive of botulinum toxin; however, the quality of data is low, and there is marked heterogeneity between studies.

CONCLUSION

Meta-analyses of randomized data do not support the use of botulinum toxin to treat pelvic floor tension myalgia and persistent pelvic pain. Failure of these data to confirm the findings of nonrandomized prospective studies that suggest a treatment benefit may be attributable to the absence of placebo control and confounding outcomes obtained from an active comparator group. Further randomized controlled trials with true placebo are strongly recommended.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO, CRD42022289132.

The Comparison of Patient Characteristics, Therapy Outcome, and Sexual Functions in Vaginismus Patients Prior to and During the COVID-19 Pandemic

Background The objective of this study conducted at one center is to compare the demographic features and female sexual functions of patients treated for vaginismus before the COVID-19 pandemic to those treated for vaginismus during the pandemic. Aim Additionally, the study intends to evaluate the results of vaginismus therapy and assess the post-treatment sexual functioning of women. Methods A retrospective analysis was conducted on the medical records of patients diagnosed with vaginismus who sought treatment between March 2018 and March 2022. The enrolled patients were categorized into two groups: the pre-COVID-19 group and the COVID-19 group. The following data have been collected: age, education level, occupation, and marriage duration. After three months of treatment, the patients were called for a follow-up examination and evaluation of their sexual functions. Outcomes Compared to the pre-COVID-19 group, an increase of 52.51% was observed in the number of patients admitted for treatment in the COVID-19 group. Results The severity of vaginismus in the patients was similar in both groups. There were no statistically significant changes observed in any of the areas of the Female Sexual Function Index (FSFI) scale. Clinical implications According to our findings, there was no significant difference in female sexual functioning between women who had vaginismus treatment during the pandemic and those who underwent pre-pandemic treatment. Strengths and limitations The research sample comprised women who sought medical care at our women's health clinic. Conclusions We believe that vaginismus patients who had previously avoided seeking treatment are now seeking it during the pandemic.

Botulinum toxin injection in vulva and vagina. Evidence from a literature systematic review

INTRODUCTION

Botulinum toxin (BoNT) administration has been proposed in the gynecologic field for pelvic, vulvar and vaginal disorders. On this regard, we aimed assessing the therapeutic effectiveness and safety of BoNT usage in the treatment of vaginal, vulvar and pelvic pain disorders.

METHODS

We searched for all the original articles without date restriction until 31.12.2021. We included all the original articles which administered botulinum toxin in the vulva or vagina of women suffering from vaginismus, dyspareunia, and chronic pelvic pain. Only English language studies and those performed in humans were eligible. We excluded all case reports and pilot study from the qualitative analysis, although we accurately evaluated them. 22 original studies were finally included in the systematic review.

RESULTS

Botulinum toxin injection was found to be effective in improving vulvar and vaginal dyspareunia, vaginismus, and chronic pelvic pain. No irreversible side effects were detected. Major side effects reported were transient urinary or fecal incontinence, constipation and rectal pain. The risk of bias assessment proved original articles to be of medium quality. No metanalysis could have been performed since lack of congruency in the definition of pathology and methods of botulinum toxin administration.

CONCLUSION

Data extraction pointed out different endpoints and different methods of analysis. Studies focus on different types of participants and use various techniques and timing. According to the best evidence available, different techniques provide evidence about positive outcomes, with the need for a standardized protocol.

Psychometric properties of the Romanian version of the female sexual function index (FSFI-RO)

BACKGROUND

Female sexual dysfunction (FSD) is a highly prevalent health disorder and no self-report questionnaire on female sexual function is available in Romanian. Therefore we considered the Female Sexual Function Index (FSFI) to be the most appropriate due to its excellent psychometric properties. The FSFI is a measuring scale with 19 items that assess the six domains of female sexual function: desire, arousal, lubrication, orgasm, satisfaction and pain. The paper aims to analyze the psychometric reliability and validity of the FSFI-RO (Romanian Version of the Female Sexual Function Index).

METHODS

385 women (aged 18 to 51) enrolled in the present study. To assess the presence of FSD we used the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5) criteria for sexual dysfunction. Then we categorized the participants into two groups: the FSD group (41%) and the healthy control group (59%). Women were then asked to fill out a form that included sociodemographic information and the FSFI-RO questionnaire. A sample of 50 women agreed to re-answer FSFI-RO in a 4-week interval in order to evaluate the test-retest validity of the questionnaire. The data were summarized using descriptive statistics: the test-retest reliability was measured by the intraclass correlation coefficient (ICC); Cronbach's alpha was employed to evaluate the internal consistency of the Romanian version of the FSFI, and validity was assessed by the content and construct validity.

RESULTS

The results showed high test-retest reliability, with ICC from 0.942 to 0.991 in the domains and 0.987 in the total score. Regarding the internal consistency of the FSFI-RO, Cronbach's α coefficients were found to be high (α = 0.944). Convergent construct validity proved to be moderate to high in desire, arousal, lubrication, orgasm and, satisfaction domains, and weak correlation in the pain domain. Regarding the discriminant construct validity, the scores for each domain and the total score showed statistically significant differences between the FSD group and the control group.

CONCLUSIONS

The FSFI-RO showed similar psychometric properties to those of the original version, therefore being a reliable and valid instrument that can be used in Romanian-speaking women.

Component of sexual health services for vaginismus management: A qualitative study

BACKGROUND

Provision of sexual health services requires gender-sensitive management, facilities, and staff, as well as planning for gender-sensitive caregivers and education. Couples suffering from vaginismus face many types of barriers to accessing sexual health services. This qualitative study was conducted to explain the needs of sexual health services in women with primary vaginismus in Iran.

METHODS

This qualitative study was conducted through the participation of 20 participants including service providers, women with vaginismus and their husbands in 2022, Iran. The samples were selected using purposive sampling method and considering the maximum variation. For data collection, in-depth semi-structured individual interviews were conducted and continued until data saturation was reached. The collected data were analyzed in MAXQDA10 software using conventional content analysis approach based on the criteria proposed by Graneheim and Lundman.

RESULTS

Data analysis led to the emergence of three main themes: 1) Comprehensive preventive sex education which included the three categories of sex education in the education system, premarital sex education through the health system, and sex education through the media with scientific content; 2) Efficient sexual health clinics which included three categories of therapist's skills, empowerment of sexual therapist, and structural features of sexual health clinics and cultural considerations in establishing sexual health clinics; and 3) Protocol for management and treatment of sexual problems which consisted of sexual education and counseling content, treatment requirements, and sex education approaches.

CONCLUSION

Based on the results of the study, comprehensive preventive sex education through the education system and the Ministry of Health can improve the attitudes of adolescents and young people. Moreover, it can take a fundamental step in solving sexual problems by providing the infrastructure necessary for the establishment of efficient sexual health clinics and protocols required to manage and treat such problems.

The Role of Vaginal Penetration Skills and Vaginal Penetration Behavior in Genito-Pelvic Pain/Penetration Disorder

Vaginal penetration skills and behavior are considered different aspects of vaginal penetration. Nevertheless, these terms are used interchangeably in most genito-pelvic pain/penetration disorder (GPPPD) intervention studies, possibly impacting the assessment and selection of intervention outcomes. This is the first theoretical essay on the relevance of nonsexual vaginal penetration skills in understanding and treating GPPPD symptoms, mainly for patients with vaginismus complaints. We aim to provide avenues for further empirical research and new perspectives for assessing, preventing, and treating GPPPD symptoms. We highlight the conceptual boundaries, overlaps, and commonalities between vaginal penetration skills and vaginal penetration behavior and the implications for measuring and selecting GPPPD treatment outcomes. We then briefly explain vaginal penetration skills as a self-learning process and review the impact of fear, anxiety, and cognitive factors on GPPPD symptoms. We also outline the role of the nonsexual genital self-exploration skills in later penetration behavior and offer implications for a new GPPPD patient-centered treatment approach.

Pain specialist management of sexual pain: III-neuromodulation

INTRODUCTION

Some women with sexual pain do not respond to conservative multi-modal care modalities. Neuromodulation is a group of methods which alter nerve activity by delivering electrical energy or pharmaceutical agents directly to target neural structures. Multiple forms of neuromodulation may provide durable treatment options to fill the unmet therapeutic need of a certain population of women with chronic sexual pain.

OBJECTIVES

To provide a current review of neuromodulation treatments used for female sexual pain and introduce neuromodulation techniques which may be applied in novel ways to specific sexual pain phenotypes.

METHODS

Internet, PubMed and Cochrane Library were searched for relevant articles on female sexual pain within the clinical purview and scope of practice of pain management.

RESULTS

A thorough review of the literature was conducted to include basic science studies, clinical trials, systematic reviews, consensus statements, and case-reports. A sampling of information on real-world patient outcomes was included. The amount and quality of evidence for neuromodulation to treat female sexual pain is low-moderate. Descriptions of neuromodulation procedures for sexual pain were made and clinical studies reviewed. The effects of autonomic nervous system (ANS) dysregulation on the experience of pain were discussed with consideration of interventional procedures to facilitate restoration of ANS equilibrium.

CONCLUSION

Treating female sexual pain is complex. There are considerable numbers of women who have unsatisfactory sexual pain relief despite evidence-based interdisciplinary care. These women may benefit from referral to consider neuromodulation treatment options. Neuromodulation is a relatively new capability in the arsenal of pain management and other specialists that can be considered for women with treatment refractory sexual pain.

Cosmetic gynecology-An emerging field for the dermatologist

INTRODUCTION

Cosmetic gynecology is an expanding field with a steep rise in awareness and demand for procedures to enhance the aesthetic appearance of female genitalia.

AIM

This article aims to provide an overview of aesthetic gynecology for a practicing dermatologist.

METHODS

A study conducted in India showed a rising trend in the demand of aesthetic vaginal procedures from 3.9% in 2012 to 28.97% in 2015.

CONCLUSION

Several aesthetic modalities such as peels, platelet rich plasma, and energy-based devices and surgical modalities have been in use, though serious evidence for efficacy of many of these procedures is lacking.

Outcomes of Vaginismus Therapy Assessed by Penetrative Intercourse, Psychiatric Symptoms, and Marital Satisfaction

We evaluated the treatment outcomes of the patients with primary vaginismus in a specialized clinic. Cognitive-Behavioral Therapies (CBT), finger exercises, and vaginal dilators were used. Symptom Checklist-90 Revised, Martial Adjustment Inventory, Female Sexual Function Index and Golombok-Rust Index for Sexual Satisfaction were applied pre-and post-treatment. Twenty-three patients were enrolled. All patients achieved sexual intercourse at the end of the treatment. After treatment, the results improved in the SCL-90 R test and sexual function indexes Marriage adjustment scores did not improve. With vaginismus, improvement in psychological scores emphasizes the importance of sexual therapy in couples having sexual dysfunctions.

Meu corpo refletindo minha história

Vaginismo é uma contração muscular que causa desconforto, dificultando e/ou impossibilitando a penetração vaginal, sendo uma temática com escassa produção nacional. Este trabalho buscou investigar a experiência de viver com vaginismo e os impactos dessa disfunção na vida das mulheres. Optou-se por um estudo qualitativo-exploratório, com nove mulheres que vivenciaram o vaginismo. A coleta foi realizada individualmente por meio de entrevistas semidirigidas, sendo os dados submetidos à análise de conteúdo. Os resultados foram organizados em três categorias referentes às primeiras manifestações dos sintomas, a descoberta e enfrentamento e, por fim, aos impactos psicossociais. Nota-se que viver com vaginismo envolve um longo processo, permeado por frustrações, que impactam profundamente a saúde mental, as relações pessoais e o cotidiano. A busca por tratamento abrange diversas dificuldades pessoais, se configurando como um investimento psíquico, físico e financeiro. Logo, compreende-se a necessidade de suporte e escuta dessas mulheres, a partir de uma compreensão ampliada da sexualidade. 

The effect of biofeedback interventions on pain, overall symptoms, quality of life and physiological parameters in patients with pelvic pain : A systematic review

BACKGROUND

Biofeedback is recognized as an effective additive method for treating certain phenotypes of chronic pelvic pain syndrome and is a therapeutic option in other pelvic pain conditions. This review aims to evaluate evidence from the literature with a focus on the effect of biofeedback on pain reduction, overall symptom relief, physiological parameters and quality of life.

METHODS

A systematic literature search was conducted using the databases PubMed, MEDLINE, Embase, Cochrane Library and PEDro from inception to July 2020. Data were tabulated and a narrative synthesis was carried out, since data heterogeneity did not allow a meta-analysis. The PEDro scale and the McMaster Critical Review Form-Quantitative Studies were applied to assess risk of bias.

RESULTS

Out of 651 studies, 37 quantitative studies of primary research evaluating pelvic pain conditions in male and female adults and children were included. They covered biofeedback interventions on anorectal disorders, chronic prostatitis, female chronic pelvic pain conditions, urologic phenotypes in children and adults and a single study on low back pain. For anorectal disorders, several landmark studies demonstrate the efficacy of biofeedback. For other subtypes of chronic pelvic pain conditions there is tentative evidence that biofeedback-assisted training has a positive effect on pain reduction, overall symptoms relief and quality of life. Certain factors have been identified that might be relevant in improving treatment success.

CONCLUSIONS

For certain indications, biofeedback has been confirmed to be an effective treatment. For other phenotypes, promising findings should be further investigated in robust and well-designed randomized controlled trials.

Guideline No. 422d: Menopause and Sexuality

OBJECTIVE

Provide strategies for improving the care of perimenopausal and postmenopausal women based on the most recent published evidence.

TARGET POPULATION

Perimenopausal and postmenopausal women.

BENEFITS, HARMS, AND COSTS

Target population will benefit from the most recent published scientific evidence provided via the information from their health care provider. No harms or costs are involved with this information since women will have the opportunity to choose among the different therapeutic options for the management of the symptoms and morbidities associated with menopause, including the option to choose no treatment.

EVIDENCE

Databases consulted were PubMed, MEDLINE, and the Cochrane Library for the years 2002-2020, and MeSH search terms were specific for each topic developed through the 7 chapters.

VALIDATION METHODS

The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See online Appendix A (Tables A1 for definitions and A2 for interpretations of strong and weak recommendations). INTENDED AUDIENCE: physicians, including gynaecologists, obstetricians, family physicians, internists, emergency medicine specialists; nurses, including registered nurses and nurse practitioners; pharmacists; medical trainees, including medical students, residents, fellows; and other providers of health care for the target population.

SUMMARY STATEMENTS

RECOMMENDATIONS.

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

INTRODUCTION

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSION

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

The role of personal factors in quality of life among Iranian women with vaginismus: a path analysis

Background

The aim of this study was to provide a path model for assessing the direct and/or indirect effects of psychological/behavioral parameters on health-related quality of life among women with vaginismus.

Methods

A cross-sectional study was conducted on a sample of 236 women with vaginismus disorder attending to sex clinics in Tehran, Iran from April 2017 to March 2018. Data were collected using a demographic questionnaire, the marital satisfaction scale, the hospital anxiety and depression scale, the rosenberg self-esteem scale, the body image concern inventory, the short-form health survey (SF-12) and the female sexual quality of life questionnaire. In addition to descriptive statistical data, the fitness of the proposed model was investigated using path analysis.

Results

The results of path analysis demonstrated that the final model had a good fit to the data (Chi-Square/degrees of freedom (Normed Chi²) = 2.12, root mean square error of approximation = 0.069, goodness fit index = 0.99, both comparative fit index = 0.99 and Tucker–Lewis index = 0.96). In this model, anxiety and depression significantly predicted health-related quality of life as measured by the SF-12.

Conclusions

Anxiety and depression are important components in predicting health-related quality of life among those suffering from vaginismus.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12955-021-01799-5.

Materials Selection for the Injection into Vaginal Wall for Treatment of Vaginal Atrophy

Vaginal atrophy caused by the aging process and perineal trauma has a negative impact on women. A new vaginal atrophy treatment is injection of materials into the vaginal wall, including platelet-rich plasma (PRP), autogenous fat graft (AFG), hyaluronic acid (HA), botulinum toxin (BTX), and collagen, but to date their efficacy has not been reviewed. Vaginal wall injection is available only for mild cases of vaginal atrophy or as an adjunct to vaginal surgery. PRP is used mainly to restore vaginal function, and multiple injections are needed to achieve good results in vaginal atrophy. HA, AFG, and collagen are used mainly to augment the vaginal wall. BTX injection can inhibit vaginal muscle spasm and reduce pain during sexual intercourse in patients with vaginismus. Injection of most of these materials into vaginal wall is effective and relatively safe. Vascular embolisms are the most serious complication of vaginal injection and should be prevented. In addition, there has been no randomized double-blind placebo-controlled trial or discussion of methods to avoid serious complications resulting from vaginal injection. Therefore, further studies of the injection of materials into the vaginal wall to treat vaginal atrophy are required, and the procedures should be standardized to benefit more patients.Level of Evidence IV This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Effect of the COVID-19 pandemic and social distancing measures on the sexual functions of women treated for vaginismus (genitopelvic pain/penetration disorder)

Introduction and hypothesis

Female sexual function is influenced by the emotional and hormonal state. COVID-19 has been the major global health crisis of our time with high psychosocial impact. Vaginismus is a form of female sexual dysfunction and a subset of genitopelvic pain/penetration disorder in which any form of vaginal penetration is painful or impossible. Our aim was to evaluate the effect of the COVID-19 pandemic on sexual function of women treated for vaginismus.

Materials and methods

All women treated using dilators between 2018–2019 were included. Data obtained 3 months after comfortable penetration and during the pandemic via telephone interview were compared. The Female Sexual Function Index (FSFI), Golombok-Rust Inventory of Sexual Satisfaction (GRISS), and Beck Depression Inventory (BDI) were used to evaluate sexual function and depression. Frequency of sexual intercourse and pain was compared using a visual analogue scale.

Results

Seventy-seven women were included. Mean duration of treatment and number of treatment sessions were 3.5 ± 2.6 months and 4.2 ± 2.6, respectively. There were significant improvements in the FSFI desire, arousal, orgasm, and pain subscales and total score and in the GRISS infrequency, noncommunication, avoidance, non-sensuality, and vaginismus subscales and total score during the pandemic. The GRISS dissatisfaction and anorgasmia subscales and BDI score significantly worsened. Mean frequency of sexual intercourse was 2.3 ± 1.8/week and did not change significantly. Pain scores decreased during the pandemic (2.7 ± 2.8) compared to post-treatment (6.2 ± 2.9).

Conclusion

Although frequency of sexual intercourse was not affected and pain scores and FSFI total and subscale scores improved, satisfaction and orgasm were adversely affected, which may be attributed to increased stress and anxiety during the pandemic.

A Novel Multimodal Treatment Method and Pilot Feasibility Study for Vaginismus: Initial Experience With the Combination of Sacral Erector Spinae Plane Block and Progressive Dilatation

Background Genito-pelvic pain/penetration disorder, commonly referred to as vaginismus, is a relatively common condition in women of childbearing age and has physical and psychological aspects. Various cognitive and behavioral therapies, dilatators, botulinum injections, and so on have been tried in the treatment. We hypothesize that the combination of sacral erector spinae plane (ESP) block and progressive dilatation treatment increases treatment quality. Methods We performed the sacral ESP block and progressive dilatation, which we added to multimodal treatment for resistant vaginismus cases. After the procedure, all patients were followed up during one menstrual cycle. They were recommended to have sexual intercourse on the day of the procedure. Results In 15 of our treatment-resistant cases, when we added the sacral ESP block, successful penetration after the first block was 73%. Pregnancy occurred in eight patients after the initial one-month follow-up. Four of the 15 patients needed a second block. Conclusions The sacral ESP block added to the multimodal treatment protocol significantly improves treatment quality.

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

BACKGROUND

Vulvodynia is a disabling condition in which pelvic floor muscles' (PFM) hypertonicity plays an important role.

AIM

To evaluate biometric changes in PFM in women with vulvodynia undergoing kinesiotherapy treatment protocol (KTP).

METHODS

A single-blinded randomized controlled trial of 57 women with vulvodynia randomly assigned to either KTP + amitriptyline or amitriptyline alone (controls) for treatment. Four-dimensional translabial ultrasound assessed PFM regarding symphysis-levator distance at rest, anorectal angle at rest, excursion of the levator plate angle, and levator hiatal narrowing. Volunteers underwent a vaginal examination for a cotton swab test (CST), fulfillment of Friedrich criteria score and PFM power of contraction, and completed a diary of sexual pain and frequency of vaginal intercourse. Outcomes were assessed at baseline and after 8 weeks of treatment.

OUTCOMES

Primary outcomes were differences in biometric parameters assessed by four-dimensional translabial ultrasound after treatment, between groups. Secondary outcomes were changes in clinical variables (CST, Friedrich criteria, PFM power of contraction, frequency of intercourse, and intensity of sexual pain) between groups and correlation analysis between biometric parameters and clinical variables.

RESULTS

Only the KTP group had statistically significant changes in biometric parameters after treatment (symphysis-levator distance: 0.22 ± 0.2, 95% CI = 0.1-0.4, P = .008; levator hiatal narrowing: -0.33 ± 0.2, 95% CI = -1 to -0.2, P = .04). Comparisons between groups showed that symphysis-levator distance (0.3, 95% CI = 0.2-0.6, P = .005) and excursion of levator plate angle (4.9, 95% CI = -0.4 to 10.1, P = .02) improved significantly after KTP treatment. Clinical variables showed greater improvement in the group treated with KTP for CST (difference of -3.7, 95% CI = -7 to -0.4, P = .01), Friedrich criteria (difference of -1.9, 95% CI = -3.2 to -0.6, P = .003), PFM power of contraction (0.3, 95% CI = 0.1-0.6, P = .05) and intensity of sexual pain (reduction of 1.7, 95% CI = -3.1 to -0.2, P = .01). Some clinical and biometric variables correlated positively, for example, frequency of vaginal intercourse and anorectal angle (P = .04; r = 0.25), or inversely, for example, pain intensity at CST and anorectal angle (P = .004, r = -0.31).

CLINICAL IMPLICATIONS

This study provides evidence on efficiency of a physical therapy protocol for improvement of symptoms of vulvodynia and hypertonicity changes.

CONCLUSION

This pilot study suggests that KTP for women with vulvodynia promoted significant changes in PFM biometric measures, consistent with alterations in hypertonicity and clinical improvement. Bardin MG, Giraldo PC, Martinho N. Pelvic Floor Biometric Changes Assessed by 4D Translabial Ultrassound in Women With Vulvodynia Submitted to Physical Therapy: A Pilot Study of a Randomized Controlled Trial. J Sex Med 2020;17:2236-2246.

Botulinum injections for myofascial pelvic pain

INTRODUCTION AND HYPOTHESIS

The aim of this study was to assess the impact of botulinum toxin injection in women with myofascial pelvic pain (MFPP) syndrome of the pelvic floor who had failed conservative treatment.

METHODS

This was a retrospective descriptive observational study of 48 consecutive patients receiving botulinum toxin to the pelvic floor for MFPP syndrome in a tertiary teaching hospital over an 8-year period. Trigger points were identified, and botulinum toxin was injected into the pelvic floor at the trigger points in doses ranging from 50 to 200 units. The patient-reported global impression of improvement scale was used to evaluate the success at follow-up, and adverse effects were recorded.

RESULTS

Forty-six women attended for follow-up at 3-6 months. Of these, 34 (74%) reported an improvement in their symptoms (slightly better, much better, very much better), 12 (26%) had no change, and no patients reported worsening of symptoms. One patient (2%) reported transient postoperative faecal incontinence, which resolved after 2 weeks. There appeared to be no difference in outcome between the doses.

CONCLUSIONS

Botulinum toxin injection into the pelvic floor of women with MFPP appears to be beneficial in those who have failed conservative treatment. Prospective studies, including dose-finding studies, are now required.

The Overactive Pelvic Floor (OPF) and Sexual Dysfunction. Part 2: Evaluation and Treatment of Sexual Dysfunction in OPF Patients

INTRODUCTION

The assessment of pelvic floor muscle (PFM) overactivity is part of a comprehensive evaluation including a detailed history (medical, gynecological history/antecedent), appraisal of the psychosocial contexts of the patient, as well as a musculoskeletal and a neurological examination.

OBJECTIVES

The aims of this article are to review (i) the assessment modalities evaluating pelvic floor function in women and men with disorders associated with an overactive pelvic floor (OPF), and (ii) therapeutic approaches to address OPF, with particular emphases on sexual pain and function.

METHODS

We outline assessment tools that evaluate psychological and cognitive states. We then review the assessment techniques to evaluate PFM involvement including digital palpation, electromyography, manometry, ultrasonography, and dynamometry, including an overview of the indications, efficacy, advantages, and limitations of each instrument. We consider each instrument's utility in research and in clinical settings. We next review the evidence for medical, physiotherapy, and psychological interventions for OPF-related conditions.

RESULTS

Research using these assessment techniques consistently points to findings of high PFM tone among women and men reporting disorders associated with OPF. While higher levels of evidence are needed, options for medical treatment include diazepam suppositories, botulinum toxin A, and other muscle relaxants. Effective psychological therapies include cognitive behavioral therapy, couple therapy, mindfulness, and educational interventions. Effective physiotherapy approaches include PFM exercise with biofeedback, electrotherapy, manual therapy, and the use of dilators. Multimodal approaches have demonstrated efficacy in reducing pain, normalizing PFM tone, and improving sexual function. Multidisciplinary interventions and an integrative approach to the assessment and management of OPF using a biopsychosocial framework are discussed.

CONCLUSION

Although the efficacy of various intervention approaches has been demonstrated, further studies are needed to personalize interventions according to a thorough assessment and determine the optimal combination of psychological, physical, and behavioral modalities. Padoa A, McLean, L, Morin M, et al. The Overactive Pelvic Floor (OPF) and Sexual Dysfunction. Part 2: Evaluation and Treatment of Sexual Dysfunction in OPF Patients. Sex Med 2021;9:76-92.

Botulinum toxin injection for chronic pelvic pain: A systematic review

INTRODUCTION

Botulinum toxin has proven therapeutic effects in alleviating pain in several myofascial disorders, with an expanding potential in chronic pelvic pain. The objective of this systematic review is to evaluate the efficacy and safety of botulinum toxin injection as an off-label treatment for female chronic pelvic pain.

MATERIAL AND METHODS

Using PRISMA guidelines, MEDLINE, EBM Reviews, PubMed, CINAHL, TRIP Database, EMBASE, Web of Science and gray literature were searched. Studies assessing the efficacy of botulinum toxin for chronic pelvic pain in adult females, with 10 or more women, published in English up to 13 January 2020, were included. All eligible studies were reviewed and data were extracted by two independent reviewers using a standardized form. Quality of evidence was graded using the Cochrane Risk of Bias 2 tool for randomized controlled trials and the Ottawa-Newcastle scale for observational studies.

RESULTS

In all, 491 records were screened. Seventeen articles were included in the final review: 5 randomized controlled trials and 12 observational studies. The quality of evidence ranged from low to high. There was a large degree of heterogeneity in study designs, and thus a meta-analysis was not feasible. All observational studies concluded that botulinum toxin was an effective treatment for chronic pelvic pain, with the greatest change in visual analog scale from 8.69 at baseline to 3.07 at 24 months post-injection. However, only one of the five randomized controlled trials found statistical significant differences favoring botulinum toxin in the reporting of the EQ-5D (botulinum 0.78 [0.69-1.00], control 0.69 [0.25-0.81], P = .03) and frequency of intercourse (botulinum 1 [1-1.75], placebo 1 [0-1], P = .025). The most common adverse effect was transient localized pain at injection site (6%-88%). No serious adverse events were reported.

CONCLUSIONS

Although observational studies were encouraging, there is insufficient high quality evidence to recommend botulinum toxin injection for chronic pelvic pain. However, it appears to be safe to use. Future studies of higher quality in its treatment efficacy are indicated.

Biofeedback versus electrical stimulation for sexual dysfunction: a randomized clinical trial

INTRODUCTION AND HYPOTHESIS

Sexual dysfunction is a common problem in the general population. We compared the effects of biofeedback and electrical stimulation on the symptoms of sexual pain dysfunction in women with urinary stress incontinence.

METHODS

We carried out a parallel randomized clinical trial in an outpatient department for physical medicine and rehabilitation at a university hospital. Based on DSM-5 criteria for sexual dysfunction, 22 patients with sexual dysfunction and stress incontinence were included and randomly allocated to each study arm. The primary outcome measure was the total score on the Female Sexual Function Index. Each group underwent pertinent treatment for 100 min, two times a week for 6 weeks.

RESULTS

Both groups showed favorable outcomes in increasing Female Sexual Function Index mean scores and their domains. However, for improving sexual function, women in the biofeedback group benefited more than those receiving electrical stimulation. Biofeedback raised desire, arousal, lubrication, orgasm, and satisfaction scores more than electrical stimulation (all p ≤ 0.025). Both interventions decreased pain during or following vaginal penetration similarly (p = 0.985).

CONCLUSIONS

Both biofeedback and electrical stimulation increased the Female Sexual Function Index score. However, to improve sexual function, women undergoing biofeedback seem to benefit more than those receiving electrical stimulation. We recommend considering the prescription of biofeedback for the treatment of sexual dysfunction because of its efficacy, lack of adverse effects, and easy application.

Effects of predisposing factors on the success and treatment period in vaginismus

Objective

There are many predisposing factors associated with vaginismus, but there is lack of data in the literature regarding which and how of these factors influence the success rate of treatment. Our aim is to investigate the effects of factors that are considered as predisposing factors for vaginismus on treatment prognosis and success rate, with cognitive-behavioral therapy and desensitization exercises after sexual therapy.

Methods

Patients with vaginismus were divided into three groups. Group 1: patients who successfully completed vaginal penetration exercises after sexual therapy and experienced vaginal sexual intercourse; Group 2: patients who started penetration exercises but could not reach success; Group 3: patients who discontinued treatment before starting exercises. Demographic and sexual parameters were compared between the groups.

Results

There were statistically significant differences between the groups in terms of history of vaginismus in relatives (4.3%, 23% and 35.7%, p=0.047, respectively), the unsuccessful therapy history (69%, 61% and 21.4%, p=0.014, respectively), and anal and/or oral sex ratios (47.8%, 7.7% and 57.1%, p=0.019, respectively). Mean number of sessions were significantly higher in patients saying, “It is my fault” than among those perceiving it as a common problem (10.6±2.9 ve 7.5±5.7, p=0.042, respectively), and in patients with sexual disorder in their male partners than those not having any problem (13.3±3.7 ve 8.2±3.7, p=0.013, respectively).

Conclusion

Patients are more resistant to treatment if they have a history of vaginismus among relatives or when one of the couple say, it is his or her fault.

Application of Botulinum Neurotoxin in Female Sexual and Genitourinary Dysfunction: A Review of Current Practices

INTRODUCTION

The past 2 decades have witnessed an increased amount of research into botulinum neurotoxin (BoNT) as a treatment for various forms of sexual dysfunction and pain syndromes refractory to other medical therapy. BoNT is postulated to reduce pain sensation by inhibiting neuropeptide release in the presynaptic neuron. Dyspareunia, vaginismus, vestibulodynia, and persistent genital arousal disorder are female sexual dysfunctions with cryptic pathophysiology and limited treatment options. BoNT has emerged as a potential treatment for many of these afflictions in women.

OBJECTIVES

To review the literature regarding BoNT as a treatment for female sexual and genitourinary dysfunction.

METHODS

A PubMed search for English-language articles was performed using the following terms: "Botox," "botulinum toxin," "botulinum toxin A," "Onabotulinum A," "Abobutlinum A," "BoNT," and "BoNT-A." The main outcomes measured by each study were resolution of dysfunction. This entailed reduction of pain with intercourse for dyspareunia, reduction of pain for vestibulodynia, decreased arousal for persistent genital arousal disorder, and ability to tolerate penetration for vaginismus.

RESULTS

A total of 12 human studies that evaluated BoNT as a treatment for female sexual disorders were included. Study types included prospective, retrospective, cohort, pilot, and open-label.

CONCLUSION

There is growing evidence suggesting that BoNT is a safe and efficacious treatment option for female patients suffering from various sexual and genitourinary disorders. However, more research is needed to develop a better understanding of the mechanisms through which BoNT treats these disorders. Dick B, Natale C, Reddy A, et al. Application of Botulinum Neurotoxin in Female Sexual and Genitourinary Dysfunction: A Review of Current Practices. Sex Med 2021;9:57-63.

Is "Dilator Use" More Effective Than "Finger Use" in Exposure Therapy in Vaginismus Treatment?

Vaginismus is the persistence of difficulties in allowing the vaginal entry of a penis, a finger or a gynecologic examination. This study aimed to compare the success rates of vaginismus therapy with exposure therapy treatment using a finger or a dilator. The finger training group (FTG) (n = 30) and the dilator training group (DTG) (n = 30) were established. Groups were trained about dilatation and desensitization. The Female Sexual Function Index (FSFI) was applied. From the baseline measurement to the post-treatment measurement, the average change in FSFI scores for both groups was statistically significant (p < 0.001). There was a significant difference between two groups in terms of patient drop-out numbers (p = 0.016); the DTG was more successful in continuing treatment than the FTG. This research revealed that DTG is more successful in treatment continuity and show more improvement in sexual functions.

Case Series: Redefining Severe Grade 5 Vaginismus

Introduction

Vaginismus is poorly understood and relatively unknown among health care providers. For those who understand and treat vaginismus, few make an assessment of the severity of this condition. The importance of classifying the severity of vaginismus impacts the clinician’s ability to diagnose and treat vaginismus, and understanding of the patient’s experience.

Aim

The aims of this paper are to identify the distinguishing features of severe grade 5 vaginismus, determine if vaginal spasm is present in severe grade vaginismus, and to establish qualifications for the Pacik grade 5 classification.

Methods

Assessment of 553 referred or self-referred women who were unable to tolerate intercourse completed a comprehensive pretreatment questionnaire. Of those women, 391 underwent a vaginal examination in a certified surgicenter using sedation and anesthesia as needed.

Main Outcome Measure

The main outcome measures were to detect the presence of a visceral reaction with an intended or actual gynecologic examination in Grade 5 patients, and to identify vaginal spasm on examination.

Results

A visceral response reaction to routine gynecologic examinations, as well as spasm of the bulbocavernosum, occurred in patients with severe vaginismus.

Conclusion

Severe vaginismus with visceral response manifestations to routine gynecologic examinations, inability to have intercourse, and spasm of the bulbocavernosum is newly defined as severe grade 5 vaginismus.

Pacik PT, Babb CR, Polio A, et al. Case Series: Redefining Severe Grade 5 Vaginismus. Sex Med 2019;7:489–497.

Sexual problems in Tehran: Prevalence and associated factors

INTRODUCTION

Sexual dysfunctions are considered as the most prevalent problems in the general population and their prevalence is so dispersed depending on different cultures and living conditions. This research investigates the prevalence of sexual dysfunctions and their relevant factors in Tehran.

MATERIALS AND METHODS

In this cross-sectional questionnaire-based study, 1129 women and men referring to health centers in 22 Districts of Tehran were selected using quota, stratified and cluster sampling. Demographic questionnaire, female sexual function index (FSFI), and Brief Sexual Function Inventory (BSFI) were used to collecting data.

DATA ANALYSIS

The data were analyzed using descriptive methods, and the findings were compared using the Chi-square, analysis of variance, and independent t-tests.

RESULTS

Totally 561 women and 568 men with the average ages of 33/06 and 34/98 participated in this study. In general, 77/6% of women and 35/6% of men complained about sexual problems. The most prevalent problems in women were sexual desire dysfunction (45/3%) and arousal dysfunction (38/85%), and the most prevalent problems in men were erection dysfunction (40/4%) and then ejaculation dysfunction (32/5%). Prevalence rates of dysfunctions of orgasm, dyspareunia, and vaginal dryness were, respectively, 9/2%, 9/0%, and 7/0%, and prevalence of sexual drive dysfunction in men was 10/6%.

CONCLUSION

The prevalence of sexual problems in Iranian women is so much higher than the global findings, and in men, this rate is somewhat higher than global prevalence. This difference can be due to the culture and the chosen silence about sexuality and specially women's sexuality in the Iranian culture that requires extra attention to this area.

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).

Therapeutic Approaches of Botulinum Toxin in Gynecology

Botulinum toxins (BoNTs) are produced by several anaerobic species of the genus Clostridium and, although they were originally considered lethal toxins, today they find their usefulness in the treatment of a wide range of pathologies in various medical specialties. Botulinum neurotoxin has been identified in seven different isoforms (BoNT-A, BoNT-B, BoNT-C, BoNT-D, BoNT-E, BoNT-F, and BoNT-G). Neurotoxigenic Clostridia can produce more than 40 different BoNT subtypes and, recently, a new BoNT serotype (BoNT-X) has been reported in some studies. BoNT-X has not been shown to actually be an active neurotoxin despite its catalytically active LC, so it should be described as a putative eighth serotype. The mechanism of action of the serotypes is similar: they inhibit the release of acetylcholine from the nerve endings but their therapeutically potency varies. Botulinum toxin type A (BoNT-A) is the most studied serotype for therapeutic purposes. Regarding the gynecological pathology, a series of studies based on the efficiency of its use in the treatment of refractory myofascial pelvic pain, vaginism, dyspareunia, vulvodynia and overactive bladder or urinary incontinence have been reported. The current study is a review of the literature regarding the efficiency of BoNT-A in the gynecological pathology and on the long and short-term effects of its administration.

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.