Psychological factors in chronic pelvic pain in women: relevance and application of the fear-avoidance model of pain

Recommendations for patient education in the management of persistent pelvic pain: a systematic review of clinical practice guidelines

ABSTRACT

Patient education has a critical role in the management of pain. There is considerable heterogeneity in patient education for females with persistent pelvic pain (PPP), and it remains unclear what is considered best clinical practice. Therefore, this systematic review identified and summarised recommendations for patient education in the management of benign gynaecological and urological conditions associated with PPP, as endorsed by international guidelines. Academic and relevant guideline databases were searched from inception to May 2022. Included guidelines were those for the management of benign gynaecological and urological conditions associated with PPP in adult females published in English, of any publication date, and endorsed by a professional organisation or society. Two independent reviewers screened 3097 records; 17 guidelines were included in the review. Guideline quality was assessed using the Appraisal of Guidelines for Research and Evaluation II (AGREE-II) tool. Recommendations were pooled using descriptive synthesis. Persistent pelvic pain guideline quality was generally poor. Three guidelines were classified as "excellent" (The NICE, RANZCOG, and ESHRE endometriosis guidelines) and therefore recommended for use. Eleven guidelines (64.7%) recommended patient education for females with PPP. Recommendations for education content were variable, however most frequently covered treatment strategies and pelvic pain diagnoses. For education delivery, the most frequent recommendations were for support groups and written/printed materials. Further research into tailored education interventions is needed for females with PPP.

"I wish I knew then what I know now" - pain science education concepts important for female persistent pelvic pain: a reflexive thematic analysis

ABSTRACT

Pain science education (PSE) provides people with an understanding of "how pain works" grounded in the biopsychosocial model of pain; it has been demonstrated to improve outcomes in musculoskeletal pain conditions. Preliminary evidence suggests PSE may be effective for female individuals with persistent pelvic pain, but how the content of PSE needs to be modified for this group remains to be determined. A reflexive thematic analysis of qualitative data was performed to identify PSE concepts that female individuals with persistent pelvic pain consider important and why. Twenty individual, semistructured interviews were conducted with adult females who had engaged with PSE and had self-identified as having "improved" pelvic pain. Most participants had been diagnosed with endometriosis (n = 16). Four themes were generated capturing PSE concepts considered important by female individuals with "improved" pelvic pain: (1) "A sensitised nervous system leads to overprotective pain" validated their pelvic pain as being real; (2) "Pain does not have to mean the body is damaged (although sometimes it does)" provided reassurance that pelvic pain does not mean their condition is worsening; (3) "How I think, feel, and 'see' my pain can make it worse" enabled participants to find optimal ways to manage their pain; and (4) "I can change my pain… slowly" provided hope that pelvic pain can improve and empowered them to pursue pain improvement as a viable goal. This study generated 4 PSE learning concepts that were important to female individuals with improved pelvic pain and may be incorporated into PSE curricula for female individuals with pelvic pain.

Guideline No. 445: Management of Chronic Pelvic Pain

OBJECTIVE

To provide evidence-based recommendations for the management of chronic pelvic pain in females.

TARGET POPULATION

This guideline is specific to pelvic pain in adolescent and adult females and excluded literature that looked at pelvic pain in males. It also did not address genital pain.

BENEFITS, HARMS, AND COSTS

The intent is to benefit patients with chronic pelvic pain by providing an evidence-based approach to management. Access to certain interventions such as physiotherapy and psychological treatments, and to interdisciplinary care overall, may be limited by costs and service availability.

EVIDENCE

Medline and the Cochrane Database from 1990 to 2020 were searched for articles in English on subjects related to chronic pelvic pain, including diagnosis, overlapping pain conditions, central sensitization, management, medications, surgery, physiotherapy, psychological therapies, alternative and complementary therapies, and multidisciplinary and interdisciplinary care. The committee reviewed the literature and available data and used a consensus approach to develop recommendations. Only articles in English and pertaining to female subjects were included.

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 conditional [weak] recommendations).

INTENDED AUDIENCE

Family physicians, gynaecologists, urologists, pain specialists, physiotherapists, and mental health professionals.

TWEETABLE ABSTRACT

Management of chronic pelvic pain should consider multifactorial contributors, including underlying central sensitization/nociplastic pain, and employ an interdisciplinary biopsychosocial approach that includes pain education, physiotherapy, and psychological & medical treatments.

SUMMARY STATEMENTS

RECOMMENDATIONS.

Recommended approaches to assessing and managing physiotherapy clients experiencing psychological distress: a systematic mapping review

BACKGROUND

Some physiotherapists find assessing and managing clients experiencing psychological distress challenging and are uncertain regarding the boundaries of the profession's scope.

OBJECTIVE

To map the approaches recommended for physiotherapists in scholarly literature, with respect to the assessment and management of clients experiencing psychological distress.

METHODS

A systematic mapping review was conducted. CINAHL, APA PsycINFO, Embase, and Medline ALL databases were systematically searched for secondary and tertiary literature relevant to the research objective. Recommended approaches were extracted from each article and analyzed descriptively and thematically.

RESULTS

3884 records were identified with 40 articles meeting the inclusion/exclusion criteria. Most recommendations related to identifying, assessing, and managing pain-related distress, with depression screening and referral also receiving some attention. Three approaches to detecting and assessing psychological distress were identified: 1) brief depression screen; 2) integrated suicide/nonsuicidal self-harm and depression screen; and 3) multidimensional screen and health-related distress assessment. Regarding the management of psychological distress the main approaches identified were: 1) education and reassurance; 2) cognitive-behavioral approaches; 3) mindfulness; and 4) case management.

CONCLUSION

While assessment and management of health-related distress by physiotherapists is commonly recommended, further guidance is needed to differentiate various forms of distress.

Symptoms of complex pelvic pain: A survey in three cohorts of women

INTRODUCTION

There has been increased interest in addressing chronic pelvic pain and its complexity in women. The often multifactorial etiology of chronic pelvic pain and its heterogeneous presentation, however, make the condition challenging to manage. Overlap with other pain-related conditions is frequently reported, and chronic pelvic pain may impact sexual function. Nevertheless, little is known about the symptom burden of chronic pelvic pain and more complex pelvic pain in different groups of women. Thus, the aim of our study was to use a newly validated Norwegian version of the Amsterdam Complex Pelvic Pain Symptom Scale (ACPPS) to describe and compare the symptom severity of complex pelvic pain in three cohorts of women and to assess associations between demographic and gynecological characteristics and the severity of the condition.

MATERIAL AND METHODS

In our cross-sectional study, we collected self-reported data from patients referred to gynecological outpatient clinics, members of vulvodynia or endometriosis patient associations, and healthy volunteers. The 397 participants (47% response rate) completed an online survey about their demographic and gynecological characteristics and symptoms related to complex pelvic pain, including the Norwegian ACPPS. Score means on questionnaires, with standard deviations and 95% confidence intervals, were recorded. We used Pearson's chi-square test, Analysis of variance and multivariable linear regression were used to assess associations of demographic and gynecological characteristics with ACPPS scores.

RESULTS

Members of the patient associations had significantly higher self-reported symptom burden than patients and volunteers. Symptom burden was lower among older and postmenopausal women, and unemployed women scored higher than employed ones. Especially high scores on the ACPPS were found among women with complaints of chronic pelvic pain, at least moderate pelvic pain intensity, and/or chronic vulvar pain. Women who had experienced sexual assault and/or reported low sexual function also reported high scores. In multivariable regression, fibromyalgia, low mental health and past sexual assault were found to be associated with high scores on the ACPPS.

CONCLUSION

Many women in our study reported complex pelvic pain, and overlap with other pain-related conditions, low mental health and past sexual assault was associated with high symptom burden. Those findings support taking a biopsychosocial approach to treating women who present with such complaints.

[Somatoform disorders-chronic pelvic pain in women]

Pelvic pain in women is a clinically common symptom and a frequent finding in general practitioner, urological, gynecological, and pediatric practice. The list of possible differential diagnoses is long and the clarification ranges from a visual diagnosis to technical and surgical examinations to complex interdisciplinary consultations. But when do we talk about chronic lower abdominal pain? What can be the cause of this and how can we approach it diagnostically and therapeutically? What should we pay attention to? The difficulty begins with the definition. If we look at the national and international guidelines and publications, we find different definitions for chronic pelvic pain. There are various causes of chronic pelvic pain. There is often a combination of physical and psychological factors, which is why it is often not possible to identify a single diagnosis behind chronic pelvic pain syndrome. The clarification of these complaints requires a biopsychosocial approach. Multimodal approaches should be considered in assessment and treatment, and experts from other disciplines should be consulted.

Endometriosis Symptomatology, Dyspareunia, and Sexual Distress Are Related to Avoidance of Sex and Negative Impacts on the Sex Lives of Women with Endometriosis

BACKGROUND

Endometriosis affects approximately 10% of women and is associated with a range of symptoms including pelvic pain, abnormal bleeding, and painful sexual intercourse. However, very little is known about the relationship between endometriosis-related symptoms and sex.

METHODS

Women with a diagnosis of endometriosis (n = 2060; mean age = 30 years) completed a questionnaire measuring the frequency of endometriosis symptoms, dyspareunia, sexual distress, avoidance of sex, and the perceived negative impact of endometriosis symptoms on sex life.

RESULTS

In bivariate and multivariate logistic regression models with avoidance of sex and perceived negative impact of endometriosis symptoms on sex life as DVs, higher endometriosis symptom frequency, dyspareunia, and sexual distress were associated with greater avoidance of sex and higher perceived negative impact of endometriosis symptoms on sex life. With a two- and three-fold increase in the odds of avoiding sex and reporting a negative impact of endometriosis on sex lives, respectively, for each point increase in dyspareunia. Similarly, there was a 7% to 11% increase in avoidance of sex and the negative impact of endometriosis on sex lives, per one-point increase in symptom frequency and sexual distress.

CONCLUSIONS

The results highlight the considerable impacts of endometriosis symptomatology on women's sex lives and wellbeing. Better medical and counselling services may be needed to ameliorate the negative impact of endometriosis on women's sex lives.

The role of catastrophizing in chronic cyclical pelvic pain: A systematic review and meta-analysis

BACKGROUND

Dysmenorrhea (painful menstrual cramps) is one of the most common gynecological complaints in women and girls. Dysmenorrhea may be a condition itself or a result of another medical condition, including endometriosis and chronic pelvic pain. Research examining the relationship between menstrual pain ratings and catastrophizing has produced mixed results.

OBJECTIVE

To review and meta-analyze the relationship between catastrophizing and pain ratings of chronic cyclical pelvic pain.

DESIGN

Cross-sectional, longitudinal, and intervention studies that reported the relationship between menstrual/pelvic pain and catastrophizing were included. Study populations had to include healthy menstruating persons or persons with a condition associated with cyclical pelvic pain including primary dysmenorrhea, endometriosis, and/or chronic pelvic pain.

DATA SOURCES AND METHODS

A systematic search of articles published since 2012 on PubMed, PsychInfo, CINHAL, and Medline was conducted in January and rerun in November of 2022. Search terms included cyclical pelvic pain, dysmenorrhea, endometriosis, pelvic pain, and catastrophizing. Data extraction was completed independently by two extractors and cross-checked for errors. A random-effects meta-regression was used to synthesize the data using restricted maximum likelihood.

RESULTS

Twenty-five studies examining 4,540 participants were included. A random effects model found a meta-correlation between catastrophizing and pain of r = .31 (95% confidence interval: .23-.40) p < .001. Heterogeneity was large and significant (I2 = 84.5%, Q(24) = 155.16, p < .001). Studies that measured general pelvic pain rather than cyclical pelvic pain specifically and those that used multi-item rather than single-item measures of pain had significantly higher correlations. Age and depression did not moderate the relationship between catastrophizing and pain.

CONCLUSION

A systematic review and meta-analysis found that catastrophizing had a small but significant positive association with pain ratings. Patients experiencing cyclical pelvic pain may benefit from interventions targeting the psychological management of pain.

REGISTRATION

This meta-analysis was registered in PROSPERO on 14 January 2022. Registration number: CRD42022295328.

Does group physiotherapy improve pain scores and reduce the impact of pelvic pain for women referred with persistent pelvic pain? A clinical trial

Introduction:

This study aimed to test group Physiotherapy sessions – pain education and supervised exercise − in addition to individual consultations, for women referred with persistent pelvic pain (with/without endometriosis), with the primary outcomes being pain scores and pain impact.

Methods:

Parallel study design with three treatment arms: (1) usual care: a suite of individual Physiotherapy consultations; (2) introductory group pain education session followed by usual care and (3) introductory group pain education session followed by usual care and an 8-week supervised group exercise programme.

Results:

Ninety women were recruited (30/treatment arm), with 66 women (73%) completing their allocated treatment. Participants were aged between 16 and 51 years; endometriosis was confirmed in 41% ( n = 27/66) of the study population. Data was analysed using descriptive and inferential statistics. Statistically significant gains ( p < 0.05) in pain scores and pelvic pain impact scores were observed in all arms. Between groups, there was statistically significant improvement ( p < 0.05) in pelvic pain impact score for those who attended the group pain education session followed by usual care (arm 2), compared to usual care (arm 1) alone. There was no significant added improvement with the weekly supervised group exercise programme (arm 3), when compared to those who received the group pain education programme and usual care (arm 2).

Conclusion:

This study has demonstrated positive benefits of a group pain education session on pain scores and pelvic pain impact for women referred with persistent pelvic pain, when added as a precursor to individual Physiotherapy consultations.

Psychological Profile in Women with Chronic Pelvic Pain

(1) Background: Chronic Pelvic Pain (CPP) is a prevalent medical condition with a complex treatment due to different variables that influence its clinical course. (2) Methods: Psychological variables such as depression, anxiety, catastrophizing or neuroticism have been described as influencing CPP. This is a cross-sectional study of 63 patients with CPP sent for a psychological evaluation due to participation in group therapy for CPP. The main purpose of this study was to characterize the baseline psychological characteristics of women with CPP. The NEO Five Factor Inventory (NEO-FFI), State and Trait Anxiety Inventory (STAI), Beck Depression Inventory-Fast Screen (BDI-FS), Pain Catastrophizing Scale (PCS) and Chronic Pain Acceptance Questionnaire (CPAQ) were performed. (3) Results: The personality profile of patients (NEO FFI) shows high neuroticism, low extraversion and low conscientiousness. The 25.4% of patients had moderate or severe depression according to BDI-FS results, almost half of the patients had high levels of anxiety trait (>P75, 49.2%) and more than half the patients had high levels of anxiety state (>P75, 59.5%). Punctuations of PCS and CPAQ are similar to patients with fibromyalgia. (4) Conclusions: CPP is associated with high levels of depression, anxiety, neuroticism, catastrophizing and low pain acceptance. It is important to develop interventions that can modify these psychological factors in order to improve the clinical course of CPP.

The effect of pelvic floor muscle exercises applied during pregnancy on genito-pelvic pain level in postpartum period

INTRODUCTION AND HYPOTHESIS

The goal of the study is to determine the effect of pelvic floor muscle exercises on genito-pelvic pain levels during the postpartum period.

METHODS

The data of the study, which was carried out in a randomized controlled experimental design, were collected in the antenatal policlinic of a public hospital from June-December 2019. There were 60 pregnant women in the experimental and control groups. Pelvic floor muscle exercises were applied to the pregnant women in the experimental group from the 30th week of gestation to the 6th week postpartum. The control group was not given pelvic floor muscle exercise training, and only data collection forms were filled in. During the study, the Descriptive Form, Verbal Category Scale, Pelvic Floor Distress Inventory-20, and Labour and Postpartum Information Form were given to the pregnant women in both groups.

RESULTS

After pregnant women in the experimental group performed pelvic floor muscle exercises, pain levels were significantly lower than in the control group (p < 0.01). Pelvic Floor Distress Inventory-20 total score and sub-dimension scores of the experimental group were statistically significantly lower than in the control group (p < 0.01). In addition, a statistically significant difference was found (p < 0.01) in the postpartum 72 h findings of the experimental group in which pelvic floor muscle exercises were applied compared to the control group.

CONCLUSIONS

According to the result of the study, as the gestational weeks progress, the genito-pelvic pain increases. Pelvic floor muscle exercises applied during pregnancy prevent the development and progression of pelvic floor disorders in both the antenatal and postnatal periods.

TRIAL REGISTRATION

NCT05343520.

The Good, the Bad, and the Ugly-Chances, Challenges, and Clinical Implications of Avoidance Research in Psychosomatic Medicine

Avoidance behaviors are shaped by associative learning processes in response to fear of impending threats, particularly physical harm. As part of a defensive repertoire, avoidance is highly adaptive in case of acute danger, serving a potent protective function. However, persistent or excessive fear and maladaptive avoidance are considered key factors in the etiology and pathophysiology of anxiety- and stress-related psychosomatic disorders. In these overlapping conditions, avoidance can increase the risk of mental comorbidities and interfere with the efficacy of cognitive behavioral treatment approaches built on fear extinction. Despite resurging interest in avoidance research also in the context of psychosomatic medicine, especially in conditions associated with pain, disturbed interoception, and disorders of the gut-brain axis, current study designs and their translation into the clinical context face significant challenges limiting both, the investigation of mechanisms involved in avoidance and the development of novel targeted treatment options. We herein selectively review the conceptual framework of learning and memory processes, emphasizing how classical and operant conditioning, fear extinction, and return of fear shape avoidance behaviors. We further discuss pathological avoidance and safety behaviors as hallmark features in psychosomatic diseases, with a focus on anxiety- and stress-related disorders. Aiming to emphasize chances of improved translational knowledge across clinical conditions, we further point out limitations in current experimental avoidance research. Based on these considerations, we propose means to improve existing avoidance paradigms to broaden our understanding of underlying mechanisms, moderators and mediators of avoidance, and to inspire tailored treatments for patients suffering from psychosomatic disorders.

Treatment recommendations for the management of persistent pelvic pain: A systematic review of international clinical practice guidelines

BACKGROUND

Females with persistent pelvic pain (PPP) report great variability in treatments they are recommended despite the availability of clinical practice guidelines (CPGs) that aim to standardise care. A clear consensus for the best practice care for PPP is required.

OBJECTIVE

Identify and summarise treatment recommendations across CPGs for the management of PPP, and appraise their quality.

SEARCH STRATEGY

MEDLINE, CENTRAL, EMBASE, EmCare, SCOPUS, the Cochrane Database of Systematic Reviews, Web of Science Core Collection, and relevant guideline databases were searched from their inception to June 2021.

SELECTION CRITERIA

Included CPGs were those for the management of urogynaecological conditions in adult females published in English, of any publication date, and endorsed by a professional organisation or society.

DATA COLLECTION AND ANALYSIS

We screened 1,379 records and included 20 CPGs. CPG quality was assessed using The Appraisal of Guidelines for Research and Evaluation II (AGREE-II) tool. Descriptive synthesis compiled treatment recommendations across CPGs.

MAIN RESULTS

CPGs for seven conditions provided 281 individual recommendations. On quality appraisal, guidelines on average scored 'excellent' for the domains 'scope and purpose' (80.6%, SD=13.3) and 'clarity and presentation' (74.4%, SD=12.0); for other domains, average scores were satisfactory or poor. Four guidelines (Endometriosis, NICE, RANZCOG, ESHRE; PCOS, Teede et al. 2018) were deemed recommended for use. Recommendations were most frequent for pharmaceutical and surgical interventions. Recommendations were variable for psychological, physiotherapy, and other conservative interventions.

CONCLUSIONS

The quality of CPGs for PPP is generally poor. Several CPGs endorse the consideration of biopsychosocial elements of PPP. Yet most recommend pharmaceutical, surgical, and other biomedical interventions.

The relationship between illness perception and worsening of interstitial cystitis/painful bladder syndrome symptoms: A cross-sectional study

OBJECTIVE

To evaluate disease perception in a cohort of patients with interstitial cystitis/painful bladder syndrome (IC/PBS) using the Brief Illness Perception-Questionnaire (BIP-Q) and to evaluate how this might relate to disease severity.

MATERIALS AND METHODS

The study is a cross-sectional survey amongst members of Bladder Health UK who had previously received a clinical diagnosis of IC/PBS. A hyperlink containing the questionnaire was sent to the patient group's website and interested members accessed and completed the survey. Participants' inclusion was based on a prior clinical diagnosis of IC/PBS, current O'Leary Sant scores supportive of the diagnosis, and age between 18 and 80. A sample size of 171 was used in the study. The Brief Illness Perception Questionnaire (BIP-Q) and the O'Leary/Sant symptoms and problem indices questionnaire were used to collect data. A multivariable logistic regression analysis was used to test the relationship between items of BIP-Q and severity of IC/PBS. Content analysis was used for the causal domain and subsequently analysed as percentages.

RESULTS

Six hundred and one members accessed the questionnaire of whom 159 returned completed questionnaires. One hundred and twenty-two of 159 (≥75%) respondents believe that their illness will continue indefinitely. The majority of the respondents indicated that IC/PBS had a negative impact on their daily lives, caused them worry and made them emotionally unstable. Of the 8 BIP-Q items, those most predictive of disease severity were (adjusted odd ratio and confidence intervals): consequence 0.094 (0.023-0.386); treatment control 2.702 (1.256-5.812); identity 0.141 (0.033-0.600); concern 9.363 (1.521-57.632).

CONCLUSIONS

Our findings show that IC/PBS negatively impacts participant's quality of life and emotional wellbeing. Higher expectation for treatment benefit and increasing levels of patient concern are predictive for severity of IC/PBS.

Psychological Interventions for Women with Persistent Pelvic Pain: A Survey of Mental Health Clinicians

Objective

To establish which psychological therapies mental health professionals use with reference to the treatment of women with persistent pelvic pain conditions. This research investigates overall therapies and specific techniques that clinicians believe are the most effective with this patient group, and the challenges mental health clinicians face in administering interventions. The study aims to suggest improvements to clinical practice and establish directions for targeted future research.

Design

Cross-sectional survey design.

Methods

An online survey was developed to ask mental health clinicians questions regarding the therapies and techniques they use with women experiencing persistent pelvic pain, their perspective on their practice in this area. The survey was advertised on relevant social media and professional websites. Survey results were tabled, and chi-square statistical analyses were undertaken to examine differences in therapy use according to country and profession.

Results

Mental health clinicians predominantly utilized cognitive behavioral therapy, acceptance and commitment therapy and associated techniques for women with persistent pelvic pain conditions. The results of the chi-square analyses showed that psychologists were more likely to use cognitive behavioral therapy or acceptance and commitment therapy, than counsellors who preferred counselling interventions. Chi-square analyses showed that Australian clinicians used acceptance and commitment therapy with a higher frequency than mental health clinicians in other countries. Clinicians provided multiple insights into their experiences working with women affected by persistent pelvic pain and their opinions as to valuable future research directions.

Conclusion

Cognitive behavioral therapy, acceptance and commitment therapy, and mindfulness therapies were most commonly used by mental health clinicians working with women with persistent pelvic pain conditions, despite severely limited evidence for the use of these psychological interventions in this client group.

Vulvodynia-It Is Time to Accept a New Understanding from a Neurobiological Perspective

Vulvodynia is one the most common causes of pain during sexual intercourse in premenopausal women. The burden of vulvodynia in a woman's life can be devastating due to its consequences in the couple's sexuality and intimacy, in activities of daily living, and psychological well-being. In recent decades, there has been considerable progress in the understanding of vulvar pain. The most significant change has been the differentiation of vulvar pain secondary to pathology or disease from vulvodynia. However, although it is currently proposed that vulvodynia should be considered as a primary chronic pain condition and, therefore, without an obvious identifiable cause, it is still believed that different inflammatory, genetic, hormonal, muscular factors, etc. may be involved in its development. Advances in pain neuroscience and the central sensitization paradigm have led to a new approach to vulvodynia from a neurobiological perspective. It is proposed that vulvodynia should be understood as complex pain without relevant nociception. Different clinical identifiers of vulvodynia are presented from a neurobiological and psychosocial perspective. In this case, strategies to modulate altered central pain processing is necessary, changing the patient's erroneous cognitions about their pain, and also reducing fear avoidance-behaviors and the disability of the patient.

Treatment of Localized Vulvar Pain with Neural Therapy: A Case Series and Literature Review

BACKGROUND

Localized vulvar pain (LVP) is a common condition among fertile women, with physical and psychosexual implications. Treatment is complex with limited benefits. Neural therapy is a regulatory therapy that uses injections of local anesthetics in low concentrations in specific points to treat different conditions.

CASE PRESENTATION

We present the cases of 5 women, ages 33-44 years, with LVP treated with procaine 0.5% injections in painful points. Complete relief from pain occurred in 2 patients, and significant improvement in 3. Only 1 or 2 sessions were required. Initial VAS score was ≥70 and decreased to ≤30 after the intervention. The improvement was maintained over time, with a minimum follow-up period of 6 months. None of the patients were able to have sex or use tampons due to pain, but they were able to resume after the intervention.

CONCLUSIONS

In this case series, local injections of procaine showed a favorable outcome. Future randomized clinical trials could help elucidate the role of this intervention in LVP.

How Might We Screen for Psychological Factors in People With Pelvic Pain? An e-Delphi Study

OBJECTIVE

Persistent pelvic pain (PPP) is a complex condition often influenced by psychological factors that can alter treatment outcomes. These factors are potentially modifiable; however, currently there is no instrument to screen for them. The purpose of this study was to determine: (1) which psychological factors should be screened in individuals with PPP, and (2) the most appropriate statements to represent these psychological factors.

METHODS

The study used a focus group design followed by an electronic-Delphi (e-Delphi) process. A focus group consisting of 8 experts was conducted to determine the relevant psychological factors to screen. These results informed round 1 of the e-Delphi process, consisting of a panel of 14 pain/pelvic pain experts. The e-Delphi process consisted of 3 rounds of online surveys and 2 teleconference discussions to establish consensus on the most appropriate statement to screen for each of the psychological factors.

RESULTS

The focus group identified 13 relevant psychological factors. During the e-Delphi process, relevant screening statements were assessed using a 100-point allocation system. Experts could reword and suggest new statements. Statements were assessed for consensus and stability and were eliminated as the rounds progressed if they met the exclusion criteria. At the termination of round 3, there were 15 statements remaining.

CONCLUSION

The final list of 15 statements will assist clinicians in screening for psychological factors and is an important step for clinicians in providing psychologically informed care to people with PPP. Future research should determine the psychometric properties of the statements to determine their clinical utility as a questionnaire.

IMPACT

This study has refined a list of statements to help screen for psychological factors in individuals with PPP. Developed robustly using an e-Delphi method, this list is an important first step forward for clinicians to provide psychologically informed care to these individuals.

International Society for the Study of Women's Sexual Health (ISSWSH) Review of Epidemiology and Pathophysiology, and a Consensus Nomenclature and Process of Care for the Management of Persistent Genital Arousal Disorder/Genito-Pelvic Dysesthesia (PGAD/GPD)

BACKGROUND

Persistent genital arousal disorder (PGAD), a condition of unwanted, unremitting sensations of genital arousal, is associated with a significant, negative psychosocial impact that may include emotional lability, catastrophization, and suicidal ideation. Despite being first reported in 2001, PGAD remains poorly understood.

AIM

To characterize this complex condition more accurately, review the epidemiology and pathophysiology, and provide new nomenclature and guidance for evidence-based management.

METHODS

A panel of experts reviewed pertinent literature, discussed research and clinical experience, and used a modified Delphi method to reach consensus concerning nomenclature, etiology, and associated factors. Levels of evidence and grades of recommendation were assigned for diagnosis and treatment.

OUTCOMES

The nomenclature of PGAD was broadened to include genito-pelvic dysesthesia (GPD), and a new biopsychosocial diagnostic and treatment algorithm for PGAD/GPD was developed.

RESULTS

The panel recognized that the term PGAD does not fully characterize the constellation of GPD symptoms experienced by patients. Therefore, the more inclusive term PGAD/GPD was adopted, which maintains the primacy of the distressing arousal symptoms and acknowledges associated bothersome GPD. While there are diverse biopsychosocial contributors, there is a common underlying neurologic basis attributable to spontaneous intense activity of the genito-pelvic region represented in the somatosensory cortex and its projections. A process of care diagnostic and treatment strategy was developed to guide the clinician, whenever possible, by localizing the symptoms as originating in any of five regions: (i) end organ, (ii) pelvis/perineum, (iii) cauda equina, (iv) spinal cord, and (v) brain. Psychological treatment strategies were considered critical and should be performed in conjunction with medical strategies. Pharmaceutical interventions may be used based on their site and mechanism of action to reduce patients' symptoms and the associated bother and distress.

CLINICAL IMPLICATIONS

The process of care for PGAD/GPD uses a personalized, biopsychosocial approach for diagnosis and treatment.

STRENGTHS AND LIMITATIONS

Strengths and Limitations: Strengths include characterization of the condition by consensus, analysis, and recommendation of a new nomenclature and a rational basis for diagnosis and treatment. Future investigations into etiology and treatment outcomes are recommended. The main limitations are the dearth of knowledge concerning this condition and that the current literature consists primarily of case reports and expert opinion.

CONCLUSION

We provide, for the first time, an expert consensus review of the epidemiology and pathophysiology and the development of a new nomenclature and rational algorithm for management of this extremely distressing sexual health condition that may be more prevalent than previously recognized. Goldstein I, Komisaruk BR, Pukall CF, et al. International Society for the Study of Women's Sexual Health (ISSWSH) Review of Epidemiology and Pathophysiology, and a Consensus Nomenclature and Process of Care for the Management of Persistent Genital Arousal Disorder/Genito-Pelvic Dysesthesia (PGAD/GPD). J Sex Med 2021;18:665-697.

Pelvic Girdle Pain, Hypermobility Spectrum Disorder and Hypermobility-Type Ehlers-Danlos Syndrome: A Narrative Literature Review

Pelvic girdle pain (PGP) refers specifically to musculoskeletal pain localised to the pelvic ring and can be present at its anterior and/or posterior aspects. Causes such as trauma, infection and pregnancy have been well-established, while patients with hypermobile joints are at greater risk of developing PGP. Research exploring this association is limited and of varying quality. In the present study we report on the incidence, pathophysiology, diagnostic and treatment modalities for PGP in patients suffering from Hypermobility Spectrum Disorder (HSD) and Hypermobility-Type Ehlers-Danlos Syndrome (hEDS). Recommendations are made for clinical practice by elaborating on screening, diagnosis and management of such patients to provide a holistic approach to their care. It appears that this cohort of patients are at greater risk particularly of mental health issues. Moreover over, they may require a multidisciplinary approach for their management. Ongoing research is still required to expand our understanding of the relationship between PGP, HSD and hEDS by appropriately diagnosing patients using the latest updated terminologies and by conducting randomised control trials to compare outcomes of interventions using standardised patient reported outcome measures.

Cognitive behavioral therapy for the treatment of chronic pelvic pain

Chronic pelvic pain (CPP) in women is defined as noncyclical and persistent pain lasting more than six months perceived to be related to the pelvis. There are many etiologies that can cause CPP, including gynecologic, urologic, gastrointestinal, musculoskeletal, neurologic, and psychosocial. There is a strong association between psychological factors and CPP. It has been noted that almost half of women being treated for CPP report a history of sexual, physical, or emotional trauma. Women with CPP have been noted to have higher rates of psychological disorders in comparison to their peers. For men, the most common etiology for CPP is chronic prostatitis and there are also correlations with psychological disorders. There are many different treatment options for CPP: surgical, pharmacological, and non-pharmacological (alternative therapies). Cognitive-behavioral therapy may be another option when treating chronic pelvic pain syndrome and should be considered.

Group-based multimodal physical therapy in women with chronic pelvic pain: A randomized controlled trial

INTRODUCTION

Chronic pelvic pain in women is a complex condition, and physical therapy is recommended as part of a broader treatment approach. The objective of this study was to compare structured group-based multimodal physical therapy in a hospital setting (intervention group) with primary-care physical therapy (comparator group) for women with chronic pelvic pain.

MATERIAL AND METHODS

Women aged 20-65 years with pelvic pain ≥6 months and referred for physical therapy were eligible. The primary outcome measure was change in the mean pelvic pain intensity from baseline to 12 months, measured using the numeric rating scale (0-10). Secondary outcomes were changes in scores of "worst" and "least" pain intensity, health-related quality of life, movement patterns, pain-related fear of movements, anxiety and depression, subjective health complaints, sexual function, incontinence, and obstructed defecation. The differences between the groups regarding change in scores were analyzed using the independent t test and Mann-Whitney U test. Sensitivity analysis of the primary outcome was performed with a linear regression model adjusted for the baseline value. A P value <.05 was considered statistically significant.

RESULTS

Of the 62 women included, 26 in the intervention group and 25 in the comparator group were available after 12 months for data collection and analysis. The difference between the groups for change in the mean pain intensity score was -1.2 (95% CI -2.3 to -0.2; P = .027), favoring the intervention group. The intervention group showed greater improvements in respiratory patterns (mean difference 0.9; 95% CI 0.2-1.6; P = .015) and pain-related fear of movements (mean difference 2.9; 95% CI -5.5 to -0.3; P = .032), and no significant differences were observed between the groups for the other secondary outcomes.

CONCLUSIONS

Although the reduction in the mean pelvic pain intensity with group-based multimodal physical therapy was significantly more than with primary-care physical therapy, the difference in the change between the groups was less than expected and the clinical relevance is uncertain.

Neuromodulation of the Dorsal Root Ganglion for Chronic Postsurgical Pain

Objective

The objective of this study is to review the available evidence for dorsal root ganglion (DRG) stimulation for the treatment of complex regional pain syndrome type II (CRPS II; peripheral causalgia) associated with chronic neuropathic postsurgical pain (NPP).

Design

Available literature was identified through a search of the US National Library of Medicine’s Medline database, PubMed.gov. References from published articles also were reviewed for relevant citations.

Results

The data published to date support the use of DRG stimulation to treat chronic NPP of the groin, knee, and foot. NPP following procedures such as thoracotomy, hernia surgery, and knee replacement surgery were identified as some of the conditions for which DRG stimulation is likely to be effective.

Conclusion

DRG stimulation is known to be an effective treatment for focal neuropathic pain. Currently, NPP of the foot, groin, and knee all appear to be the conditions with the most clinical experience, backed by a limited but growing body of evidence. However, prospective studies lag behind real-world clinical experience and are needed to confirm these findings.

Biased Partner Perceptions of Women's Pain Self-Efficacy in Postpartum Pain During Intercourse: A Dyadic Longitudinal Examination

Postpartum pain during intercourse is a prevalent and distressing problem that has substantial consequences for affected couples. Partner perceptions-such as how partners perceive women's pain self-efficacy-contribute to an individual's pain experience. This study examined whether partners under- or over-estimate women's intercourse pain self-efficacy at 3-months postpartum and the implications of this bias for women's pain and couples' sexual functioning at 3- and 6-months postpartum. Women who reported pain during intercourse and their partners (N = 89 couples) completed online measures assessing pain self-efficacy (own or partner perceptions), pain intensity, and sexual functioning at 3- and 6-months postpartum. Analyses were based on the Truth and Bias Model of Judgement and Response Surface Analysis. Partners were accurate in their estimates of women's pain self-efficacy (ie, their estimates were positively correlated with women's), but they also underestimated it by perceiving women to be less efficacious than women themselves reported. When couples showed greater agreement for lower levels of pain self-efficacy at 3 months, women reported greater pain intensity and both partners reported poorer sexual functioning at 3- and 6-months postpartum. Findings may inform interventions that promote pain self-efficacy to improve partner support and couples' sexual functioning. PERSPECTIVE: When women report-and their partners perceive-low levels of women's self-efficacy for managing painful intercourse, women report greater postpartum pain during intercourse and couples indicate poorer sexual functioning. These findings suggest that interventions aimed at promoting couples' agreement at high pain self-efficacy may improve their adjustment to postpartum pain.

Pain, Anxiety, Depression, and Quality of Life in Patients with Vulvodynia

BACKGROUND/AIMS

The term vulvodynia refers to vulvar pain of unknown origin lasting at least 3 months. Psychiatric comorbidities are a common feature and, along with pain, may severely affect patients' wellbeing. We aimed to determine the characteristics of pain in vulvodynia, to correlate characteristics with symptoms of anxiety and depression, and to analyse the impact of these factors on patients' quality of life.

METHODS

This cross-sectional observational study analysed pain, anxiety, and depression and the effects of these factors on quality of life. Pain, anxiety, and depression were assessed using validated tools in 110 women.

RESULTS

Statistical analyses found correlations between pain and anxiety and between anxiety and worsened quality of life. Patients often reported stinging, burning, pain, itching, and dyspareunia, pointing to the importance of temporal, localisation, punctate pressure, thermal, tactile sensitivity, and emotional tension characteristics. Most patients had severe pain related to psychiatric comorbidities and decreased quality of life.

CONCLUSION

Using descriptors of pain quality and assessing anxiety and depression might help to define subgroups of patients that may benefit from different therapeutic approaches and thus enable treatments to be tailored to individual patients.

Self-management strategies amongst Australian women with endometriosis: a national online survey

Background

Endometriosis has a significant negative impact on the lives of women, and current medical treatments often do not give sufficient pain relief or have intolerable side effects for many women. The majority of women with primary dysmenorrhea use self-management strategies (including self-care techniques or lifestyle choices) to help manage period related symptoms, but little is known about self-management in women with endometriosis. The aim of this survey was to determine the prevalence of use, safety, and self-rated effectiveness of common forms of self-management.

Methods

A cross-sectional online survey was distributed via social media using endometriosis support and advocacy groups in Australia between October and December 2017. Women were eligible to answer the survey if they were 18–45, lived in Australia, and had a confirmed diagnosis of endometriosis. Survey questions covered the types of self-management used, improvements in symptoms or reduction in medication, and safety.

Results

Four hundred and eighty-four valid responses were received. Self-management strategies, consisting of self-care or lifestyle choices, were very common (76%) amongst women with endometriosis. The most common forms used were heat (70%), rest (68%), and meditation or breathing exercises (47%). Cannabis, heat, hemp/CBD oil, and dietary changes were the most highly rated in terms of self-reported effectiveness in pain reduction (with mean effectiveness of 7.6, 6.52, 6.33, and 6.39, respectively, on a 10-point scale). Physical interventions such as yoga/Pilates, stretching, and exercise were rated as being less effective. Adverse events were common, especially with using alcohol (53.8%) and exercise (34.2%).

Conclusions

Self-management was very commonly used by women with endometriosis and form an important part of self-management. Women using cannabis reported the highest self-rated effectiveness. Women with endometriosis have unique needs compared to women with primary dysmenorrhea, and therefore any self-management strategies, especially those that are physical in nature, need to be considered in light of the potential for ‘flare ups’.

Electronic supplementary material

The online version of this article (10.1186/s12906-019-2431-x) contains supplementary material, which is available to authorized users.

The Efficacy of Manual Therapy for Treatment of Dyspareunia in Females: A Systematic Review

Background

Pelvic floor physical therapy is a noninvasive option for relieving pain associated with dyspareunia, genital pain associated with sexual intercourse. Manual therapy is a clinical approach used by physical therapists to mobilize soft tissues, reduce pain, and improve function. To date, the systematic efficacy of manual therapy for treating dyspareunia has not been investigated.

Objective

To examine the efficacy of manual therapy in reducing pelvic pain among females with dyspareunia.

Study Design

Systematic review.

Methods

A systematic literature search was conducted in MEDLINE, EMBASE, and CINAHL databases for articles published between June 1997 and June 2018. Articles were reviewed and selected on the basis of defined inclusion and exclusion criteria. The articles were assessed for quality using the PEDro and Modified Downs and Black scales.

Results

Three observational studies and 1 randomized clinical trial met inclusion criteria. The primary outcome measured was the pain subscale of the Female Sexual Function Index. All studies showed significant improvements in the pain domain of the Female Sexual Function Index (P < .5), corroborating manual therapy as a viable treatment in relieving pain associated with dyspareunia. However, the quality across studies ranged from poor to good.

Conclusions

Although these findings support the use of manual therapy for alleviating pain with intercourse, few studies exist to authenticate this claim. Moreover, the available studies were characterized by small sample sizes and were variable in methodological quality. More extensive research is needed to establish the efficacy of manual therapy for dyspareunia and the specific mechanisms by which manual therapy is beneficial.

Can muscle weakness and disability influence the relationship between pain catastrophizing and pain worsening in patients with knee osteoarthritis? A cross-sectional study

OBJECTIVE

To verify if the relationship between pain catastrophizing and pain worsening would be mediated by muscle weakness and disability in patients with symptomatic knee osteoarthritis.

METHODS

This was a cross-sectional study in a hospital out-patient setting. Convenience sampling was used with a total of 50 participants with symptomatic knee osteoarthritis. Pain and the activities of daily livings (ADL) were assessed using the Knee Injury and Osteoarthritis Outcome Score (KOOS) subscale. Pain catastrophizing was assessed using the Coping Strategy Questionnaire (CSQ) subscale. Muscle strength of knee extension and 30-s chair stand test (30CST) were also assessed. Path analysis was performed to test the hypothetical model. Goodness of fit of models were assessed by using statistical parameters such as the chi-square value, goodness of fit index (GFI), adjusted goodness of fit index (AGFI), comparative fit index (CFI), and root mean square error of approximation (RMSEA).

RESULTS

The chi-square values were not significant (chi-square=0.283, p=0.594), and the indices of goodness of fit were high, implying a valid model (GFI=1.000; AGFI=0.997; CFI=1.000; RMSEA=0.000). Pain was influenced significantly by muscle strength and ADL; muscle strength was influenced significantly by ADL via 30CST; ADL was influenced by pain catastrophizing.

CONCLUSION

The relationship between pain catastrophizing with pain worsening are mediated by muscle weakness and disability.

Integrative Women's Health

This article addresses the common women's health concerns of menopause-related symptoms, premenstrual syndrome, and chronic pelvic pain. Each can be effectively addressed with an integrative approach that incorporates interventions such as pharmaceuticals, nutraceuticals, mind-body approaches, acupuncture, and lifestyle modification.

Is uncertain vulvovaginal candidiasis a marker of vulvodynia? A study in a Dutch general practice research database

Background

A recent Dutch study in general practice showed a clear relationship between the diagnosis of vulvovaginal candidiasis (VVC) and symptoms suggestive of provoked vulvodynia (PVD). PVD accounts for the largest group of vulvar pains, but is often not recognised by GPs.

Aim

To investigate whether diagnostic uncertainty about VVC in general practice could also point to the diagnosis of PVD, and whether and how this diagnostic uncertainty affects management.

Design & setting

An observational study in 2014 in Dutch general practices of the NIVEL Primary Care Database.

Method

Women with an uncertain diagnosis of VVC were distinguished from those with certain VVC based on the occurrence of recurrent episodes and persisting complaints, despite treatment. Factors known to be associated with PVD were hypothesised to be more prevalent in women with uncertain VVC. Data on symptom management by GPs were collected.

Results

In total 7066 women with VVC or uncertain VVC were included. Uncertain VVC was found to account for 28% of these patients. Compared to VVC, the group uncertain VVC included significantly more women with female genital symptoms, tiredness, irritable bowel syndrome (all P<0.001), feeling anxious, reduced sexual desire, depressive disorder, relationship problems, and micturition symptoms (all P<0.05). Compared to VVC, the group uncertain VVC included significantly higher mean numbers of telephone consultations (P<0.001), more referrals to gynaecology (P = 0.009), and higher mean numbers of prescriptions per patient (P<0.001).

Conclusion

This study's findings indicate that uncertain VVC could be a marker of PVD. GPs might reconsider their diagnostics and management when women present recurrent and persistent vulvovaginal complaints, especially if accompanied by dyspareunia, functional syndromes, micturition symptoms, and psychological conditions.

The psychological profile of women presenting to a multidisciplinary clinic for chronic pelvic pain: high levels of psychological dysfunction and implications for practice

Objective

Chronic pelvic pain (CPP) is widely acknowledged as a common problem with significant consequences for those diagnosed with this condition. There is a lack of studies with good sample size that provide a comprehensive psychological profile of women presenting to specialist chronic pain clinics. Therefore, the objective of this study was to describe the psychological profile of a representative sample of women presenting with CPP at a tertiary referral center.

Design

This was a cross-sectional study. Women were asked to complete a questionnaire assessing symptoms of anxiety and depression, pain severity and interference, pain self-efficacy and catastrophizing beliefs, and sexual functioning.

Methods

One-hundred and seventy-five women with CPP were recruited when they attended their initial assessment at a specialist CPP clinic of the Royal Women’s Hospital, a public hospital in Melbourne, Australia.

Results

Over 75% of the participants had experienced pain for longer than 2 years. Fifty-three percent of women experienced either moderate or severe anxiety, and 26.7% experienced moderate-to-severe depression. There were strong correlations between depressive symptoms and pain interference, pain catastrophizing and self-efficacy beliefs.

Conclusion

Our findings confirm previous evidence for high levels of psychological distress and functional impairment associated with this condition, and extend these findings by including measures that are highly relevant to treatment planning, such as thinking styles and pain self-efficacy. Therefore, treatment of this complex condition needs to be holistic, and a multidisciplinary approach is likely to be the best way to achieve this.

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.

Gender-specific mental health care needs of women veterans treated for psychiatric disorders in a Veterans Administration Women's Health Clinic

OBJECTIVE

This pilot study aims to ascertain the prevalence of self-reported premenstrual, perinatal, and perimenopausal influences on mental health, and of gynecologic conditions that could interact with psychiatric conditions, among women veterans receiving psychiatric care within a Veterans Administration (VA) Women's Health Clinic (WHC).

METHODS

Participants included all women veterans (N=68) who received psychiatric evaluations within a VA WHC over a 5-month period. This setting encompasses colocated and coordinated primary care, gynecologic and mental health services. Evaluations included a Women's Mental Health Questionnaire, a psychiatric interview, and medical record review. Deidentified data were extracted from a clinical data repository for this descriptive study.

RESULTS

High proportions of study participants reported that their emotional problems intensified premenstrually (42.6%), during pregnancy (33.3%), in the postpartum period (33.3%), or during perimenopause (18.2%). Unintended pregnancy (70.0% of pregnancies) and pregnancy loss (63.5% of women who had been pregnant) were prominent sex-linked stressors. Dyspareunia (22.1% of participants) and pelvic pain (17.6% of participants) were frequent comorbidities.

CONCLUSIONS

Among women veterans receiving psychiatric care within a VA WHC, there are high rates of self-reported premenstrual, perinatal, and perimenopausal influences on mental health. This population also has substantial comorbidity of psychiatric disorders with dyspareunia and pelvic pain. This underscores the importance of recognizing and addressing women veterans' sex-specific care needs, including interactions among reproductive cycle phases, gynecologic pain, and psychiatric symptoms. The findings support the need for greater awareness of the sex-specific mental health needs of women veterans, and for more definitive studies to further characterize these needs.

Painful intercourse is significantly associated with evoked pain perception and cognitive aspects of pain in women with pelvic pain

Introduction

Evidence suggests that painful intercourse, pain-related psychosocial factors, and altered pain processing magnify the pain experience, but it is not clear how these factors are related to each other.

Aim

The aims were to (i) characterize differences between women with pelvic pain and pain-free women using a battery of pain-related psychosocial measures, clinical pain ratings, and evoked local and remote pain sensitivity; and (ii) examine the relationship between intercourse pain, clinical pain, and local and remote evoked pain sensitivity.

Methods

Women with pelvic pain lasting at least 3 months and pain-free women completed questionnaires and underwent pain sensitivity testing. Self-report measures included clinical pain intensity, pain catastrophizing, pain-related fear, pain anxiety, depression, sexual function, and self-efficacy. Pain sensitivity measures included threshold and tolerance and temporal summation of pain. Separate analyses of variance (anova) were used to test group differences in self-report and pain sensitivity measures. Correlations were calculated among dyspareunia, psychosocial factors, and evoked pain.

Main Outcome Measures

Self-reported pain and pain sensitivity measures.

Results

Twenty-eight pain-free women and 14 women with pelvic pain participated in this study. Women with pelvic pain reported greater pain intensity and greater psychosocial involvement compared with pain-free women. No differences existed between groups for thermal or pressure measures, but women with pelvic pain rated their pain with pain testing significantly higher than pain-free women. Intercourse pain was significantly associated with affective and sensory pain and pressure pain ratings at the puborectalis, vulvar vestibule, adductor longus tendons, and tibialis anterior muscle.

Conclusions

Differences in local pain ratings suggest that women with pelvic pain perceive stimuli in this region as more painful than pain-free women although the magnitude of stimuli does not differ. Alappattu MJ, George SZ, Robinson ME, Fillingim RB, Moawad N, LeBrun EW, and Bishop MD. Painful intercourse is significantly associated with evoked pain perception and cognitive aspects of pain in women with pelvic pain. Sex Med 2015;3:14–23.

Prevalence and predictors of genito-pelvic pain in pregnancy and postpartum: the prospective impact of fear avoidance

INTRODUCTION

There is limited knowledge regarding the symptom profile of genito-pelvic pain in pregnancy and postpartum, and potential psychosocial predictors of this pain. Prior studies have reported a positive association between prepregnancy pain and postpartum genito-pelvic pain. Greater fear avoidance has been associated with increased genital pain intensity in women, unrelated to childbirth. This relationship has not been examined prospectively in a postpartum population.

AIMS

The study aims were to examine the symptom profile of genito-pelvic pain during pregnancy and at 3 months postpartum, and the impact of prepregnancy nongenito-pelvic pain and fear avoidance in pregnancy on genito-pelvic pain at 3 months postpartum.

METHODS

First-time expectant mothers (N = 150) completed measures of fear avoidance (pain-related anxiety, catastrophizing, hypervigilance to pain), prepregnancy nongenito-pelvic pain, childbirth-related risk factors (e.g., episiotomy), and breastfeeding.

MAIN OUTCOME MEASURES

Those reporting genito-pelvic pain in pregnancy and/or at 3 months postpartum answered questions about the onset (prepregnancy, during pregnancy, postpartum) and location (genital, pelvic, or both) of the pain and rated the intensity and unpleasantness of the pain on numerical rating scales.

RESULTS

Of 150 women, 49% reported genito-pelvic pain in pregnancy. The pain resolved for 59% of women, persisted for 41%, and 7% of women reported a new onset of genito-pelvic pain after childbirth. Prepregnancy nongenito-pelvic pain was associated with an increased likelihood of postpartum onset of genito-pelvic pain. Greater pain-related anxiety was associated with greater average genito-pelvic pain intensity at 3 months postpartum.

CONCLUSIONS

Results suggest that about half of women may develop genito-pelvic pain during pregnancy, which will persist for about a third, and a subset will develop this pain after childbirth. Prior recurrent nongenito-pelvic pain may enhance the risk of developing genito-pelvic pain postpartum, while greater pain-related anxiety in pregnancy may increase the risk for greater intensity of postpartum genito-pelvic pain.