Vestibular Anatomic Localization of Pain Sensitivity in Women with Insertional Dyspareunia: A Different Approach to Address the Variability of Painful Intercourse.

Ahinoam Lev-Sagie,Osnat Wertman,Yoav Lavee,Michal Granot

doi:10.3390/jcm9072023

Ahinoam Lev-Sagie, Osnat Wertman + Show 2 more

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https://doi.org/10.3390/jcm9072023

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Abstract

The pathophysiology underlying painful intercourse is challenging due to variability in manifestations of vulvar pain hypersensitivity. This study aimed to address whether the anatomic location of vestibular-provoked pain is associated with specific, possible causes for insertional dyspareunia. Women (n = 113) were assessed for “anterior” and “posterior” provoked vestibular pain based on vestibular tenderness location evoked by a Q-tip test. Pain evoked during vaginal intercourse, pain evoked by deep muscle palpation, and the severity of pelvic floor muscles hypertonicity were assessed. The role of potential confounders (vestibular atrophy, umbilical pain hypersensitivity, hyper-tonus of pelvic floor muscles and presence of a constricting hymenal-ring) was analyzed to define whether distinctive subgroups exist. Q-tip stimulation provoked posterior vestibular tenderness in all participants (6.20 ± 1.9). However, 41 patients also demonstrated anterior vestibular pain hypersensitivity (5.24 ± 1.5). This group (circumferential vestibular tenderness), presented with either vestibular atrophy associated with hormonal contraception use (n = 21), or augmented tactile umbilical-hypersensitivity (n = 20). The posterior-only vestibular tenderness group included either women with a constricting hymenal-ring (n = 37) or with pelvic floor hypertonicity (n = 35). Interestingly, pain evoked during intercourse did not differ between groups. Linear regression analyses revealed augmented coital pain experience, umbilical-hypersensitivity and vestibular atrophy predicted enhanced pain hypersensitivity evoked at the anterior, but not at the posterior vestibule (R = 0.497, p < 0.001). Distinguishing tactile hypersensitivity in anterior and posterior vestibule and recognition of additional nociceptive markers can lead to clinical subgrouping.

Highlights

Among sexual dysfunctional conditions, insertional dyspareunia is a general term describing extreme discomfort or pain felt at the entrance of the vagina during vaginal penetration or penetration attempt
Assuming that grouping together all women with vestibular tenderness overlooks potentially crucial differences and may result in inadequate therapeutic intervention, we aimed to explore whether distinctive presentation and location of vestibular tenderness may further identify different causes for insertional dyspareunia
Of the 154 patients who were evaluated for insertional dyspareunia, 26 were excluded for the following reasons: 10 had mixed vulvodynia, five were breastfeeding, seven were receiving medication effecting neuromodulation and four had concurrent vulvar dermatosis

Summary

Introduction

Insertional dyspareunia is a general term describing extreme discomfort or pain felt at the entrance of the vagina during vaginal penetration or penetration attempt. The severity can range from a total inability to tolerate penetration, to a feasible but painful experience. The provoking stimulus is typically the attempted entry and movement of the penis, but it can be a finger, dildo, speculum or tampon. As this disorder may involve different etiologies and characteristics, both physical and psychological, it has been investigated for many years by various disciplines (pain, gynecology, sexology, psychiatry etc.), and was described using multiple.

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