Genito-pelvic Pain Research Articles

Partner responses to low desire among couples coping with male hypoactive sexual desire disorder and associations with sexual well-being.

Hypoactive sexual desire disorder (HSDD) is characterized by persistently low desire and associated distress. Low desire is one of the most common sexual complaints among men and is associated with poor well-being. Interpersonal factors are key to understanding low desire, yet there are few dyadic studies of HSDD in men. Previous work on genito-pelvic pain and low desire in women has established that greater facilitative (eg, affectionate) partner responses are associated with greater sexual satisfaction and function and that more negative (eg, critical) or solicitous (eg, sympathetic, avoidant) partner responses are associated with lower sexual satisfaction and function. Examining how partner responses are associated with adjustment to HSDD may shed light on the interpersonal dynamics of this understudied sexual dysfunction. In a cross-sectional study, we examined whether partner responses to low desire in men were associated with sexual desire, sexual satisfaction, and sexual distress for both members of the couple. Men with HSDD and their partners (N = 67 couples) completed measures of facilitative, negative, and avoidant partner responses to men's low sexual desire-as perceived by the man with HSDD and self-reported by their partner-and sexual desire, sexual satisfaction, and sexual distress. Data were analyzed using multilevel modeling guided by the actor-partner interdependence model. Outcomes included the partner-focused subscale of the Sexual Desire Inventory-2, Global Measure of Sexual Satisfaction, and Sexual Distress Scale-Revised. When men with HSDD perceived more facilitative partner responses to their low desire, they and their partners reported greater sexual satisfaction. When men with HSDD perceived and their partners self-reported more negative partner responses, they each reported lower sexual satisfaction. In addition, when men with HSDD perceived more avoidant partner responses, their partners reported greater sexual distress. Partner responses were not associated with sexual desire for either member of the couple. Findings support the importance of the interpersonal context for HSDD in men and suggest potential future targets of treatment when working with affected couples. This study is one of the only dyadic studies of HSDD in men, as assessed via clinical interview or self-report symptoms reviewed by the clinical team. Despite our best efforts to recruit this sample over 6 years, the small size limited power to detect all predicted effects. More facilitative and fewer negative or avoidant partner responses to low desire are associated with greater sexual well-being in couples coping with HSDD.

(031) Update from the Female Genitopelvic Pain Subcommittee of the International Consultation of Sexual Medicine on a systematic review of the efficacy and safety of treatments for vulvodynia

Abstract Introduction Literature on vulvodynia treatment is heterogeneous regarding intervention type and study quality. A recently published systematic review (SR) of treatments focusing on randomized controlled trials (RCTs) and non-RCTs for provoked vestibulodynia (a vulvodynia subtype) concluded that most studies had very low certainty of evidence, which limited the ability to draw conclusions. In addition, the authors noted that their strict eligibility criteria resulted in a restricted number of included studies. It suggests a need for broader, more inclusive SRs to be conducted, which could inform much needed intervention recommendations for vulvodynia. Objective The Female Genitopelvic Pain Subcommittee is conducting a SR of treatments for vulvodynia to assess their effectiveness, safety, and acceptability. The results will provide stakeholders with empirically based treatment recommendations for patients with vulvodynia. Methods Selection criteria: Interventions of interest consist of pharmacological, surgical, psychological, physical therapy, and acupuncture treatments of premenopausal women with clinician-diagnosed vulvodynia (primary, secondary), defined as idiopathic, chronic (≥3 months) vulvar pain. Included studies are RCTs, SRs, and comparative observational studies. Primary outcomes are pain and sexuality, safety, and adverse events, with additional outcomes focusing on mood and quality of life. Selection of studies was done in DistillerSR by two independent reviewers. Conflicts were resolved by discussion or by involving a third reviewer, with excluded studies documented. Full-text screening adheres to the same process. Search methods: A comprehensive search strategy was developed by an information specialist and was peer reviewed. Numerous electronic databases were searched from 1997 to present. No language limit was used. Published filters for controlled trials and other study designs were applied. PubMed/MEDLINE was used to develop the search strategy, which was translated into other databases. A limited grey literature search was also conducted. Data collection and analysis: Data extraction and risk of bias assessment (ROB) will be done in DistillerSR using pre-piloted data extraction forms. Studies will be extracted by one reviewer and independently checked by a second reviewer. Disagreements will be resolved by discussion or by involving a third reviewer. We will extract study characteristics and outcome data. For ROB, we will use the Cochrane Risk of Bias tool and the ROBINS-I tool. We will narratively synthesize the results by comparisons and outcomes. If appropriate, we will conduct a meta-analysis for studies regarded as suitably homogeneous. Last, the certainty of the body of evidence will be assessed using the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) approach. Results The search yielded 10,171 references after duplicates were removed for title and abstract screening. Of these, 599 full-text articles were assessed for inclusion. All screening and preliminary data extraction will be completed by October 2022. General characteristics of the included studies, including interventions identified, will be presented. Conclusions We will report on interim progress of the SR. It will be an opportunity to gather initial input from stakeholders on this evidence-based approach. Discussion of possible multi-organization involvement will also help unify intervention recommendations for those with vulvodynia. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Andrew Goldstein – Daré Bioscience (employee), Incyte (consultant), Gynecologic Cancers Research Foundation (Board of Directors, Research Funding).

(049) Blue Balls: Fact or Fiction? Experiences of Genitopelvic Pain and Sexual Coercion Among People with Penises and Vulvas

Abstract Introduction The term “blue balls”, formally known as epididymal hypertension, is often used in public discourse to describe scrotal pain following sexual arousal that did not result in orgasm. Even though many health-related and popular online sources feature information on its potential causes and treatments, only one interview-based study and one case report exist on this phenomenon in the scientific literature. Controversy exists around the factual nature of blue balls/vulva considering its use for sexual coercion. Objective This cross-sectional, mixed-methods, online study aimed to characterize and evaluate the experience and prevalence of discomfort/pain following sexual arousal without orgasm, and assess whether individuals have been pressured to continue sexual activity because of a partner’s fears of experiencing discomfort/pain without orgasm. Methods A total of 2621 individuals with a penis (N = 1483) or vagina (N = 1138) were recruited for an online survey on the experience of “blue balls/vulva”. Analyses included descriptive statistics, between-group chi-squared analyses, and thematic analysis on several open-ended questions. Results Results from a chi-square test of independence suggested significantly more individuals with a penis than a vagina reported believing blue balls are real, and significantly more individuals with a vagina than a penis reported being pressured into engaging sexually because of a partner’s fear of getting blue balls. Descriptive statistics indicated that for the individuals who disclosed experiencing blue balls/vulva, the experience of pain/discomfort is reportedly mild, with few participants rating the experience as severe. Thematic analysis results indicated that overall, participants felt people with vulvas are expected to engage in sexual acts to prevent their partner’s experience of blue balls despite endorsing that it shouldn’t be used as a sexual coercion tactic. Conclusions Despite public discourse that “blue balls” is extremely painful and common, this study suggests that severe pain exists in a minority of people, that solitary sexual and nonsexual activities can alleviate discomfort/pain, and that pain experiences are not a valid reason to pressure others into engaging sexually. Disclosure No

(065) Let’s Talk about Sex: Resident Run Didactic Curriculum

Abstract Introduction The Council on Resident Education in Obstetrics and Gynecology (CREOG) includes sexual health learning objectives as part of the core education for Ob/Gyn training. Residents are expected to gain understanding of normal sexual function as well as common areas of sexual dysfunction. Unfortunately, several studies have demonstrated a lack of knowledge in this area by Ob/Gyn residents and that educational didactic programs are not standardized on this topic. In 2010, over 90% of post graduate year (PGY)3 and PGY4 residents reported attending fewer than 5 didactic activities on sexual function/dysfunction, with only 50% feeling able to perform a targeted physical exam. Over the past decade, there has not been substantial improvement in this subject matter. In a 2021 survey evaluating the sexual health CREOG objectives showed that more than half of Ob/Gyn residents were not able to describe the disorders of sexual function or list common medications that effect sexual function. This is not isolated to the US, with studies in other countries including Singapore and Brazil, showing residents lack formal training and residents want increased didactic time focused on sexual health. Objective Our hypothesis was that at our institution the baseline knowledge of sexual dysfunction among Ob/Gyn residents would be low. The primary objective was formulating a needs assessment through implementation of a pre/post survey with a curriculum component. The secondary objective was to determine what areas of sexual medicine are most commonly areas of confusion or where residents lack comfort in regard to patient care. Methods The resident-designed curriculum was built with collaboration from a pelvic floor physical therapist. The journal club format was based on American College of Obstetricians and Gynecologists (ACOG) Practice Bulletins, the International Society for the Study of Women’s Sexual Health (ISSWSH) clinical pearls, and the North American Menopausal Society (NAMS) position statements. The pelvic floor physical therapy component focused on pelvic pain, perinatal considerations, and incontinence. The WCG IRB deemed this study exempt. After the pre-curriculum assessment was used to identify knowledge gaps, a month of one-hour weekly sexual health sessions were implemented followed by a post-curriculum survey. Results Due to small sample size, (N=14) there was no way to establish significance in our results. In general, areas that residents were weak and the curriculum focused on were: 1) Pelvic floor/vulvar/vestibular disorders. 2) Genitourinary syndrome of menopause and vasomotor symptoms of menopause. 3) Sexual medicine disorders (hypoactive sexual desire disorder, female sexual arousal disorder, persistent genital arousal disorder, female orgasm disorders, genitopelvic pain penetration dysfunction). Conclusions The baseline knowledge of sexual dysfunction and menopausal concerns among Ob/Gyn residents was low. However, implementation of a structured curriculum after a formal needs assessment improved comfort with these topics. Now that the baseline curriculum is designed it is imperative to expand to further residency programs (in Ob/Gyn as well as other specialties) to disseminate the knowledge to providers in training who require competency in sexual health concerns. Disclosure No

(188) The Female Genitopelvic Pain Subcommittee of the International Consultation of Sexual Medicine: Update on a systematic review of the efficacy and safety of pharmacological, surgical, psychological, and physical therapy treatments for vulvodynia

Abstract Introduction Literature on vulvodynia treatment is heterogeneous in terms of intervention type and study quality. A recently published systematic review (SR) of treatments focusing on randomized controlled trials (RCTs) and non-RCTs for provoked vestibulodynia (a vulvodynia subtype) concluded that most studies had very low certainty of evidence, which limited the ability to draw conclusions. The authors noted that their strict eligibility criteria resulted in a restricted number of included studies. It suggests a need for broader, more inclusive SRs to be conducted, the results of which could inform much needed intervention recommendations for vulvodynia. Objective The Female Genitopelvic Pain Subcommittee is conducting a SR of treatments for vulvodynia to assess their effectiveness, safety, and acceptability. The results will provide stakeholders with empirically based treatment recommendations for patients with vulvodynia. Methods Selection criteria: Interventions of interest include pharmacological, surgical, psychological, and physical therapy treatments of premenopausal women with clinician-diagnosed vulvodynia (primary, secondary), defined as idiopathic, chronic (≥3 months) vulvar pain. Included studies are RCTs, SRs, and comparative observational studies. The primary outcomes are pain and sexual outcomes, and safety and adverse events, with additional outcomes focusing on mood and quality of life. Selection of studies was done in DistillerSR by two independent reviewers. Conflicts were resolved by discussion or by involving a third reviewer with excluded studies documented. Full-text screening is adhering to this same process. Search methods: A comprehensive search strategy was developed by an information specialist and was peer reviewed. Numerous electronic databases were searched. No language limit was used, and a date limit was set (1997 or later). Published filters for controlled trials and other study designs were applied. PubMed/MEDLINE was used to develop the search strategy, which was then translated into other databases. A limited grey literature search was also conducted. Data collection and analysis: Data extraction and risk of bias assessment (ROB) will be done in DistillerSR using pre-piloted data extraction forms. Studies will be extracted by one reviewer and independently checked by a second reviewer. Disagreements will be resolved by discussion or by involving a third reviewer. We will extract study characteristics and outcome data. For ROB, we will use the Cochrane Risk of Bias tool and the ROBINS-I tool. We will narratively synthesize the results by comparisons and outcomes. If appropriate, we will conduct a meta-analysis for studies regarded as suitably homogeneous. Last, the certainty of the body of evidence will be assessed using the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) approach. Results After duplicates were removed, the search yielded 10,171 references for title and abstract screening. Of these, 599 full-text articles were assessed for inclusion. All screening and preliminary data extraction will be completed by October 2022. General characteristics of the included studies including interventions identified will be presented. Conclusions We will report on interim progress of the SR. It will be an opportunity to gather initial input from stakeholders on this evidence-based approach. Discussion of possible multi-organization involvement will also help unify intervention recommendations for those with vulvodynia. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Andrew Goldstein – Daré Bioscience (employee), Incyte (consultant), Gynecologic Cancers Research Foundation (Board of Directors, Research Funding).

Applications of botulinum toxin to the female pelvic floor: Botulinum toxin for genito-pelvic pain penetration disorder and chronic pelvic pain in women

Chronic pain conditions like genito-pelvic pain penetration disorder and chronic pelvic pain cause significant morbidity in women worldwide and yet are underdiagnosed and undertreated. While the use of botulinum toxin for pain conditions has expanded, there are few randomized controlled studies of botulinum toxin for pelvic pain conditions in women. This paper provides an update on the current status and context for considering botulinum toxin treatment for these conditions to complement and expand currently available approaches. High quality clinical trials to evaluate safety and efficacy and to determine optimal doses and approaches to injection are urgently needed.

Eradication of Long-Term Vaginismus Type of Genito-Pelvic Pain/ Penetration Disorder by Treating with Dextroamphetamine Sulfate

There are many therapies for the vaginismus type of genito-pelvic pain/penetration disorder. However, as frequently found when there are multiple treatments for a given pathological disorder, not any of them are highly effective for this problem. It has been hypothesized that increased tissue permeability may be the etiologic factor causing inflammation in various tissues leading to a variety of different pain syndromes in various organ systems, including, but not limited to, the pelvis. Treatment with dextroamphetamine sulfate has resulted in significant palliation of the pain in the majority of cases treated. The hypothesized mechanism is that this amphetamine releases dopamine from sympathetic nerve fibers, which, in turn, diminishes excessive infiltration of irritants, which are the etiologic factor for the pain. Ideally, the best proof of efficacy for the treatment of this type of vaginismus/dyspareunia syndrome by dextroamphetamine sulfate would be to conduct a randomized prospective double-blinded multi-center study. However, because of the generic status of this drug, it is highly unlikely that any pharmaceutical company would fund such a study. The most practical feasible method to determine efficacy would be to try the drug on a very convincing cases of long-term severe vaginismus/dyspareunia syndrome that failed to respond to standard therapy. Indeed, such a case was found in a 32-year-old woman whose vaginismus was detected at puberty, that was associated with severe dyspareunia 10 years later, so that neither insertion of tampons nor intercourse had been possible. Within one month of treatment her vulvodynia/dyspareunia were eradicated. The relief has persisted for three years. Hopefully this case report may encourage treating physicians who treat a lot of similar cases to evaluate a large series or conduct a randomized study comparing amphetamine therapy vs. their best treatment option to date.

Mediators of change in cognitive-behavioral couple therapy for genito-pelvic pain: Results of a randomized clinical trial.

A novel cognitive-behavioral couple therapy (CBCT) has shown efficacy for treating provoked vestibulodynia (PVD), the most common type of genito-pelvic pain, in comparison to topical lidocaine. However, mechanisms of therapeutic change have not been determined. We examined women's and partners' pain self-efficacy and pain catastrophizing as mediators of change in CBCT, using topical lidocaine as a control group. 108 couples coping with PVD were randomized to 12-week CBCT or topical lidocaine and assessed at pre-treatment, post-treatment, and six-month follow-up. Dyadic mediation analyses were conducted. CBCT was not more effective in increasing pain self-efficacy than topical lidocaine, so this mediator was discarded. In women, decreases in pain catastrophizing at post-treatment mediated improvement in pain intensity, sexual distress, and sexual function. In partners, decreases in pain catastrophizing at post-treatment mediated improvement in sexual function. Partners' decreases in pain catastrophizing also mediated reductions in women's sexual distress. Pain catastrophizing may be a mediator specific to CBCT for PVD, explaining improvements in pain and sexuality. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

"Blue balls" and sexual coercion: a survey study of genitopelvic pain after sexual arousal without orgasm and its implications for sexual advances.

Blue balls/vulva has received increasing interest from the public in recent years, sparking debate about genital physiology, controversy around "sexual release" as a treatment for this type of pain, and sexual consent. This cross-sectional, mixed-methods online study aimed to evaluate the general understanding and frequency of blue balls/vulva and whether individuals have ever been pressured to continue sexual activity because of a partner's fears of experiencing pain without orgasm. A total of 2621 individuals with a penis (n = 1483) or vagina (n = 1138) were recruited for an online survey on the experience of "blue balls/vulva." Quantitative analyses consisted primarily of descriptive statistics and chi-square analyses. Between-group differences were analyzed (based on whether respondents reported having a penis or vagina), and responses to open-ended questions were examined via thematic analysis. The primary outcomes of interest were reports of the belief in blue balls/vulva, the frequency and pain characteristics of blue balls/vulva, and the incidence of being pressured to continue sexual activity due to a partner's fears of experiencing pain without orgasm. Results indicated that significantly more individuals with a penis than a vagina reported believing that blue balls are real, endorsed experiencing pain when they approached orgasm but did not ejaculate, and reported moderate and severe pain. Significantly more individuals with a vagina than a penis reported being pressured into a sexual act due to a partner's fear of experiencing pain without orgasm. Results from the thematic analysis indicated that participants recognized that those with a vagina are expected to act sexually to prevent their partners' experience of blue balls, despite agreement that this phenomenon should not be used to coerce or manipulate partners into engaging sexually. Education on the frequency of this phenomenon and methods to relieve pain alternative to partnered sexual activity should be addressed in patients who present with this condition. Although the survey was brief, it provided information from a relatively large sample about whether people believe that this phenomenon exists, how many experience it, how painful it is, and how often it has been used as an excuse for a partner to continue sexual activity. Results indicated that severe pain exists in a minority of individuals, that solitary sexual and nonsexual activities can help to alleviate the discomfort, and that this pain is not a valid reason to continue unwanted sexual activity.

Association Levels Between Results from a Therapeutic Educational Program on Women Suffering from Genito-pelvic Pain Penetration Disorder and Their Socioeconomic Status

IntroductionSexual health is fundamental in an individual’s well-being. Genito-pelvic pain/penetration disorder, also known as dyspareunia, is one of the most common sexual disorders, and approaches from physiotherapy include multimodal options, being education, a recent resource often used. Social and economic factors might influence the effectiveness of educational therapies in patients suffering this affliction. The objective of this study was to determine if there is an existing correlation between the participant’s socioeconomic status and the results of a therapeutic educational program.MethodsA randomized controlled trial was performed using therapeutic education as intervention in a sample of 69 women suffering from genito-pelvic pain/penetration disorder. Results over time were assessed regarding pain intensity, pain-related outcomes, and sexual functioning. Socioeconomic status measurements were obtained in February 2022, and these included age, educational level, household monthly income, or job rank. A correlation analysis was performed between these outcomes using Pearson’s correlation index and Spearman’s rho statistic.ResultsResults from the correlation analysis show that there is no significant correlation between any of the outcomes found in the results of the intervention and the socioeconomic status measurements.ConclusionA therapeutic educational program improves pain intensity, pain-related outcomes, and sexual functioning in patients with persistent pelvic pain, independently from their age, educational level, household monthly income, or job rank.Policy ImplicationsEducation is a powerful resource that improves sexuality outcomes despite the patient’s socioeconomical status in patients suffering from genito-pelvic pain/penetration disorder.

Psychosexual therapy in an interdisciplinary approach. Case study: patient with anxiety disorders and excessive pelvic floor muscle tension

AimThis article presents psychosexual conceptualization and methods of therapeutic work with a patient in an interdisciplinary approach. It was based on the techniques of cognitive-behavioral psychotherapy (CBT) and urogynecological physiotherapy. MethodsThe most important elements of the diagnostic interview and work techniques based on the CBT approach and physiotherapy were presented. The therapy was focused on the issues of anxiety, helplessness, and anger. At later stages of the therapy, sexological topics and physiotherapy were introduced. In addition, the patient received treatment from other specialists: a psychiatrist and an endocrinologist. ResultsThe patient managed to achieve some of the goals set together with the therapist and eliminate genito-pelvic pain. An additional benefit was the complete medical diagnosis of the patient and commencement of the treatment related of her hormonal imbalance. ConclusionsInterdisciplinary treatment resulted in beneficial effects. This type of cooperation of many specialists in treating patients reporting emotional, mental, and sexual difficulties seems to give the best results. This indicates the value of teamwork and the need for the cooperation of specialists in various fields.

Sexual pain disorder

Sexual pain disorder, combining the terms dyspareunia, vaginismus, genitopelvic pain, and penetration disorder, is common in women of reproductive and postmenopausal age worldwide (up to 34-45%) and is more often manifested as recurrent acute pain. A diagnosis of genitopelvic pain/penetration disorder (GPPD) is made when at least one of the following symptoms is present: persistent or recurrent difficulty with vaginal penetration; marked vulvovaginal or pelvic pain during vaginal intercourse and attempts of vaginal penetration; marked fear or anxiety about vulvovaginal or pelvic pain in anticipation, during or as a result of vaginal penetration; marked tension of the pelvic floor muscles during attempts of vaginal penetration. Additional criteria include the presence of the listed symptoms for at least 6 months, resulting in significant sexual distress that causes serious problems in the relationship and is not related to the effects of any substance or any other medical condition. The mechanisms of sexual pain are determined by a wide range of biological, psychiatric and social factors, which explains the difficulty in diagnosing and treating it, as well as the negative impact on sexual functioning in the couple. Timely multidisciplinary care for women suffering from a sexual pain disorder can effectively alleviate the condition and ensure marital sexual harmony in the couple. The modern range of treatment options includes both conservative and surgical treatment methods, the rational choice of which can significantly improve patients’ quality of life.

Pain-Related Anxiety in Chronic Vulvar Pain Conditions Associated with Vulvodynia

ABSTRACT Introduction Chronic, idiopathic vulvar pain (vulvodynia) is often treated as a unilateral condition. However, there are likely multiple causes to vulvar pain, relating to nerves, muscles, hormones, and inflammation, as well as psychosocial factors. Pain-related anxiety is a known contributor to the cycle of chronic pain. Rates of pain-related anxiety have been explored in vulvodynia associated with hypertonic pelvic floor muscle dysfunction; however, the roles in other associated genitopelvic pain conditions are still unknown. Objective Evaluate pain-related anxiety in the context of chronic vulvar pain conditions associated with vulvodynia: pudendal neuralgia (PN), hypertonic pelvic floor dysfunction (PFD), provoked vestibulodynia (PVD), and lichen sclerosus (LS). Methods A retrospective chart review was conducted for all new patients presenting to two metropolitan gynecology clinics specializing in vulvar pain for one full year. Patients were evaluated by a vulvar pain specialist to receive a specific vulvar pain diagnosis based on history and physical examination. Pain-related anxiety scores were measured with the Pain Anxiety Symptoms Scale-20 (PASS-20) prior to evaluation. Adult women presenting with vulvar pain who completed the PASS-20 and received a diagnosis of hypertonic pelvic floor muscle dysfunction were included in the study. Patients with concomitant vulvovaginal infections were excluded. Patients were grouped according to diagnosis: pudendal neuralgia (PN), overactive pelvic floor dysfunction alone (PFD), provoked vestibulodynia (PVD), or vulvar lichen sclerosus (LS). Independent two-tailed t-tests and one-way ANOVAs were performed comparing the distributions and scores for each of the four aspects of the PASS-20. Results 126 patients were included in the analysis: PN (17), PFD (43), PVD (57), and LS (9). Pain-related anxiety was highest for those with PN (mean score=47.18, SD=24.66) with 76.5% scoring above the 30-point cutoff for maladaptive levels of pain-related anxiety. This was followed by those with PFD (mean=37.02, SD=18.91, 65.1% scored >30), PVD (mean=32.53, SD=17.60, 43.9% scored >30), and LS (mean=23.44, SD=19.98, 33.3% scored >30). The PN group scored highest in cognitive, fear, and physiological anxiety, while the PFD group scored higher in escape and avoidance. One-way ANOVAs with post-hoc analysis yielded significant differences between the cognitive anxiety scores of PN vs PFD (p=0.03), PN vs PVD (p<0.01), and PN vs LS (p<0.01); as well as with the physiological anxiety scores of PN vs PFD (p=0.02), PN vs PVD (p=0.01), and PN vs LS (p<0.01). Comparing PFD and PVD, those with PFD alone had significantly higher scores in cognitive anxiety (t(498) = 2.12, p<0.04) and fear of pain (t(495) = 2.76, p<0.006). Conclusions Vulvar pain conditions in addition to hypertonic PFD can differentially impact pain-related anxiety. Notably, patients with PN have higher cognitive, physiologic, and fear-related anxiety compared to patients with other distressing vulvar pain conditions. Differences in pain-related anxiety between the additional vulvar pain conditions and PFD alone may reflect the severity of hypertonic PFD, which was not delineated in this study. These findings highlight the importance of identifying all causes of genitopelvic pain in the evaluation of vulvodynia, as well as acknowledging and addressing the role of pain-related anxiety in chronic genitopelvic pain. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Consultant for Good Clean Love and Mahana Therapeutics; Consultant to SST, Ipsen, Amag, Lupin, an employee of Dare, and received research funding from Elen, Ipsen, En

Clinical Presentation of Clitorodynia associated with Clitoral Adhesions and Keratin Pearls

ABSTRACT Introduction Clitoral adhesions occur when the clitoral prepuce adheres to the glans clitoris. This can lead to accumulation of desquamated epithelial cells under the prepuce, resulting in the formation of smegmatic pseudocysts and keratin pearls. A keratin pearl is a focus of central keratinization within concentric layers of squamous cells. Presence of these firm, millimeter-sized masses can lead to clitoral pain (similar to a grain of sand in the eye). Although keratin pearls have been described in the literature, there is little known about their clinical presentation or association with female sexual dysfunction (FSD). Objective Explore the clinical presentation of clitoral pain associated with clitoral adhesions and keratin pearls related to concomitant genitopelvic pain conditions and sexual dysfunction. Methods A retrospective chart review was conducted in two metropolitan gynecology clinics specializing in vulvar pain between January 2018 and September 2021. Patients presenting with clitoral pain (clitorodynia) were identified in the electronic medical record through a search of physician-entered diagnoses and confirmed by review of the clinical notes. Adult patients with documented clitoral pain as well as clitoral adhesions (clitoral phimosis) and keratin pearls noted on exam were included in the study. FSD was measured with the Female Sexual Function Index (FSFI) and Female Sexual Distress Scale-Revised (FSDS-R). Data was presented in means and percentages. Results Forty-one patients met inclusion criteria. Average age at presentation was 35 years (range 19-73 years). Self-reported ethnicity of the study population was 73% White, 5% Hispanic, 5% Asian, 2% Black, with no response from 15% of participants. Vulvar lichen sclerosus was noted in 17% (7/41) of patients, with an average age of 46 years (range 24-73 years). Seventy-six percent (31/41) of patients also had the diagnosis of overactive (hypertonic) pelvic floor muscle dysfunction (PFD), 25% (8/31) had pudendal neuralgia and 10% (3/31) had interstitial cystitis/painful bladder syndrome. Forty-six percent (19/41) of patients had provoked vestibulodynia (PVD) associated with a hormonal factor (hormonal contraceptive use, postpartum/breastfeeding, perimenopause, or menopause). Recurrent vulvar candidiasis or tinea cruris was noted in 5% of patients. Four patients (10%) presented with clitoral pain alone and were not found to have other identified genitopelvic pain conditions. Baseline FSFI and FSDS-R data were available in 35 patients. Mean FSFI score was 13.25, with 91% of patients meeting criteria for FSD (total FSFI score < 26.55). Mean scores for FSFI domains were: desire (2.4), arousal (2.1), lubrication (2.5), orgasm (2.0), satisfaction (2.5), and pain (1.6). Mean FSDS-R score was 29.42, with 89% of patients meeting criteria for FSD (FSDS-R score ³11). Conclusions Clitoral pain associated with clitoral adhesions and keratin pearls occurs in women of all ages. Clitoral adhesions are not confined to patients with vulvar lichen sclerosus. A vast majority of patients with clitoral adhesions and keratin pearls have additional chronic vulvar pain conditions, most commonly overactive PFD, pudendal neuralgia, or hormonally-associated PVD. Clitoral pain with clitoral adhesions and keratin pearls is associated with FSD and sexual distress. Clitorodynia and clitoral phimosis should be identified in the clinical evaluation of genitopelvic pain. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Consultant for Good Clean Love and Mahana Therapeutics; part-time employee of Dare Bioscience. Received research funding from Dare Science, SST, Endoceutics, The Cellular Medicine Association, and Ipsen for other projects. He is a consultant for Ipsen, SST, and AMAG

Anxiety and Anticipated Pain Levels of Women With Self-Reported Penetration-Related Genito-Pelvic Pain are Elevated in Response to Pain-related Images

BackgroundGenito-pelvic pain (GPP) affects a sizable minority of women and results of existing treatments can be variable. A method of general pain treatment that has not yet been extended to penetration-related GPP is Explicit Motor Imagery (EMI), which uses pain-related images to help individuals with pain alter their responses to pain, resulting in reduced pain, less pain-related anxiety, and improved function. AimAs a first step toward determining if EMI is a feasible method for treating penetration-related GPP, this study examined whether images that potentially signal genital pain are sufficient to induce an anxiety or anticipated pain response in women. MethodsParticipants were 113 women (62 with genital pain, 51 pain-free) recruited to complete an online study. Participants viewed randomized images of women engaging in various activities that potentially cause pain for people with penetration-related GPP (sitting, walking, running, lifting, inserting a tampon, implied penetrative sex, actual penetrative sex, implied gynecological exam, actual gynecological exam). Participants then rated each image on how much anxiety they experienced viewing the picture (viewing anxiety), and how much anxiety (anticipated anxiety) and pain (anticipated pain) they expected to experience doing the activity in the picture. OutcomesOutcomes were the self-reported viewing anxiety, anticipated anxiety, and anticipated pain of women with and without self-reported penetration-related GPP in response to the pain-related images. ResultsWomen who experienced self-reported penetration-related GPP reported significantly higher levels of viewing anxiety, anticipated anxiety, and anticipated pain in almost all categories of images, compared to women who were free of pain. The key exception was that women with and without self-reported penetration-related GPP reported similar levels of viewing anxiety when looking at images of implied and actual penetrative sex. Clinical TranslationThese results support that pelvic and genital imagery serve as a sufficient stimulus to generate anxiety and anticipated pain in our study sample. EMI, which targets desensitization of heightened anxiety warrants further research as a potential novel treatment option. Strengths & LimitationsThis study was the first to assess responses to a wide array of pain-eliciting images in women with and without self-reported penetration-related GPP. A key limitation was that the pain sample was self-reported and not clinically diagnosed. ConclusionImages of pain-related stimuli were sufficient to induce anxiety and anticipated pain in women with self-reported penetration-related GPP. This first step suggests that EMI may be a useful treatment option for women with penetration-related GPP.Kelly KJM, Fisher BL, Rosen NO, et al. Anxiety and Anticipated Pain Levels of Women With Self-Reported Penetration-Related Genito-Pelvic Pain are Elevated in Response to Pain-related Images. J Sex Med 2022;19:1281–1289.

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

The goal of the study is to determine the effect of pelvic floor muscle exercises on genito-pelvic pain levels during the postpartum period. 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. 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. 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. NCT05343520.

Endometriosis and Sexual Functioning: How Much Do Cognitive and Psycho-Emotional Factors Matter?

Women with endometriosis often suffer from genito-pelvic pain. The objective of the present study was to analyze the relationship between cognitive and psycho-emotional factors and sexual functioning of women with endometriosis, comparing women with and without endometriosis. A total of 87 women with endometriosis (EG) and 100 women without endometriosis (CG) completed a socio-demographic questionnaire; the short-form of McGill Pain Questionnaire (SF-MPQ); the Female Sexual Functioning Index (FSFI); the Sexual Distress Scale (SDS); the Symptoms Checklist (SCL-90-R); the Toronto Alexithymia Scale (TAS-20); the Positive and Negative Affects Scale (PANAS); the Sexual Dysfunctional Belief Questionnaire (SDBQ); the Sexual Modes Questionnaire (SMQ); and the Questionnaire of Cognitive Schema Activation in Sexual Context (QCSASC). EG obtained worse scores than CG in SF-MPQ, Pain subscale of FSFI, and SDS. EG reached higher scores than CG on almost all scales of SCL-90-R and lower scores in the “Identifying Feelings” scale of TAS-20. Furthermore, EG reported more negative emotions toward sexuality than CG (PANAS) higher scores on the “Affection Primacy” scale of SDBQ and the “Helpless” sexual cognitive schema of QCSASC than CG. No significant differences were found in SMQ. Sexual health professionals should address psychological, emotional, and cognitive factors since they seem involved in patients’ sexual experiences.

Deep pelvic myofascial release (Broad Ligament Maneuver) associated or not with LPF

Background: Among genitopelvic pain is the pain deep into the vagina and deeper than the uterine cervix, different from pain related to penetration or superficial connective pain. Aims: To test the view of abdominal and pelvic fascia, muscles and viscera by ultrasound (USG), as well as the view of two myofascial techniques, one intravaginal and the other external, and diaphragmatic aspiration of LPF, comparing the effectiveness of each technique alone or in combination, regarding the mobilization of visceral and parietal fasciae. Method: Exploratory experimental study guided by USG. Results: Muscles, fasciae and organs were well seeing by USG, as well as the fascial movements caused by each technique. LPF mobilized visceral fascia better, but manual techniques mobilized parietal fascia better. The Broad Ligament Maneuver mobilized both fasciae. The combination of manual techniques with LPF was superior in releasing parietal and visceral fasciae. Conclusion: Fascial mobilization can be effectively visualized by USG. The combination of manual myofascial release techniques with LPF is more effective in mobilizing all fasciae and should be the first choice.

The Biopsychosocial Puzzle of Painful Sex.

Genital pain associated with sex is a prevalent and distressing problem with a complex research and clinical profile. This article reviews the historical context of the "sexual pain disorders" and the circuitous trajectory that has led from the first mention of painful sex in ancient documents to the latest diagnostic category of genito-pelvic pain penetration disorder in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders as well as in other existing and proposed nomenclatures. Prominent etiologic research and emergent theoretical models are critically assessed, as is the latest treatment outcome research of note. Finally, the review points to a number of extant needs in the research and clinical effort, including an integrated biopsychosocial and multidisciplinary approach, randomized clinical trials, targeting of treatment barriers, and expansion of the entire enterprise to include populations that have not been considered.

Case study on penetrating genito-pelvic pain disorder and proposal for evaluation and treatment by digital S-ONapp applications

Objective: The case study shows an improvement in genito-pelvic pain at acquired penetration, with moderate severity, characterized by persistent recurrent pain for 7 months. Therapeutic methods: According to the patient's evaluation and psychometric tests, the result consisted of differentiated diagnosis of dyspareunia, with moderate severity. During the treatment, psychotherapeutic techniques were applied - purely cognitive therapy validated and standardized by Delcea et al., Relaxation techniques, desensitization therapy and pelvic floor. Outcome of therapy: During sex therapy for a period of 4 months, with individual sessions - two with each individual and 10 couple sessions, the sexual disorder was improved, from 4 to 2, the quantification of the pain by the patient, on a scale of 1 to 5. Conclusion: Sex therapy has been a real success by improving the relationship and sex of the couple. The two managed to improve their communication, to manage stress and nervousness situations through conflict management and in particular, to reconnect sexually through a better intimacy of the couple, rediscovering eroticism and sexual desire, thus ameliorating the genito-pelvic pain disorder. penetration.