Pain-free Intercourse Research Articles

Pain Characteristics, Fear-avoidance Variables, and Pelvic Floor Function as Predictors of Treatment Response to Physical Therapy in Women With Provoked Vestibulodynia.

The aim was to investigate whether pretreatment pain characteristics, psychological variables, and pelvic floor muscle (PFM) function predict the response to physical therapy (PT) in women with provoked vestibulodynia (PVD). One hundred-five women diagnosed with PVD underwent 10 weekly sessions of individual PT comprising education, PFM exercises with biofeedback, manual therapy, and dilators. Treatment outcomes were evaluated at pretreatment, post-treatment, and 6-month follow-up and included pain intensity (numerical rating scale 0 to 10) and sexual function (Female Sexual Function Scale). Multilevel analyses were used to examine the potential predictors of response over time including pain characteristics (PVD subtype, pain duration), psychological variables (fear of pain, pain catastrophizing), and PFM function assessed with a dynamometric speculum (tone, flexibility, and strength). PVD subtype and PFM tone were significant predictors of greater treatment response for pain intensity reduction. Secondary PVD (ie, pain developed after a period of pain-free intercourse) and lower PFM tone at baseline were both associated with greater reduction in pain intensity after PT and at follow-up. Among the psychological variables, fear of pain was the only significant predictor of better treatment response when assessed through improvement in sexual function, where higher fear of pain at baseline was associated with greater improvement after PT. This study identified PVD secondary subtype, lower PFM tone, and higher fear of pain as significant predictors of better treatment response to PT in women with PVD.

The Vulvar Vernacular: Dilemmas Experienced and Strategies Recommended by Women with Chronic Genital Pain

ABSTRACTThis manuscript uses Goldsmith’s (2004) normative model of social support to explore conversations women have with a romantic partner about vulvodynia. Twenty-six women with vulvodynia participated in semi-structured interviews in which they described conversational goals, discussed challenges, and offered advice to others managing vulvodynia. As this study was concerned with interactions with romantic partners both present and past, women with vulvodynia, not their partners, were the targets of recruiting efforts. Two key communicative dilemmas emerged from the data analysis: (a) I need to talk to you, but I can’t, and (b) I want to be honest, but not too honest. These dilemmas represent ambiguity about the causes and duration of pain and the implications that being unable to have pain-free intercourse has for their relationships and identities as women. Three strategies, communicative practices for managing dilemmas, also emerged: (a) reframe the illness, (b) refocus the relationship, and (c) redefine intimacy. The theoretical and practical implications of this research are socially situated within timely conversation about women, their bodies, and their roles.

Pelvic Floor Muscle Morphometry and Function in Women With Primary and Secondary Provoked Vestibulodynia

IntroductionProvoked vestibulodynia (PVD) can be categorized as primary PVD affecting women from their first sexual intercourse or secondary PVD, which appears after a period of pain-free intercourse. There is growing evidence that these subgroups may be distinct entities presenting different pathophysiological mechanisms. Although there are documented pelvic floor muscle alterations in provoked vestibulodynia, no study has yet evaluated whether the pelvic floor muscle morphometry or function differed between women with primary and secondary provoked vestibulodynia. AimTo assess and compare pelvic floor muscle morphometry and function in women with primary and secondary provoked vestibulodynia. MethodsA total of 212 women with provoked vestibulodynia (primary = 75 and secondary = 137) participated in the study after completing a gynecologic exam to confirm their diagnosis. Main Outcome MeasurePelvic floor muscle morphometry was evaluated at rest and during maximal contraction using 3D/4D transperineal ultrasound and pelvic floor muscle function (tone, strength, speed of contraction, endurance) was assessed with a dynamometric speculum. ResultsPelvic floor muscle morphometry at rest and during contraction was not statistically different between women with primary and secondary provoked vestibulodynia (P > .327 adjusted for the duration of symptoms; P > .137 unadjusted t-tests). Regarding pelvic floor muscle function assessed with the dynamometric speculum, no differences were found in tone, strength, speed of contraction, endurance between the 2 groups (P > .144 adjusted for duration of symptoms; P > .118 unadjusted t-tests). Clinical ImplicationsWomen with primary and secondary PVD do not differ on pelvic floor muscle morphometric or dynamometric characteristics, suggesting that physical therapy modalities should be offered to both subgroups of PVD. Strengths & LimitationsThe current study used a large and mixed clinical and community sample providing more representative findings. Moreover, the analyses were adjusted for relevant variables such as duration of symptoms. Although the inclusion of nulliparous women below 45 years of age ensured the homogeneity of the sample, it may limit the external validity. ConclusionThese findings suggest that primary and secondary subgroups of provoked vestibulodynia cannot be differentiated by morphometric or dynamometric characteristics. Pelvic floor muscles alterations in provoked vestibulodynia are therefore not influenced by the onset of the symptoms.Fontaine F, Dumoulin C, Bergeron S, et al. Pelvic floor muscle morphometry and function in women with primary and secondary provoked vestibulodynia. J Sex Med 2018;15:1149–1157.

Vaginismus Treatment: Clinical Trials Follow Up 241 Patients.

IntroductionVaginismus is mostly unknown among clinicians and women. Vaginismus causes women to have fear, anxiety, and pain with penetration attempts.AimTo present a large cohort of patients based on prior published studies approved by an institutional review board and the Food and Drug Administration using a comprehensive multimodal vaginismus treatment program to treat the physical and psychologic manifestations of women with vaginismus and to record successes, failures, and untoward effects of this treatment approach.MethodsAssessment of vaginismus included a comprehensive pretreatment questionnaire, the Female Sexual Function Index (FSFI), and consultation. All patients signed a detailed informed consent. Treatment consisted of a multimodal approach including intravaginal injections of onabotulinumtoxinA (Botox) and bupivacaine, progressive dilation under conscious sedation, indwelling dilator, follow-up and support with office visits, phone calls, e-mails, dilation logs, and FSFI reports.Main Outcome MeasuresLogs noting dilation progression, pain and anxiety scores, time to achieve intercourse, setbacks, and untoward effects. Post-treatment FSFI scores were compared with preprocedure scores.ResultsOne hundred seventy-one patients (71%) reported having pain-free intercourse at a mean of 5.1 weeks (median = 2.5). Six patients (2.5%) were unable to achieve intercourse within a 1-year period after treatment and 64 patients (26.6%) were lost to follow-up. The change in the overall FSFI score measured at baseline, 3 months, 6 months, and 1 year was statistically significant at the 0.05 level. Three patients developed mild temporary stress incontinence, two patients developed a short period of temporary blurred vision, and one patient developed temporary excessive vaginal dryness. All adverse events resolved by approximately 4 months. One patient required retreatment followed by successful coitus.ConclusionA multimodal program that treated the physical and psychologic aspects of vaginismus enabled women to achieve pain-free intercourse as noted by patient communications and serial female sexual function studies. Further studies are indicated to better understand the individual components of this multimodal treatment program.Pacik PT, Geletta S. Vaginismus Treatment: Clinical Trials Follow Up 241 Patients. Sex Med 2017;5:e114–e123.

For new mothers, the relationship matters: Relationship characteristics and postpartum sexuality

Postpartum sexuality has traditionally been studied using a biomedical framework, which focuses on how the physical and biological changes that occur during pregnancy and childbirth affect the resumption of pain-free intercourse. The current study sought to use a more inclusive and contextual approach by investigating how relationship characteristics are related to postpartum sexual desire and predict the resumption of a variety of sexual activities. A total of 188 new mothers who were within one year postpartum completed an online study. The Sexual Desire Inventory was used to measure solitary and dyadic sexual desire. Relationship satisfaction was measured using the Relationship Assessment Scale and perception of partner's sexual desire was measured using three modified questions from the Sexual Desire Inventory. New mothers were also asked to report when they resumed a variety of sexual activities in the postpartum period. Relationship satisfaction and perceptions of partner's desire were negatively correlated with solitary sexual desire, and relationship satisfaction was positively correlated with dyadic sexual desire. Birth-related factors were not related to postpartum sexual desire. New mothers' perception of their partner's desire predicted the resumption of most sexual activities in the postpartum (i.e., manual stimulation of new mother's and partner's genitals, oral stimulation of partner's genitals, penile-vaginal intercourse). Relationship satisfaction predicted the resumption of oral stimulation of the new mother's genitals. The results of this study support the incorporation of contextual factors, such as relationship characteristics, and the inclusion of non-penetrative sexual activities in the study of postpartum sexuality.

Understanding and Treating Vaginismus

This article was written to raise the awareness of clinicians about vaginismus, an underdiagnosed and inadequately treated condition characterized by painful intercourse. Although it was first described over 150 years ago, vaginismus is rarely taught in medical schools and residencies or discussed at medical meetings. Despite numerous hypotheses on possible causes, its etiology is unknown. Vaginismus affects 5% to 17% of women seen in a clinical setting. Its true incidence is unknown, because many patients remain silent about this problem. Women with this disorder cannot tolerate vaginal penetration via intercourse, tampons, vaginal dilators, or gynecological examinations because of severe pain resulting from involuntary spasm of the vaginal muscles. Vaginal penetration is impossible for these women despite their desire to achieve it. Because of inadequate education and training, many clinicians are unable to diagnose and treat vaginismus. Women with primary vaginismus have never experienced pain-free intercourse, whereas those with secondary vaginismus were comfortable with intercourse at one time in their lives prior to progression to painful intercourse. A carefully constructed medical and psychosexual history and use of the Female Sexual Function Index facilitate the diagnosis of this disorder. The ability to successfully treat severe vaginismus requires a careful consideration of its diagnostic features, which include (1) a history of intercourse feeling such as hitting a wall that is suggestive of vaginal spasm of the introitus and (2) the inability to tolerate a gynecological examination. The presence of spasm or its severity and the degree of fear and anxiety over vaginal penetration distinguish between mild and severe forms of this disorder. Women with situational vaginismus cannot tolerate certain forms of penetration such as intercourse, but insertion of tampons or finger penetration is possible. Women with complete vaginismus are unable to tolerate any vaginal penetration. There is potential for a high rate of treatment success in patients with vaginismus unlike other sexual pain disorders such as vulvodynia and vestibulodynia. Vaginismus is a physical and psychological condition, and both components must be treated. Treatments that have been used to help women overcome vaginismus include dilators, physical therapy, sex counseling, psychotherapy, hypnotherapy, cognitive behavioral therapy, and a multimodal program using botulinum toxin A (onabotulinum toxin A). Kegel exercises, hymenectomy, lubricants, topical anesthetics, antidepressants, antianxiety medication, sedatives, alcohol, hallucinogenic drugs, and muscle relaxants are not shown to be helpful. For 10 years, the author has been developing a treatment program utilizing botulinum toxin A injections, bupivacaine injections, progressive dilation under anesthesia, and posttreatment counseling. This article describes his prospective pilot study that involved 30 patients with vaginismus. Effectiveness was assessed using Female Sexual Function Index scores and daily logs. At 1 year after treatment with this multimodal program, comfortable intercourse (or use of large dilator by single women without partners) was achieved in 97% of the patients. No recurrences or adverse events were noted. Long-term follow-up and blinded, randomized studies are needed to confirm these findings. No improvement in the diagnosis or management of this treatable disorder can be achieved without greater awareness among clinicians and physicians in training. The emotional needs of patients must be addressed whatever treatment is used. Stratifying the severity of vaginismus is important to determine the best course of treatment. Posttreatment counseling and follow-up are essential for success regardless of the treatment program used.

Remission of vulvar pain among women with primary vulvodynia.

To determine whether rates of remission differed among women with primary versus secondary vulvodynia. Using a community-based observational study based in Minneapolis/St. Paul, 138 clinically confirmed cases of vulvodynia between 18 and 40 years old were classified as primary (vulvar pain starting at the time of sexual debut or first tampon insertion) or secondary (vulvar pain starting after a period of pain-free intercourse) and queried regarding their pain history to determine whether they had ever experienced any vulvar pain-free time (remission) or pain-free time lasting 3 months or longer. Remission prevalence was 26% (9/34) for women in the shortest quartile of duration of vulvar pain (<3.8 y) and 38% (13/34) for the longest quartile of duration (≥13 y). After adjusting for vulvar pain duration, generalized vestibular pain, medical treatment, body mass index, and history of pregnancy, women who had primary vulvodynia were 43% less likely to report remission (95% CI = 0.33-0.99) than women with later onset (secondary cases). The association was strengthened when restricting to only remissions lasting 3 months or longer (adjusted risk ratio = 0.43, 95% CI = 0.22-0.84). Generalized vestibulodynia and obesity also reduced the likelihood of remission. Our study underscores the heterogeneity of vulvodynia and provides evidence that primary vulvodynia may have a less wavering course and, as such, a potentially different underlying mechanism than that of secondary vulvodynia.

Botox for the Treatment of Vaginismus: A Case Report

Aim: This case report aims to present our experience with intra-vaginal injections for the treatment of primary vaginismus. Methods: The patient underwent intra-vaginal injections of Botox and insertion of a dilator under anesthesia with follow up progressive dilation. Results: The patient experienced complete resolution of vaginismus and pain-free intercourse within 10 days of the procedure. Conclusion: Intra-vaginal Botox injections with progressive dilation should be considered for treatment of primary vaginismus.

Diagnosis and Management of Vulvar Vestibulitis Syndrome in 559 Women (1991–2011)

Objective: This study was carried out to determine factors involved in the etiology and propagation of vulvar vestibulitis syndrome. The study benchmarked elimination of vulvar pain and capability of engaging in pain-free intercourse as objective parameters for determining the effectiveness of nonsurgical versus surgical treatment. Study Design: This was a prospective evaluation of 502 women, all of whom participated in a structured medical regimen of treatment for vulvar vestibulitis syndrome for a minimum of 4 months, and 404 women who underwent surgery. Materials and Methods: Between 1991 and 2011, 559 women were diagnosed and treated for vulvar vestibulitis syndrome. Of these women, 502 were available for follow-up. Each woman was given a minimum of 4 months of conservative therapy. This program consisted of systemic medications for neuropathic pain, biofeedback by a specifically trained physical therapist, a low-oxalate diet, calcium citrate, abstention from intercourse for 6 weeks, and elimination of all topical agents. Each patient had a complete vaginal culture profile and a colposcopic examination of the vulva, vagina, and cervix (if present). After 4 months, those patients with no or marginal improvement were offered a surgical option of either vestibulectomy only or vestibulectomy and excision of the Bartholin glands. Results: Of the 502 women, 98 continued on the medical regimen and had low levels of pain or no pain with intercourse. The remaining 404 underwent vestibulectomy, with or without Bartholin-gland removal. Of the women undergoing surgery, 391 were able to have pain-free intercourse. Fifteen percent of women who had gland excision developed postoperative pudendal neuralgia. Five percent of women who underwent vestibulectomy only developed cysts secondary to Bartholin-gland secretion coupled with the absence of a duct. Conclusions: Vulvar vestibulitis is a problem affecting a substantial number of women numbering in the millions. The symptoms include pruritus, burning, and stinging pain limited to the vulvar vestibule. Nonsurgical therapy results in a small number of remissions and an even lower number of cures. Vulvar vestibulectomy coupled with excision of the paraurethral ducts and vaginal advancement lead to >90% elimination of pain. (J GYNECOL SURG 28:1)

Parallel Incisions Procedure for Penile Curvature—Short Term Outcomes

Objective: A modified corporotomy technique has been developed in order to overcome the problems of previous techniques such as tissue removal, urethral mobilisation, palpable knots, ‘dog ears’ and leakage on testing after repair. Our objective is to describe the technique and review the outcomes in the short term. Methods: The procedure involves two transverse parallel incisions at the bite points of Allis forceps used to correct curvature. The intervening tunica is buried, sealing the incision and preventing leakage. The incision is closed with 2–0 Polydioxanone sutures and a single 2–0 Polyglycolic to maintain knot burial. Data were collected retrospectively on all patients undergoing this technique from our department. Results: Thirty-two patients underwent daycase surgery. Mean duration of disease was 12.5 months. At three months the cosmetic result was excellent (straight) or good (&lt;20° bend) in 97%. Patient satisfaction was high with 87% being happy with the outcome and 88% able to have pain free intercourse. Complications of note included glans numbness in 1 patient and chronic granuloma related to suture placement requiring excision in 1 patient. Conclusions: The modified parallel incisions procedure is easy to perform and is efficacious in the short term with good cosmetic results and high patient satisfaction. Longer term follow-up is planned in a prospective fashion.

Prospective Follow‐Up of Female Sexual Function after Vaginal Surgery for Pelvic Organ Prolapse Using Transobturator Mesh Implants

Although the use of transobturator mesh implants for pelvic organ prolapse repair has been shown to be safe and effective, concern exists that the presence of prosthetic material in the vagina may adversely affect sexual function. To evaluate the impact of transobturator mesh implantation on sexual function using validated questionnaire. Female Sexual Function Index (FSFI), a validated 19-item questionnaire that assesses six domains of sexual function (desire, arousal, lubrication, orgasm, satisfaction, and pain), was used. The questionnaire was administered preoperatively, and at 3, 6, 12, and 24 months postoperatively. Clinical data were also recorded at each time point. Prospective nonrandomized study including 96 women with pelvic organ prolapse (cystocele, rectocele, vault prolapse). Transvaginal anterior or posterior wall repair using transobturator mesh implants with or without concomitant transobturator sling procedure. Mean age was 51.4 ± 5.2 years. Mean operating time was 47.6 ± 23.4 minutes, and the mean hospitalization period was 3.8 ± 1.6 days. After initial decrease during the first 3 months, patients experienced a steady improvement in their sexual function. At 24 months postoperatively, the total mean FSFI score reached significantly higher values compared to the baseline (P = 0.023). Furthermore, pain-free intercourse improved during the follow-up reaching mean score of 4.27 ± 0.79 (P < 0.05) after 2 years. Pelvic floor examination at 2 years follow-up showed excellent surgical results with only 3.1% of the patients presenting with stage II vaginal wall prolapse. Surgical repair of symptomatic pelvic organ prolapse using mesh implants results in improvement of major parameters of sexual function. A worsening in pain with intercourse during the initial months postoperatively lessens after 3 months as healing is completed.

Sexual function in women after surgery for pelvic organ prolapse

Our objective was to evaluate the effect of surgical repair of pelvic organ prolapse on female sexual function. Sixty seven women with pelvic organ prolapse were recruited in the study. Degree of pelvic organ prolapse was assessed using pelvic organ prolapse quantitation (POPQ) staging system. Female sexual function index (FSFI) questionnaire was used to assess sexual function of the cases preoperatively and 12-16 weeks after the operation. Mean age of the cases was 36.03 +/- 5.38 years. The total mean FSFI score increased from 15.9 +/- 10.7 to 21.9 +/- 11.1 (P < 0.05). Domain scores of desire, arousal, lubrication, orgasm, and satisfaction were increased significantly (P < 0.05). The mean score for the pain-free intercourse decreased significantly. Results demonstrated that sexual function was improved postoperatively. Using various instruments to assess female sexual function and differences in demographic and cultural characteristics of study groups might be the reasons of discrepancy between the reports.

Surrogate Versus Couple Therapy in Vaginismus

Women who do not have a cooperative partner cannot complete the usual therapeutic process in the treatment of vaginismus, because they cannot progress to the stage of practicing the insertion of the man partner's fingers and the insertion of a penis. To compare traditional couple therapy with therapy utilizing a surrogate partner. The study was controlled and retrospective. Data were obtained from the treatment charts of patients who had come to the clinic for treatment of vaginismus. Sixteen vaginismus patients who were treated with a man surrogate partner were compared with 16 vaginismus patients who were treated with their own partners. Successful pain-free intercourse upon completion of therapy. One hundred percent of the surrogate patients succeeded in penile-vaginal intercourse compared with 75% in the couples group (P = 0.1). All surrogate patients ended the therapy because it was fully successful, compared with 69% in the couples group. Twelve percent of the couples group ended the therapy because it failed, and 19% because the couples decided to separate. Treating vaginismus with a man surrogate partner was at least as effective as couple therapy. Surrogate therapy may be considered for vaginismus patients who have no cooperative partner.

Long-Term Coital Behaviour in Women Treated with Cognitive Behaviour Therapy for Superficial Coital Pain and Vaginismus

The purpose of the present study was to investigate long-term coital behaviour in women treated with cognitive behaviour therapy (CBT) for superficial coital pain and vaginismus. Data were taken from a questionnaire concerning long-term coital behaviour sent to 59 women who presented to Linköping University Hospital because of superficial coital pain, had been diagnosed with vaginismus, and had been treated with CBT. Data were also traced from therapy records: mean follow-up time was 39 months, the women had suffered for an average of almost 4 years, and required a mean of 14 treatment sessions. Forty-four of the 59 women returned the questionnaire, for a response rate of 74.6%. At follow-up, 81% of the treated women had had intercourse. A majority (61%) rated their ability to have intercourse without pain as 6 or higher (on a scale from 0–10), and 61% rated their ability to enjoy intercourse as 6 or higher (on a scale from 0–10). The proportion of women with positive treatment outcome at follow-up ranged from 81% (able to have intercourse) to 6% (able to have pain-free intercourse). An ability to have intercourse at end of therapy was maintained at follow-up. Two-thirds of the women reported high fulfilment of individual treatment goals. At follow-up, the women estimated a significantly higher self-worth as sex partners, and as women and human beings, than before treatment. Twelve per cent of the original sample had healed after a few assessment sessions and without treatment.

Patient satisfaction after the treatment of vulvovaginal erosive lichen planus with topical clobetasol and tacrolimus: a survey study

Objective The purpose of this study was to compare patient satisfaction with the topical immune system modulator tacrolimus to topical clobetasol during treatment for vulvovaginal erosive lichen planus. Study design Subjects who had been diagnosed with vulvovaginal erosive lichen planus between June 2000 and May 2001 received a mail survey regarding clinical satisfaction and response to treatment with clobetasol and tacrolimus. Satisfaction was assessed with a 100-mm visual analogue scale (very unsatisfied, 0; very satisfied, 100). Satisfaction was compared with the use of a paired t-test. Results Nineteen subjects met the inclusion criteria; 17 subjects (89%) returned completed surveys. Sixteen of the 17 women reported clobetasol therapy, and 11 of the 17 subjects acknowledged the use of tacrolimus therapy. All but 1 of the women who received tacrolimus had been treated previously with clobetasol therapy. All subjects reported experiencing sexual pain before their initial examination. After treatment with clobetasol, 2 of 16 women reported pain-free intercourse. Two additional women reported pain-free intercourse after switching to tacrolimus therapy. Ten subjects who had used both treatments rated tacrolimus therapy as significantly more satisfactory than clobetasol therapy (63 vs 38 mm; P = .03). Conclusion The use of topical tacrolimus improves satisfaction and may result in better clinical outcomes than therapy with clobetasol for the treatment of vulvovaginal erosive lichen planus.

Episiotomy closure comparing enbucrilate tissue adhesive with conventional sutures

Objectives: The purpose of the study was to evaluate the use of enbucrilate tissue adhesive compared with subcuticular polyglycolic acid sutures in episiotomy wound closure. Methods: In a prospective controlled trial, two groups were studied after undergoing an episiotomy skin wound repair using either enbucrilate tissue adhesive ( n=32) or a subcuticular polyglycolic acid suture ( n=30). The variables measured included pain scores during selected activities in the first 5 postnatal days, the time taken to become pain free after childbirth and the time taken to resume pain free sexual intercourse. Suitable patients were invited by the midwives to participate in the trial. If they gave consent to the trial, the gynecologist was contacted. If available, he would perform a repair using enbucrilate tissue adhesive. If he was not available, one of the midwives would perform a repair using subcuticular polyglycolic acid sutures. In this group, 90% of the women were recruited and sutured by one midwife. Results: Patients treated with enbucrilate were found to have significantly less postnatal pain while walking, became pain free in a shorter period (mean=25 days vs. 18 days; P<0.01) and were able to resume pain-free intercourse sooner (mean=34 days vs. 52 days; P<0.001). Conclusions: Tissue adhesives incorporate the qualities of an ideal skin-closure material. The results demonstrate their advantage over the current standard suture-based methods of repair in the perineum. The use of adhesives merits further evaluation.

The Ipswich childbirth study: one year follow up of alternative methods used in perineal repair

Objective To assess the long term implications of four alternative approaches to postpartum perineal repair. Design A stratified randomised controlled trial using a 2x2 factorial design. Setting Original recruitment at the Maternity Unit at Ipswich Hospital NHS Trust, a district general hospital, between 1992 and 1994. Sample Seven hundred and ninety three women who had participated in the Ipswich Childbirth Study – a trial among women who had required repair of episiotomy or first or second degree tears – at least one year previously. Methods Self-completed postal follow up at least one year after recruitment to trial comparing 1. two-stage repair leaving the skin unsutured with standard three-stage repair, and 2. polyglactin 910 with chromic catgut as suture material for the repair. Main outcome measures Failure to resume pain-free intercourse; persistent perineal pain; perineum feeling different; resuturing; time to resume pain-free intercourse; and dyspareunia. Results Fewer women allocated two-stage repair reported that the perineum felt different (30% versus 40%; RR 0.75; 95% CI 0.61 to 0.91; 2 P<0.01); otherwise there were no clear differences between the two methods. Women allocated polyglactin 910 were less likely to have dyspareunia (8% versus 13%; RR 0.59, 95% CI 0.39 to 0.91; 2 P= 0.02) and less likely to fail to resume pain-free intercourse (8% versus 14%; RR 0.57, 95% CI 0.38 to 0.87; 2 P<0.01). Conclusion Two-stage repair of perineal trauma leaving the skin unsutured appears to reduce the likelihood of the perineum feeling different from before delivery, in addition to less pain and dyspareunia initially; there were no apparent disadvantages. Polyglactin 910 reduces dyspareunia long term, indicating that the short term benefits of this material over chromic catgut persist.

The Ipswich Childbirth Study

Objective To evaluate a policy of two stage postpartum perineal repair leaving the skin unsutured. Design A stratified randomised controlled trial using a 2 × 2 factorial design. Setting The maternity unit at Ipswich Hospital NHS Trust, a district general hospital, between 1992 and 1994. Sample 1780 women requiring surgical repair of episiotomy or first or second degree tear following a spontaneous or simple instrumental delivery. Methods A policy of two-stage perineal repair leaving skin unsutured was compared with a policy of three stage repair including skin closure with interrupted or subcuticular sutures. Both groups were assessed by a research midwife, blind to the allocation, completing questionnaires at 24 to 48 hours and 10 days postpartum, and by self-completed questionnaires at three months after birth. Main outcome measures 1. 24 to 48 hours postpartum: perineal pain; healing; 2. 10 days postpartum: perineal pain, healing and removal of sutures; 3. three months postpartum: perineal pain, removal of sutures, resuturing, dyspareunia, and failure to resume pain-free intercourse. Results Completed questionnaires were returned for 99% of women at both 24 to 48 hours and ten days and by 93% of women three months postpartum. No differences were detected in perineal pain at 24 to 48 hours (62%vs 64%; RR 0.96, 95% CI 0.90–1.03; 2P = 0.3) and 10 days (25%vs 28%; RR 0.90,95% CI 0.77–1.06; 2P = 0.2). Significantly fewer women allocated to two-stage repair reported tight stitches at ten days (14%vs 18%; RR 0.77, 95% CI 0.62–0.96, 2P = 0.02); similar numbers of repairs were judged to be breaking down (five compared with seven women). At three months postpartum fewer women allocated to the two-stage repair reported perineal pain and more had resumed pain-free intercourse. Amongst women who had resumed intercourse there was a significant difference in dyspareunia (15%vs 19%; RR 0.80, 95% CI 0.65–0.99; 2P = 0.04). Significantly fewer women in the two-stage repair group (7%vs12%; RR 0.61, 95% CI 0.45–0.83; 2P = < 0.01) reported removal of suture material. Four women in the two-stage repair group had required resuturing, compared with nine allocated to the three-stage repair. Conclusions Two-stage repair of perineal trauma leaving the skin unsutured appears to reduce pain and dyspareunia three months postpartum. There are no apparent disadvantages, in particular no evidence of an increased risk of breakdown of the repair and resuturing.

Urinary Oxalate Excretion and its Role in Vulvar Pain Syndrome

Abstract Objective: This study was undertaken to determine the urinary oxalate excretion patterns in patients with vulvodynia compared with controls and to evaluate antioxalate therapy in women with vulvar pain syndrome (vulvodynia). Study design: A total of 130 consecutive patients with vulvar pain syndrome and 23 volunteers without symptoms collected urine specimens for 24 hours; each voiding was saved in individual labeled containers and refrigerated. The specimens were analyzed individually for oxalate and calculated according to 24-hour concentration, volume, and peak oxalate by hour. A total of 59 patients were treated with low-oxalate diets and calcium citrate for 3 months and evaluated for objective relief of vulvar pain. Results: The 24-hour excretion of oxalate was almost identical in controls and vulvodynia patients. The total 24-hour excretion was directly proportional to the volume of urine excreted ( p p 1 mg/40 dl) were treated with an antioxalate regimen. Fourteen (24%) demonstrated an objective response, but only 6 (10%) could have pain-free sexual intercourse. Conclusions: Urinary oxalates may be nonspecific irritants that aggravate vulvodynia; however, the role of oxalates as instigators is doubtful.

The Ipswich Childbirth Study: 1. A randomised evaluation of two stage postpartum perineal repair leaving the skin unsutured

To evaluate a policy of two stage postpartum perineal repair leaving the skin unsutured. A stratified randomised controlled trial using a 2 x 2 factorial design. The maternity unit at Ipswich Hospital NHS Trust, a district general hospital, between 1992 and 1994. 1780 women requiring surgical repair of episiotomy or first or second degree tear following a spontaneous or simple instrumental delivery. A policy of two-stage perineal repair leaving skin unsutured was compared with a policy of three stage repair including skin closure with interrupted or subcuticular sutures. Both groups were assessed by a research midwife, blind to the allocation, completing questionnaires at 24 to 48 hours and 10 days postpartum, and by self-completed questionnaires at three months after birth. 1. 24 to 48 hours postpartum: perineal pain; healing; 2. 10 days postpartum: perineal pain, healing and removal of sutures; 3. three months postpartum: perineal pain, removal of sutures, resuturing, dyspareunia, and failure to resume pain-free intercourse. Completed questionnaires were returned for 99% of women at both 24 to 48 hours and ten days and by 93% of women three months postpartum. No differences were detected in perineal pain at 24 to 48 hours (62% vs 64%; RR 0.96, 95% CI 0.90-1.03; 2P = 0.3) and 10 days (25% vs 28%; RR 0.90, 95% CI 0.77-1.06; 2P = 0.2). Significantly fewer women allocated to two-stage repair reported tight stitches at ten days (14% vs 18%; RR 0.77, 95% CI 0.62-0.96, 2P = 0.02); similar numbers of repairs were judged to be breaking down (five compared with seven women). At three months postpartum fewer women allocated to the two-stage repair reported perineal pain and more had resumed pain-free intercourse. Amongst women who had resumed intercourse there was a significant difference in dyspareunia (15% vs 19%; RR 0.80, 95% CI 0.65-0.99; 2P = 0.04). Significantly fewer women in the two-stage repair group (7% vs 12%; RR 0.61, 95% CI 0.45-0.83; 2P = < 0.01) reported removal of suture material. Four women in the two-stage repair group had required resuturing, compared with nine allocated to the three-stage repair. Two-stage repair of perineal trauma leaving the skin unsutured appears to reduce pain and dyspareunia three months postpartum. There are no apparent disadvantages, in particular no evidence of an increased risk of breakdown of the repair and resuturing.