Sexual Dysfunction: Beyond the Brain-Body Connection

R. Balon

• Publisher: S. Karger
• Year: 2011
• ISBN:
  9783805598255
• Topic: Medicine
• Subtopic: Psychiatry & Mental Health

During the last years human sexuality has been the focus of interest and study by various disciplines. In this volume a multidisciplinary team of international experts discuss contemporary issues of human sexuality from updates on diagnosis to the management of various sexual dysfunctions. Reviews of the management of several female sexual dysfunctions, the impact of cancer on sexual functioning, the impact of trauma on sexual desire and function as well as the newest trends in sex therapy; androgen deprivation treatment of sexual behavior and autogynephilia are discussed in detail. Further, the complex interplay between the field of human sexuality and the Internet, psychological and cultural aspects of infertility are reviewed. A large amount of clinical material on topics rarely covered in other volumes will prove invaluable reading to clinicians from various disciplines such as psychiatry, psychology, urology, gynecology, sexology and sex therapy.

Balon R (ed): Sexual Dysfunction: Beyond the Brain-Body Connection.
Adv Psychosom Med. Basel, Karger, 2011, vol 31, pp 83–104

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Management of Female Sexual Pain Disorders

Stéphanie C. Boyer ^a· Corrie Goldfinger ^a· Stéphanie Thibault-Gagnon ^b· Caroline F. Pukall ^a

^aDepartment of Psychology,^bSchool of Rehabilitation Therapy, Queen’s University, Kingston, Ont., Canada

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Abstract

Our understanding of the sexual pain disorders vaginismus and dyspareunia has been fundamentally altered over the past two decades due to increased attention and empirically sound research in this domain. This increased knowledge base has included a shift from a dualistic view of the etiology of painful and/or difficult vaginal penetration being due to either psychological or physiological causes, to a multifactorial perspective. The present chapter reviews current classification and prevalence rates, including ongoing definitional debates. Research regarding the etiology, assessment and management of sexual pain disorders is discussed from a biopsychosocial perspective. Cyclical theories of the development and maintenance of sexual pain disorders, which highlight the complex interplay among physiological, psychological and social factors, are described. Medical/surgical treatment options, pelvic floor rehabilitation and psychological approaches are reviewed, as well as future directions in treatment research.

Copyright © 2011 S. Karger AG, Basel

Pain during sexual activity has been described for thousands of years, long before the terminology for the sexual pain disorders dyspareunia and vaginismus was coined in the 1800s [1, 2]. Since the 1990s, there has been an astronomical increase in research examining these conditions and their treatment. A sizeable portion of recent research has focused on provoked vestibulodynia (PVD; formerly termed ‘vulvar vestibulitis syndrome’), a prevalent vulvar pain condition causing painful vaginal penetration. One of the major advances in our understanding of dyspareunia and vaginismus has been the shift from a dualistic to a multifactorial conceptualization of these conditions. Research has demonstrated that the symptoms experienced by women with dyspareunia and vaginismus are not purely psychological or physiological in origin, but rather represent a complex interplay among physiological, psychological and social factors; the present chapter conveys information about sexual pain disorders from this biopsychosocial perspective. Current definitions, classification and estimated prevalence rates are reviewed. Research on factors involved in the development and maintenance of these conditions are presented, as well as current assessment and treatment approaches.

Definitions, Classification and Prevalence

Dyspareunia and vaginismus are classified as mutually exclusive sexual dysfunctions in the current edition of the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision (DSM-IV-TR) [3]. The International Statistical Classification of Diseases and Related Health Problems (ICD-10) also classifies them as sexual dysfunctions in addition to including them under the category of pain and other conditions associated with female genital organs and the menstrual cycle [4]. Both classification systems distinguish sexual pain disorders due to physiological versus psychological causes, in line with the traditional dualistic view of these conditions. The DSM-IV-TR includes specifiers for each diagnosis relating to the onset (lifelong vs. acquired) and breadth of situations in which symptoms occur (generalized vs. situational) [3].

Dyspareunia

In the DSM-IV-TR, dyspareunia is described as ‘recurrent or persistent genital pain associated with sexual intercourse’ causing significant distress and/or interpersonal difficulties [3, p. 556]. The location of the pain is typically categorized as superficial (i.e. vulvar region) and/or deep (i.e. pelvic/abdominal region). Table 1 provides a list of conditions associated with experiencing dyspareunia, based on pain location. One of the most common causes of superficial dyspareunia in premenopausal women is PVD, a subtype of vulvodynia [5, 6].

Vulvodynia is defined as vulvar pain or discomfort which occurs in the absence of relevant physical findings (e.g. infection) [6]. The International Society for the Study of Vulvovaginal Disease classifies vulvodynia based on the location (localized, generalized) and temporal pattern (provoked, unprovoked, mixed) of the pain [6]. The pain may be confined to a specific area of the vulva or experienced throughout the vulvar region. The pain may be provoked (i.e. the pain is triggered by contact with the affected region) or unprovoked (i.e. the pain occurs spontaneously in the absence of a specific trigger) or have a mixture of both characteristics. Women with PVD experience provoked pain at the vulvar vestibule (i.e. the mucosal tissue surrounding the vaginal and urethral openings). The most commonly reported symptom by women with PVD is dyspareunia; however, the pain also typically occurs in other sexual (e.g. finger insertion) and nonsexual contexts (e.g. tampon insertion, gynecological examinations) [7], a pattern which has also been found in women with non-PVD-related dyspareunia [8]. There are no specific duration criteria for a diagnosis of dyspareunia or vulvodynia, but a minimum of 3–6 months is typically suggested [7, 9].

Table 1. Conditions associated with dyspareunia

Superficial

• Allergic reaction (e.g. to semen) • Congenital anomalies (e.g. imperforate hymen, vaginal septum)^* • Dermatological conditions (e.g. lichen sclerosus and lichen planus of the genitals) • Fistulas^* • Gynecological cancer (e.g. vulvar cancer, treatment via intravaginal radiation)^* • Inadequate lubrication (e.g. arousal difficulties, estrogen deficiency)^* • Interstitial cystitis^* • Mechanical or chemical irritation • Pelvic organ prolapse^* • Physical trauma^* • Pudendal neuralgia^* • Sexually transmitted infections (e.g. genital herpes, human papillomavirus) • Vaginal atrophy^* • Vaginal infections (e.g. yeast infection, bacterial vaginosis) • Vulvodynia

Deep

• Chronic pelvic pain • Crohn’s disease • Endometriosis • Hemorrhoids • Irritable bowel syndrome • Neuropathies (e.g. nerve entrapment) • Pelvic floor muscle dysfunction • Sexually transmitted infections (e.g. pelvic inflammatory disease) • Vaginitis

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^*These conditions may also be associated with deep dyspareunia.

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Vaginismus

The main criterion for vaginismus in the DSM-IV-TR is the presence of involuntary vaginal muscle spasms that interfere with sexual intercourse [3]. The focal role of vaginal muscle spasms in vaginismus has remained unchanged since Sims [2] first described and named this condition in 1861. Empirical research has not, however, supported a spasm-based definition of vaginismus. In a seminal research study, Reissing et al. [10] found low rates of diagnostic agreement for this condition based on the presence of vaginal muscle spasm during a gynecological examination. In addition, less than one quarter of the women in the study meeting a set of behavioral criteria for vaginismus reported experiencing vaginal muscle spasms during sexual intercourse attempts. Another criticism of the current DSM definition is that pain and fear of vaginal penetration are not explicitly included, despite the role of these factors in vaginismus as suggested by research and clinical opinion [11]. Based on issues with the current definition of this disorder, an international expert committee proposed reconceptualizing vaginismus as ‘persistent difficulties to allow vaginal entry of a penis, a finger, and/or any object, despite the woman's expressed wish to do so. There is variable involuntary pelvic muscle contraction, (phobic) avoidance and anticipation/fear/experience of pain’ [12, p. 226].

Differentiating between Vaginismus and Dyspareunia: DSM-5

Perhaps the most pressing concern for those in the field is whether dyspareunia and vaginismus are truly mutually exclusive diagnostic entities. Empirical findings and clinical reports suggest that there is a great deal of overlap between the two diagnoses, particularly superficial dyspareunia and vaginismus [10, 13–15]. Indeed, women with PVD and vaginismus do not differ with regard to pain reports [10, 14], and health professionals cannot reliably differentiate between women with superficial ...