SEXUALITY MATTERS

Clinical Update: Dyspareunia in Women

Susan Kellogg-Spadt, PhD, CRNP; Jennifer Fariello, MSN, CRNP; Pegah Safaeian, MS
may be completely unable to engage in sexual intercourse or any form of penetrative activity. Penetrative dyspareunia differs from less common deep (thrusting) dyspareunia. The latter is more often associated with upper pelvic disorders such as endometriosis, pelvic inammatory disease, interstitial cystitis, and irritable bowel syndrome. These patients may state that their pain is positional or limits the length or rigorousness of intercourse.

Breakthroughs in the understanding of neural stimulation and inammation are leading to new treatments for disorders that have long been a source of frustration and shame.

FOCUSPOINT

The most common form of dyspareunia is penetrative, which may prevent any sexual intercourse and is often a result of localized vulvar dysthesia.

n estimated 6 million women in the United States experience dyspareuniacomprising 16% of women aged 18 to 64 years.1 For these women, sexual activity results in burning pain that can alter a womans sense of sexual competency and identity. A myriad of relationship-affecting sexual sequelae can ensue, including hypoactive sexual desire, sexual aversion, arousal disorder, and performance anxiety. The most common form of female sexual pain is penetrative (supercial) dyspareunia. It is often the result of localized vulvar dysesthesia (LVD), also referred to as vulvar vestibulitis syndrome (VVS) or vestibulodynia. Patients

LOCAL DYSESTHESIA
Vulvar vestibulitis syndrome is characterized by focal erythema with generalized rawness and discomfort. Common signs are a clinical history of at least 3 to 6 months of allodynia in the vulvar vestibule and erythema and sensitivity at the inferior introital sulcus, medial to Harts line. Erythema and sensitivity may or may not extend upward to the ostia of Skenes glands and/or anterior fourchette. While usually prominent during sexual activity, VVS symptoms may also occur with constrictive clothing, insertion of a tampon, or a pelvic examination.

Susan Kellogg-Spadt, PhD, CRNP, is Co-Director, Pelvic and Sexual Health Institute, Philadelphia, PA; Assistant Professor, Department of Obstetrics and Gynecology, Robert Wood Johnson Medical School, New Brunswick, NJ; and Associate Professor of Human Sexuality, Widener University, Wilmington, DE. Jennifer Fariello, MSN, CRNP, is Womens Health Nurse Practitioner, Pelvic and Sexual Health Institute; an Adjunct Clinical Faculty Member, School of Nursing, University of Pennsylvania, Philadelphia, PA; and a doctoral candidate in Human Sexuality, Widener University. Pegah Safaeian, MS, is an Adjunct Faculty Member, Department of Internal Medicine, Drexel University, Philadelphia, PA.

CHANGING TERMINOLOGY
Historically, the term vulvodynia has been used to describe any type of chronic vulvar pain, regardless of distribution. It is now recognized that dysesthetic pain can exist in a localized area (consistent with VVS) or a generalized area (consistent with central sensitization/dysesthetic vulvodynia with or without pudendal neuropathy). These subtypes and diagnostic classications are neither completely standardized nor

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evidence-based. One solution proposes using the terms generalized vulvar dysesthesia (GVD) and LVD, and employing a pain map during the diagnostic work-up.2 Women with localized dysesthesia can have either primary or secondary onset. The primary subgroup reports pain with rst intercourse or other penetrative act, whereas the secondary subgroup experiences pain only after at least 6 months of pain-free penetration.2

ETIOLOGY
The etiology of LVD/VVS is unknown. Sentinel events may include vaginal or urinary tract infections, viral exposure, prolonged antibiotic use, or a history of local chemical, mechanical, or allergic trauma. Women with LVD/VVS may be homozygous for allele 2 of the IL-1RA gene (IL1RN*2), a phenotype that is associated with ulcerative colitis, Crohns disease, and systemic lupus erythematosus. People with this phenotype have more prolonged and severe proinammatory responses than those with other IL-1RA genotypes. Alternatively, neurogenic inammation of the vulvar vestibule may occur in response to noxious environmental stimuli, resulting in parasympathetic efferent and visceral nociceptive afferent hyperactivity. In response, the body releases antidromic substance P and calcitonin gene-related peptide, with nitric oxide processing occurring in the areas surrounding introital glandular ostia. Women with LVD/VVS may also have increased vestibular neural ber proliferation, suggesting a higher number of vulvar nociceptors and greater neuronal ring. A study examined abnormalities in three independent systems in women with LVD/VVS: the vestibular mucosa, the CNS pain regulation pathways, and the pelvic oor muscles. After initial mucosal inflammation, immunohistochemical assays indicated more proinammatory substances and fewer anti-inammatory substances in the vulvar vestibule.3 Chronic inammation is thought to result in proliferation of neuronal C-bers,

reducing the sensory threshold. Thus, even a light touch can trigger the release of additional inammatory cytokines and neuropeptides. Prolonged inammation may result in central sensitization, rendering patients hypersensitive to painful stimuli in areas other than the genitals. Candidal infection is a common risk factor for local dysesthetic symptoms. A relationship may also exist between chronic pain and melanocytestimulating hormone. Women with LVD/VVS are three times more likely than controls to have a genetic variant of MC1-R.4 Alteration of this gene appears to result in a loss of anti-inammatory, antinociceptive, and Candida-inhibitory capa- FOCUSPOINT bilities, as well as higher concentrations of proinammatory, The diagnosis of nociceptor-sensitizing cytokines.4

DIAGNOSIS

The competent care of women with dyspareunia begins with accurate and timely diagnosis. Conducting a simple physical examination that includes the touch test can quickly identify a local dysesthetic pattern. To perform this test, the clinician uses a saline-moistened swab to rmly touch areas on the labia majora, interlabial sulci, and lateral labia minora. A comparison is made between the womans response to these stimuli and to swabs applied to the ostia of Skenes glands and the major and minor vestibular glands. A woman with LVD/VVS will report little or no pain when structures such as the labia majora or perineum are touched, but will demonstrate painful sensitivity when the gland openings are touched. If the diagnosis is in doubt, the touch test should be repeated after placing 5% lidocaine gel in the vestibule. If a previously positive touch test fails to produce pain after lidocaine application, a diagnosis of LVD/VVS is probable. The patient can view the vestibule with a mirror during the examination to help her understand the organic (as opposed to psychological) nature of her condition.

vulvar vestibulitis is likely when a cotton swab applied to the ostia of the minor/ major vestibular glands elicits pain.

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Dyspareunia in Women

TREATMENT
Pharmacotherapy
Although no single treatment can cure LVD/VVS, low-dose tricyclic antidepressants (eg, amitriptyline, nortriptyline, desipramine) are often used to help manage symptoms. These medications are commonly prescribed in much lower dosages than those used for antidepressant purposes (eg, 10 to 25 mg/d).5,6 Selective serotonin reuptake FOCUSPOINT inhibitors, serotonin-norepinephrine reuptake inhibitors, and antiTreatment includes convulsants have also been used to treat sexual pain. In one study, therapy with a variety gabapentin was started at ~300 of medications, physical mg/d and titrated to 900 mg/d over therapy, biofeedback, 3 weeks. About 64% of patients and psychotherapy. reported a decrease in symptoms over 30 months, and the most comVulvar vestibulectomy mon side effect was fatigue (10%).6 is a possibility and Newer treatment options that botulinum toxin is have been compared with placebo being investigated. and produced favorable results in limited study populations include daily application of 4% cromolyn cream, 5% lidocaine gel, or 0.2% atropine cream.7 Compounded creams and ointments using hypoallergenic bases such as acid mantle or petrolatum jelly decrease the incidence of irritant dermatitis secondary to base additives, and are generally best tolerated.4,5 Capsaicin cream activates A- sensory neurons and unmyelinated C-bers, facilitating depolarization of afferent neurons. When used on painful, erythematous areas of the vestibule, it can desensitize tissue through degeneration of C-ber afferent neurons and depletion of neuropeptides. In a retrospective study of 54 women with LVD/VVS who topically applied compounded 0.025% capsaicin cream to vestibular ostia for 20 min/d over 12 weeks, 95% of patients were able to have pain-free (or mildly uncomfortable) vaginal intercourse and reported more frequent sexual activity.8

Nonpharmacologic Therapy
Physical Therapy. Treatment for pelvic oor hypertonus (also termed pelvic oor

dysfunction) may decrease the dyspareunia associated with LVD/VVS and other types of genital dysesthesia. Whether pelvic oor dysfunction is secondary to LVD/VVS or is the primary disorder is unknown. The pelvic oor muscle group has supportive, sphincteric, and sexual functions, and pelvic oor dysfunction may cause disturbances in one or all of them. Musculoskeletal dysfunction, muscle pain, and overactivity of the levator ani are potential causes of dyspareunia. Thus, women with dyspareunia and LVD/VVS may benet from physical therapy to reduce pelvic oor overactivity. Physical therapy for dyspreunia focuses on muscle stretching, core strengthening, and stabilization exercises for the outer pelvic oor muscles. Direct massage can be used to release internal pelvic oor muscle trigger points formed due to the deposition of brous tissue (crosslinks). These crosslinks are a natural response to soft tissue strain or injury. In the fascia, they distort the anatomy and cause decreased mobility and function. Manual massage can restore function by gently breaking down the crosslinks, decreasing hypertonus, and allowing the muscle to move more freely. In a small number of studies examining the use of direct pelvic oor muscle massage in conjunction with pelvic stabilization for the treatment of LVD/VVS, there was marked improvement in symptoms after a prescribed course of manual external and transvaginal physical therapy.9-12 Biofeedback is a useful tool for teaching pelvic oor muscle self-awareness.10,11,13 It can be an effective treatment for sexual pain because the supercial and deep pelvic oor muscles are under voluntary control. Biofeedback is used to help normalize pelvic oor tone by relaxing hypertonic muscles and improving muscle stability during rest and contraction.10 Electromyography may be used to measure the activity of the muscles and provide visual and auditory feedback about the patients ability to relax and contract her muscles.10,14

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A randomized, controlled trial followed women with dyspareunia who received electromyography biofeedback or topical lidocaine for 4 months. Pretreatment and posttreatment questionnaires documented signicant improvement in vestibular pain and pressure at 12 months, as well as improvement in sexual functioning and psychological adjustment. The researchers observed no differences between the two groups and no severe side effects, FOCUSPOINT favoring a combination of the two treatments for women with sexual pain.15 For many women with LVD/ A combination of VVS, a home program of internal medical and psychoself-massage and biofeedback can reduce the recurrence of sexual approaches trigger-point formation and produces the most maintain sexual function.9 A favorable outcomes progressive dilator insertion for dyspareunia. program can help to maintain sexual function, and can be an important adjuvant to biofeedback. In-ofce demonstration allows observation of the patients response to dilation, and provides an opportunity to discuss sexual positions. At home, women can progressively increase the size of the dilator until comfortable penetration can be accomplished.15,16 Botulinum Toxin.The injection of botulinum toxin A into pelvic oor muscle is also being explored as a possible treatment for LVD/VVS.17 When injected intramuscularly at therapeutic doses, the toxin produces a localized, partial, reversible chemical denervation of the muscle that results in muscle weakness or paralysis. In a hypertonic pelvic oor, such relaxation can decrease pain, pressure, and dyspareunia. Researchers administered botulinum toxin A to 7 women with vulvar pain who had not responded to conventional pain management.18,19 Results suggested a decreased pain rating, with no side effects. Psychotherapy. Other nonpharmacologic approaches to sexual pain have focused on sex therapy and pain man-

agement techniques, including cognitive behavioral therapy (CBT). One study showed that CBT in women with LVD/ VVS resulted in improved sexual functioning, pain control, and vaginal muscle control.13 Surgery.Patients who do not experience symptom improvement with nonsurgical therapies may pursue excisional treatment. In severe or recalcitrant cases, surgical intervention for supercial dyspareunia can be a viable option with high rates of success. 20 The surgical approach to localized dysesthesia is grouped into three categories: local excision, total vestibulectomy, and perineoplasty. Possible complications of surgery for LVD/VVS include: blood loss, infection, granulation tissue, ssuring, cyst formation, vulvar adhesions, hematoma, poorly approximated incision lines, decreased lubrication, and continued pain.19 In a study of 134 patients 5 years after vulvar vestibulectomy, approximately 90% expressed satisfaction with their outcomes. The remaining 10% reported persistently worsening symptoms or recurrence of symptoms, and 11% were still unable to engage in sexual activity after surgery.20

CONCLUSION
Research suggests that outcomes are more favorable for LVD/VVS when medical and psychosexual approaches are combined.9 Until a de nitive cure is identied, the provision of supportive care and knowledgeable referrals will assist women as they face the dilemma of managing the chronicity and complexity of dyspareunia.

Resources for Patients and Clinicians

National Vulvodynia Association www.nva.org International Pelvic Pain Society www.pelvicpain.org

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REFERENCES
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