Sexological aspects of genital pain

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1 Sexological aspects of genital pain Annamaria Giraldi, professor, MD, PHD Sexological Clinic, Psychiatric Centre Copenhagen 1

2 Disclosures Speaker: Eli Lilly, Pfizer Consultant: Eli Lilly,Palatin 2

3 Agenda How do we define sexual pain? Presentation of sexual problems in women with genital pain Coping strategies and reaction patterns in women with genital pain Treatment aspects of sexual pain 3

4 Sexual Medicine Definitions Dyspareunia: Persistent or recurrent pain with attempted or complete vaginal entry and/or penile vaginal intercourse. Can be superficial or deep Vaginism: Persistent or recurrent difficulties to allow vaginal entry or a penis/finger/any object despite her expressed wish to do so Both can be generalised or situational, lifelong or acquired 4 Fugl-Meyer et al. 3rd International consultation on sexual dysfunctions, 2010

1. Region Hovedstadens Psykiatri 2015 ISSVD, ISSWSH and IPPS consensus terminology and classification of persistent vulvar pain and vulvodynia Bornstein J et al. J.Sex.Med.

5 1. Region Hovedstadens Psykiatri 2015 ISSVD, ISSWSH and IPPS consensus terminology and classification of persistent vulvar pain and vulvodynia Bornstein J et al. J.Sex.Med.2016:13; ISSVD: International Society for the Study of Vulvovaginal Disease ISSWSH: International Society for the Study of Women s Sexual Health IPPS: International Pelvic Pain Society 5

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7 Genital pain a sexual dysfunction? Psychosocial conditions Medical condition Genital pain syndromes Pelvic pain, IBS, IC Vulvar pain Vestibular pain/tenderness, erythema of the vestibule, Caused by a specific cause Vulvodynia Chronic discomfort in the vulva Vaginism Difficulties to allow vaginal entry despite her expressed wish to do so Dyspareunia Pain related to sex 7

8 What definitions shall we use? Is dyspareunia a sexual dysfunction or rather a pain syndrom? Are dyspareunia and vaginismus the same, different or overlapping conditions? Does it make sense to divide defintions into the somatic and psychiatric diagnostic systems? Do we miss important information if we categorize sexual pain 8

9 DSM 5 definition Genito-Pelvic Pain/Penetration Disorder A. Persistent or recurrent difficulties for at least 6 months with one or more of the following: Inability to have vaginal intercourse/penetration Marked vulvovaginal or pelvic pain during vaginal intercourse/penetration attempts Marked fear or anxiety either about vulvovaginal or pelvic pain or vaginal penetration Marked tensing or tightening of the pelvic floor muscles during attempted vaginal penetration 9

10 DSM 5 The problem causes clinically significant distress or impairment The sexual dysfunction is not better accounted for by another Axis I disorder (except another Sexual Dysfunction) and is not due to the effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition Subtypes: Early-Onset (Lifelong) vs Late-Onset (Acquired) Generalized vs. Situational 10

11 Specifiers With concomitant problems in sexual interest/sexual arousal Partner factors (partner's sexual problems, partner's health status) Relationship factors (e.g., poor communication, relationship discord, discrepancies in desire for sexual activity) Individual vulnerability factors or psychiatric comorbidity (e.g., depression or anxiety, poor body image, history of abuse experience) Cultural/religious factors (e.g., inhibitions related to prohibitions against sexual activity) With medical factors relevant to prognosis, course, or treatment 11

12 ICD-11: Dyspareunia (GA12) In: Diseases of female genital system, Noninflammatory disorders of the female genital tract Description: A symptom of the genital system affecting females, caused by physical determinants. This symptom is characterized by recurrent genital pain or discomfort that occurs before, during, or after sexual intercourse, or superficial or deep vaginal penetration that is related to an identifiable physical cause, not including lack of lubrication. Confirmation is by medical assessment of physical causes. Exclusion: Sexual pain-penetration disorder (HA20) 12

13 ICD-11: Sexual pain-penetration disorders (H) Sexual pain-penetration disorder is characterized by at least one of the following: Marked and persistent or recurrent difficulties with penetration, including due to involuntary tightening or tautness of the pelvic floor muscles during attempted penetration; Marked and persistent or recurrent vulvovaginal or pelvic pain during penetration Marked and persistent or recurrent fear or anxiety about vulvovaginal or pelvic pain in anticipation of, during, or as a result of penetration. 13

14 ICD-11: Sexual pain-penetration disorders (H) The symptoms are recurrent during sexual interactions involving or potentially involving penetration, despite adequate sexual desire and stimulation Are not entirely attributable to a medical condition that adversely affects the pelvic area and results in genital and/or penetrative pain or to a mental disorder Are not entirely attributable to insufficient vaginal lubrication or postmenopausal/ age-related changes And are associated with clinically significant distress. Exclusions: Dyspareunia, pain related to vulva, vagina or pelvic floor 14

15 ICD-11: Sexual pain-penetration disorders (H) Lifelong: generalised (HA 20.0) or situational (HA 20.1) Acquired: generalised (HA 20.2) or situational (HA 20.3) These may be associated with aetiological considerations 15

16 Aetiological considerations in sexual dysfunctions and sexual pain disorders Associated with a medical condition, injury, or the effects of surgery or radiation treatment Associated with psychological or behavioural factors, including mental disorders Associated with use of psychoactive substance or medication Associated with lack of knowledge or experience Associated with relationship factors Associated with cultural factors Other specified aetiological considerations in sexual dysfunctions and sexual pain disorders 16

17 Prevalence, sexual genital pain/vaginismus Vaginismus in 1 6% of women Genital pain and dyspareunia in 1-27 % of women. If including milder symptoms a 2-3 fold increase Variation within age, culture and countries McCabe et al. J.Sex.Med. 2016:13;

Sexual Genital Pain Introital pain (affecting the vulva, vestibule, hymen, pelvis muscles) Deeper pain (affecting reproductive organs and deep muscles of the pelvis) Combination of

18 Sexual Genital Pain Introital pain (affecting the vulva, vestibule, hymen, pelvis muscles) Deeper pain (affecting reproductive organs and deep muscles of the pelvis) Combination of superficial and deeper pain Damsted Petersen, 2010 Nicolosi et al.urology 2004:64; Sexual behaviors and sexual dysfunctions after age 40: The global study of sexual attitudes and behaviors

19 Sexual pain and other sexual problems A study of 132 women with PVD: 88% penetration occacionally, not possible due to pain 77% had problems with sexual interest 74% problems with sexual arousal 53% problems with orgasm 65% lack of enjoyment of sexual activity 38% avoided all types of intimacy Brotto et al. J.Sexual Med. 2015:12;

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23 Sexual coping strategies Avoidance: Avoids sexual activity to reduce pain. Effective in short term, but maintain and excaberate pain and anxiety, decrease sexual function in the long term Endurance: Endure pain and keep having sex. Motivation can be different: The goal is emotional intimacy, to pleasure the partner, to be normal, to avoid anger, feeling of guilt, fear of loosing relationship. = avoiding negative outcomes and therefore also an avoiding strategy. Maintains the pain. Dewitte M et al. Pain 2011:152; , Engman L. et al. Eur.J.Pain.2018:22;

24 Fear-avoidance model of pain Women with pain have a higher level of: Anxiety Pain catastrophizing thougths Fear avoidance Lack of desire Thomten & Karlsson. Psychological factors in genital pain, Catastrophizing and anxiety sensitivity among women living In Sweden. Scand.J.Pain. 2014:5; Thomten 24

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26 Basson R. JSM 2012;9:

27 Basson R. JSM 2012;9:

28 Etiology vulvodynia Vulvodynia/sexual pain High Psychological distress High state of Pain amplification Physical/ anatomical factors Anxiety Depression Stress response Somatization Sexual factors Peripheral sensitization Central Sensitization Peripheral allodynia Inflammatory response Christina D. Petersen: Modified after Zolnoum et al. Obstet & Gynaecol Survey 2006 Pelvic muscles Prior Chronic infection Prior Inflammation Trauma Genetic factors Hormonal factors 28

29 Interpersonal Social/cultural Intrapersonal Sexual Genital Pain Biological Predisposing Precipitating Maintaining 29

30 Case history including Pain mapping & pain scale Provoked vs unprovoked Occurrence of extra-genital pain Coping with pain Occurrence of sexual dysfunctions; own & partners Sexual behaviour; with & without partners Sexual satisfaction & relationship satisfaction Psychological health Own attempts to find solutions Motivation & expectations 30

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32 Treat if possible the underlying medical condition first or in parallel with the sexual genital pain 33

33 Basson R. JSM 2012;9:

34 Specific sexual focus What is good/ pleasurable sex? Change focus from penetrative sex as the goal both for the woman and the therapist When to say no and yes to sex focus on coping strategies Motives for having sex, contextual and relational factors Sensate focus with partner and alone Physiotherapy Sexual curiosity and self-stimultation Pain problems in other aspects of life 35

35 Conclusion Sexual pain is often not just sexual All types of sexual problems are very common in women with genital pain The sexual pain and problems have a significant impact on the womens life and needs to be adressed. A multidiciplinary approach is preferable 37

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Nivedita Dhar M.D. Wayne State University April 25, 2013

Female Sexual Dysfunction Nivedita Dhar M.D. Wayne State University April 25, 2013 Outline Define Sexual Health and Wellness and discuss how it is unique to each individual Discuss the current terminology