Genitopelvic pain/penetration disorder involves involuntary contraction of the pelvic floor muscles when vaginal entry is attempted or completed (levator ani syndrome, or vaginismus), pain that occurs during deep penetration (dyspareunia) or that is localized to the vestibule (provoked vestibulodynia), anxiety about penetration attempts, or difficulty having intercourse.
(See also Overview of Female Sexual Function and Dysfunction.)
Women with genitopelvic pain/penetration disorder commonly have impaired arousal, orgasm, or both.
Causes of genitopelvic pain/penetration disorder may involve physical and psychologic factors.
Superficial vulvar pain may result from provoked vestibulodynia, genitourinary syndrome of menopause, dermatologic disorders (eg, lichen sclerosus, vulvar dystrophies), congenital malformations, genital herpes simplex, vaginitis, Bartholin gland abscess, radiation fibrosis, postsurgical introital narrowing, or recurrent tearing of the posterior fourchette.
Provoked vestibulodynia (PVD) can be primary or secondary:
The etiology of PVD is not entirely understood and may result from multiple factors, possibly including an inflammatory or immune response, an increased number of nerve fibers resulting in hyperesthesia, a hormonal imbalance, and pelvic floor dysfunction. PVD can occur in chronic pain syndromes, including fibromyalgia, interstitial cystitis, and irritable bowel syndrome.
Deep dyspareunia may result from pelvic floor muscle hypertonicity or uterine or ovarian disorders (eg, fibroids, chronic pelvic inflammatory disease, endometriosis).
A history of trauma or sexual abuse can also contribute to a genitopelvic pain/penetration disorder.
The term levator ani syndrome is being increasingly used to replace vaginismus because symptoms of vaginismus typically result from levator ani muscle dysfunction. Levator ani syndrome may combine pain and emotional components. This disorder may be primary, occurring with the first attempt at sexual intercourse or secondary, occurring after a period of pain-free sex.
Women with primary provoked vestibulodynia report that pain occurred during their first experience with penetration. Many notice the pain first in adolescence, when they first try to use a tampon. They may report that they have never been able to have had comfortable sexual intercourse. Often, pain is described as a burning or stabbing pain caused by insertion of something into the vagina. Women with secondary PVD have similar symptoms, but they report symptoms after a period of sexual activity without pain.
Women with genitopelvic pain/penetration disorder may develop a phobia-like avoidance of penetration. They may have an intense fear of and anxiety about pain before or during vaginal penetration. When women anticipate that pain will recur during penetration, their vaginal muscles tighten, making attempts at sexual intercourse even more painful. However, most women with this disorder can enjoy nonpenetrative sexual activity.
The inability to have sexual intercourse can strain a relationship. Women may feel ashamed, embarrassed, inadequate, or depressed. It causes significant stress for women who want to become pregnant.
Diagnosis of genitopelvic pain/penetration disorder is based on symptoms and results of a pelvic examination, which can detect or rule out physical abnormalities.
The examination focuses on inspecting all the vulvar skin (including the creases between the labia minora and majora [eg, for fissures typical of chronic candidiasis]), as well as the clitoral hood, urethral meatus, hymen, and openings of major vestibular gland ducts (for atrophy, signs of inflammation, and abnormal skin lesions requiring biopsy).
A moist cotton swab can then be used to map out the woman’s pain. Provoked vestibulodynia manifests with pain that is reproduced when the vestibule is palpated. The pain may occur along the entire vestibule (from 1 to 11 o’clock) or sometimes only posteriorly (from 4 to 8 o’clock). If only the posterior part of the vestibule is affected, pelvic floor dysfunction may also be present.
A digital examination is then done to check for pelvic floor hypertonicity, which can be elicited by palpating the levator ani muscles. The urethra and bladder should also be palpated anteriorly to identify abnormal tenderness. A speculum examination can be done to evaluate the cervix, and bimanual examination to palpate the uterus and ovaries can help identify causes of deeper pain.
Examination can sometimes be difficult because of the patient’s pain and/or anticipation of pain. In many women with levator ani syndrome, the speculum and bimanual part of the examination cannot be done. Clinicians should explain each step of the examination to women to help them relax and to get as much information as possible from the examination.
Diagnosis of genitopelvic pain/penetration disorder is based on specific criteria in the DSM-5. The criteria require persistence or recurrence of one or more of the following:
Symptoms must have been present for ≥ 6 months and must cause significant distress in the woman. Also, the diagnosis of genitopelvic pain/penetration disorder requires that sexual dysfunction is not better explained by the presence of another disorder, severe relationship distress (eg, intimate violence), or other significant stressors or by use a substance or drug.
Management of genitopelvic pain/penetration disorder frequently includes the following:
Topical estrogen is helpful for genitourinary syndrome of menopause, atrophic vaginitis, and recurrent posterior fourchette tearing. Topical estrogen, intravaginal prasterone (a DHEA preparation), or ospemifene (a selective estrogen receptor modulator [SERM]) may be useful in women with dyspareunia due to vulvar dystrophies, or genitourinary syndrome of menopause.
Data about the optimal treatment of genitopelvic pain/penetration disorder are limited, and many approaches are currently used depending on the specific presentation.
The first approach is always a reminder to practice good vulvar hygiene, including wearing cotton underwear during the day, washing with a mild soap, and avoiding douching and over-the-counter vaginal deodorants. If a lubricant is used during sex, it should be nonscented and water-based.
Pelvic floor physical therapy can often benefit women with genitopelvic pain/penetration disorder; it includes pelvic floor muscle training, sometimes with biofeedback, to teach pelvic muscle relaxation. Other therapies include soft-tissue mobilization and myofascial release, trigger-point pressure, electrical stimulation, bladder and bowel retraining, and therapeutic ultrasonography.
Prescription and nonprescription devices are available for self-dilation if women with genitopelvic pain/penetration disorder have tight pelvic muscles that contribute to painful intercourse. Self-dilation in the presence of a therapist and the woman’s partner plus psychotherapy has been shown to enable women with levator ani syndrome to have sexual intercourse more frequently (1).
Levator ani syndrome (previously called vaginismus) can be treated with progressive desensitization; women progressively accustom themselves to self-touch near, on, then through the introitus. Each stage in the progression begins only when the woman is comfortable with the previous stage.
For PVD, first-line treatment includes pelvic floor physical therapy because pelvic floor muscle hypertonicity is often present.
A topical hormone cream can often help when used for several months. For example, a topical cream or gel that contains estradiol 0.01% and testosterone 0.1% can be applied to the vaginal vestibule nightly or twice a day. Topical estrogen is helpful for genitourinary syndrome of menopause and recurrent posterior fourchette tearing.
A topical lidocaine gel can also be applied before activities that cause discomfort during sexual intercourse; this gel should be used only for a short time.
Topical estrogen, intravaginal prasterone (a DHEA preparation), or ospemifene (a selective estrogen receptor modulator [SERM]) may be useful in women with dyspareunia due to genitourinary syndrome of menopause.
Drugs used to treat neuropathic pain (eg, gabapentin, pregabalin) can be useful for PVD. These drugs can lessen pain when they are used with other treatments for PVD.
Tricyclic antidepressants, often used to treat chronic pain disorders, are a 2nd-line treatment for PVD. Amitriptyline and nortriptyline are the tricyclic antidepressants most commonly used and should be started at a low dose and titrated up.
Various topical compounds containing combinations of gabapentin and amitriptyline may also be effective and, when applied directly to the vaginal vestibule, have fewer systemic adverse effects.
Botulinum toxin type A, injected into the pelvic floor muscles, has been used to treat levator ani syndrome and provoked vestibulodynia, but it is normally used only for short-term treatment of refractory cases .
Vestibulectomy (removal of the vaginal vestibule) is not done often but can be considered on a case by case basis. Women with primary PVD are usually the best candidates for this surgical procedure.
Referral to a certified sex therapist for psychologic therapies such as cognitive-behavioral therapy, and mindfulness-based cognitive therapy can often help women manage their fear of and anxiety about pain and penetration.
