By Deborah Coady, MD, FACOG
One-third of women at some point in their lives experience painful sexual activity for 3 or more months. Sexual pain may occur during arousal or intimate contact or afterward and may persist for days. Genital and vulvar pain may also exist steadily and independently, with sex heightening its severity. Sexual pain is a feature of chronic pelvic pain (CPP), a condition affecting 30 million women in North America at any one time.1-3 Most women with various types of CPP experience painful sexual activity. For example, 75% of women with interstitial cystitis/painful bladder syndrome (IC/PBS) report sexual pain.4
Sexual intimacy is a fundamental desire of most women. Women suffering from pain disorders consistently report that lack of sexual activity or enjoyment is their main reason for low quality of life.5,6 Secondary depression, anxiety, low libido, and relationship difficulties are understandably common in these individuals.7
Compounding this decline in overall quality of life are feelings of shame, guilt, confusion, and isolation. Despite increasing cultural openness about sexuality, more than one-third of women with sexual pain never seek help from healthcare professionals. When they do, many feel misunderstood or dismissed. Fifty percent are dissatisfied with their encounters with doctors.8,9 Women frequently report being told after cursory pelvic exams that their pain must be “in their head.” Fortunately, women with sexual pain are benefiting from social media, self-education, sharing experiences and resources, and self-care.
Ob/gyns are on the front line of care for women with sexual pain. But because most of them have received little formal training in or practical experience with this common problem, they often feel ill-equipped to evaluate patients who are distressed, skeptical, or hopeless due to previous negative experiences. Ob/gyns also may hold preconceptions that the evaluation of sexual pain is more complex and time-consuming than it really is, and that there are few effective treatments anyway. But many advances have been made in understanding the multi-layered causes of sexual pain, and most women can improve and resume or begin satisfying sexual lives after diagnosis and up-to-date treatment. Postgraduate ob/gyn training on CPP is being updated, through the Committee on Resident Education in Obstetrics and Gynecology’s (CREOG) expanded core competencies, which will improve the future for women with these conditions.10
Ob/gyns must accept and acknowledge that sexual pain is a physical pain condition, not a sexual dysfunction or a psychological disorder. Some patients have wasted months or longer in sex therapy, when in fact pain was the primary issue, and function could not be helped until pain was recognized and treated. Once this fact is established and a patient is invited to become a partner in caring for this upsetting medical condition, healing can occur. A mental health therapist who is knowledgeable about the physical causes of painful sex may then join the team.
Couples counseling is valuable, as the intimate partner often suffers along with the patient, and may experience sexual dysfunction and mood disorders. Stress reactions often accompany sexual pain, affecting the immune and autonomic nervous systems (ANS), which affects physical healing.11,12 Coping strategies and mind-body therapies such as meditation and yoga mitigate the physical consequences of stress.13-15
The layered approach
When I first began to care for women with sexual pain, organized evaluation methods were unavailable. Not wanting to miss any causes or triggers of pain, I developed for my own benefit a layered approach to evaluating the pelvis that soon became a teaching tool for patients and students. At that time, only 2 layers were recognized as causing sexual pain: the surface (vulva and vagina) and the internal organs (eg, endometriosis). I knew that the structures between those 2 layers needed to be evaluated: the muscles, nerves, connective tissues, bones, and joints of the lumbopelvic region. Working closely with pioneering pelvic physical therapists (PTs) who were steadily gaining an understanding of these “in between” layers, I realized that most sexual pain intimately involved these structures.
The most revealing step in evaluation is obtaining a complete history, which establishes rapport and validates a patient’s pain. Supplement with forms such as the International Pelvic Pain Society’s, which is available at www.pelvicpain.org. Include baseline self-reported pain measures, such as the Visual Analog Scale (VAS), and the Vulvar Pain Functional Questionnaire (VQ).16 The patient should be fully clothed, seated with you in a private consult room, if possible, and given time to detail her history, including childhood symptoms.
What sexual activities, positions, menstrual cycle phase, and other triggers cause or worsen her pain? Is the pain burning, raw, itching, cramping, sharp, or knife-like? Allow her to use her own words. Did it begin after starting combined hormonal contraception or other medications? Is her pain provoked by simply touching the vulvar surface, is it more intermediate in location within the vaginal canal, deeper with full penetration, or a combination of these? Give her a diagram of the vulva to mark and include in her chart for future comparisons.
What are the patient’s short and long-term goals? Specific goals may vary greatly among women. She may want to be able to sit through a whole movie with her partner without severe pain, perform specific sexual activities or positions, use a vibrator or tampon, conceive naturally with intercourse, or avoid days of pain after sex. Clarifying goals early, in writing, can be enlightening to a patient, and periodically reviewing progress during treatment serves as an objective measure of improvement.
Because of the time constraints of most busy ob/gyns, this part of the evaluation often takes up the entire first visit. Prepare the patient for this and reassure her that your full understanding of her pain and previous treatments promotes effective care. Because the physical exam is detailed and cannot be rushed, schedule a second visit in the very near future to perform it. If a patient brings up her chronic sexual pain during a scheduled routine checkup, it may be best to postpone the exam; devote the rest of the allotted time to obtaining the all-important history. Provide the patient with written or online educational materials for self-care between visits.
At the second visit (or the first, if time allows) perform a layer-by-layer exam as described below, and formulate working diagnoses. Schedule testing as needed and formulate a preliminary treatment plan. Be open at all visits for an intimate partner or other support person to be present, take notes, add overlooked items to the history, and help the patient to feel safe, which is especially important for women who have had demoralizing experiences with other healthcare providers. You may be the first person to whom the patient has revealed her pain, and she may be nervous.
The vulvar surface requires a comprehensive magnified inspection from above the mons pubis to behind to the anus. Lithotomy stirrups that support the patient’s knees are comfortable and less tiring for a patient. Use a handheld magnifier or colposcope and a light source without a bulb that heats up during a long exam, as burns can occur.
The patient can be your best assistant: have her hold a magnifying mirror in one hand and prop herself up by leaning on her opposite elbow so she can view her vulva in the mirror. She can point out her painful areas and feel in control as she participates in and observes your exam. Have her open her labia and retract her clitoral hood herself, as she can more easily tolerate her own touch. All skin and mucosa should be inspected for red, white, or dark lesions, erosions, ulcers, nodules, edema, architectural changes, and fissures. Ask the patient to rate on a scale of 0 to 5 the pain she may feel with touch. Use vulvar diagrams to record findings; documenting with digital photography helps assess the benefits of therapy later.
Do not perform a typical bimanual exam until the very end of the evaluation of all layers, after deciding if it will add information. In cases of chronic sexual pain it usually will not, and often triggers surface pain or muscle spasms that hinder the rest of the exam.
By far the most common cause of sexual pain in premenopausal women is localized provoked vestibulodynia (LPV). Research is leading to a better understanding of this mucosal disorder.17,18 It is crucial that LPV not be missed. After your general inspection, give specific attention to the vestibule, at first without touching it, using your patient-assistant for exposure. Note and document all areas of erythema, even if tiny and subtle. To identify LPV’s diagnostic feature, allodynia, the Q-tip (swab) test is key. Begin checking for provoked pain systematically at the outer labial skin, an area unlikely to startle the patient. Gently press the cotton tip enough to dent the surface just 1 mm, and note her pain level, as well as superficial muscle responses. Repeat, gradually moving inward to the smooth vestibule mucosa between Hart’s line and the hymenal ring, to delineate tender areas. Repeat this testing “around the clock” with the midpoint of the introitus the clock’s center. Be sure to assess the vestibule around the urethra, and the urethra itself, as its mucosa is contiguous and often involved in LPV.
Chronic or recurrent fissures in the posterior fourchette are another cause of introital dyspareunia. Inspect for midline scars in this area, because it may tear, heal, remain weak, then re-tear with the next penetration, so fissures may only be seen soon after sex. Complete your surface evaluation by assessing for vulvovaginal infections or inflammation, such as desquamative inflammatory vaginitis, with the use of a warmed, lubricated, very narrow speculum, or obtain wet smears and cultures with just a swab. Patients with LPV and pelvic floor (PF) disorders often cannot tolerate a speculum, and in these conditions it is usually not necessary, at least at initial exam. Use of dilute acetic acid may also cause significant pain and is rarely needed.
Vulvar biopsies are best avoided unless a lesion is suspicious for neoplasia, because results rarely affect management. A biopsy of the vestibule is not needed. Biopsies of specific lesions to diagnose vulvar dermatoses can be delayed until a follow-up visit, after potential causes of pain in other layers have been assessed. Many patients attribute worsening pain to previous biopsies, so if one is needed, take as small a piece of tissue as possible and use a pathologist experienced in vulvar dermatology.
Disorders of pelvic nerves may cause chronic sexual pain in women and men.19,20 These long nerves are subject to the same injuries and diseases as peripheral nerves that run through other parts of the body. Nerve compression, injuries resulting in formation of neuromata, and peripheral sensitization all can occur in the pelvis.
During your vulvar exam, work with the patient to localize the area that is painful (eg, clitoris, anus, posterior left vestibule), and if surface conditions do not explain her pain, determine which nerve likely innervates that sensory area. Patients with generalized vulvodynia (GV) may have trouble isolating specific areas of pain, as burning and itching nerve pain may be felt broadly. Patients may sense unilateral conditions as involving the entire vulva, due to global PF responses. Your careful history and neuroanatomy-based exam will clarify which pelvic nerves may be pain generators.
Because the pudendal nerve (PN) is the main sensory nerve of the external genitalia, mentally visualize the course of its 3 main branches through the PF while palpating. Inspect for scarring from surgery or childbirth that may have lacerated a nerve branch, creating a neuroma. Neuromata are only occasionally large enough to be palpable and may present as small areas of exquisite tenderness. Consider whether pain is localized to a single PN branch or if the whole nerve itself is involved, deeper in the PF proximal to its division into branches. The landmark of the ischial spine, under which the pudendal neurovascular bundle passes, is quite easy to locate by single-digit vaginal exam; specific pain elicited at this point by light touch is suggestive of PN involvement. If the PN is compressed here or proximally in its path from the sacral nerve roots, all its branches will be affected, including the rectal branch, generating pain that includes the anal area.
Digitally guided transvaginal, or transperineal, perineural pudendal nerve injections (PNPI) at the ischial spine avoid expense, sedation, and x-ray exposure for a patient. Such injections are simple for ob/gyns to perform in-office, and many gained experience using them for childbirth analgesia. If a PNPI alleviates a patient’s pain temporarily, the PN is a component that needs to be addressed. An image-guided PNPI from the posterior approach can be planned with an interventional radiologist if clinical suspicion for PN pain remains high despite a negative (ineffective) injection, or if a patient needs sedation for the procedure.
Pain located in the field of one branch of the PN, or of the perineal branch of the posterior femoral cutaneous nerve, can be evaluated by performing specific small-volume anesthetic injections directed to a convenient point along a branch’s usual course, or where you think a neuroma may be. Nerve branch injections that relieve pain indicate involvement of that branch primarily, or secondarily from myofascial abnormalities as discussed below.
Clitoral pain (clitorodynia) and the related pain disorder persistent genital arousal may result from multiple etiologies, but irritation or compression of the dorsal branch of the PN usually plays a role. Some cases of clitoral pain result from surgical injury to the nerves above the clitoris (the ilioinguinal, iliohypogastric, and genitofemoral) so check for suprapubic and groin scarring. Diagnostic blocks of these, and of the dorsal branch, performed along their course well away from the clitoris, will clarify their involvement and direct therapy.
MYOFASCIAL LAYER – THE PELVIC FLOOR
Just under the surface of the vulva lies the invisible layer of the PF, made up of muscles and the fascia covering and attaching them to each other, and forming their origins and insertions into bone and cartilage. Whether sexual pain begins in this layer or not, the PF almost always contributes to its intensity and chronicity. Muscle spasms, muscle shortening, myofascial trigger points, and secondary dystrophic changes add to nerve irritation and compression. Patients often sense both PF and PN pain as a foreign object in the vaginal canal, which corresponds to the bulkiness of muscles remaining in an abnormal contracted state. Dysfunction of the PF is a common component of all types of CPP and is “the missing link” in making a complete diagnosis.21 In women with sexual pain, it is crucial that the PF be systematically evaluated.
The vast majority of women who have been told they have “vaginismus” actually suffer from LPV and severe PF dysfunction. Painful experiences from touching, sexual activity, and medical exams understandably result in avoidance of vulvar contact, which is often misinterpreted as a psychological problem. For these patients, perform exams under anesthesia only as a last resort, because with muscle relaxation, important PF and nerve findings may disappear. Oral or intravaginal diazepam is an option an hour before an exam, but you may underappreciate the severity of myofacial abnormalities with this premedication.
PF evaluation needs to attend both vaginally and rectally to superficial and deep myofascial structures. Palpate the bulbocavernosus, ischiocavernosus, transverse perineal, levator ani (puborectalis, pubococcygeus, iliococcygeus), obturator internus, piriformis, and anal sphincter for tenderness, high tension, tight bands, trigger points, bilateral symmetry, and hypertrophy or atrophy, and the connective tissue for string-like restrictions. Constrictions around the courses of nerves hinder normal stretching and gliding in the tissues during sexual activity, causing burning pain. Dry-needling tight bands and trigger points, or injecting them with 0.5 cc lidocaine, then palpating to confirm their release and effect on pain, is a useful diagnostic tool.
Note findings of vaginal relaxation, pelvic organ prolapse, and Bartholin’s cysts, but keep in mind that these are usually not sexual pain generators. Many patients with unappreciated LPV have had small Bartholin’s cysts surgically excised without benefit. If they are present, be sure to continue to evaluate all layers for more likely causes of sexual pain.
PTs who specialize in PF dysfunction have taken up the challenge of caring for women with sexual pain, and can help us improve our PF exam skills.22
The musculoskeletal structures of the lumbopelvic area intimately affect the PF and may cause pain with sexual activity. Intra-articular hip disorders such as femoroacetabular impingement are common in women and hip evaluation via history and exam is needed.23 Observe gait and routinely perform a provocative test for hip impingement, such as the FABER (flexion, abduction, external rotation) test. The obturator internus, part of the PF along which the PN runs, is a main hip rotator; pain on palpation of this muscle, and at the greater trochanter of the hip, is suggestive of hip dysfunction contributing to painful sex. Also assess for tenderness at the pubic symphysis, coccyx, and sacroiliac joint. Lumbar disc disease and osteoarthritis are common with age, and older women may report pain during sexual activity in positions that stress these conditions. Further evaluation by an orthopedist and PT may be needed.
It has been recognized for years that deep dyspareunia suggests endometriosis, but clinicians should remember to evaluate for painful PF responses that usually coexist, adding to sexual pain. After endometriosis surgeries, ongoing painful sex is an often-overlooked concern, and hormonal therapies routinely used postoperatively may cause the additional painful consequence of atrophy of genital tissues.
We now appreciate that sexual pain is a usual component of the 3 main CPP disorders that are often comorbid: endometriosis, interstitial cystitis/painful bladder syndrome (IC/PBS), and irritable bowel syndrome (IBS). IC/PBS causes significant introital pain, as LPV often coexists, as well as urethrodynia. Penetration may also induce severe long-lasting pain flares, as the base of the bladder and the often hypertonic PF are compressed. Include gentle specific assessment for tenderness of the urethra and bladder base in your single digit exam. Similarly, IBS sufferers frequently have PF hypertonicity, as well as defecatory dysfunction and anal fissures.
A complete evaluation must attend to the possibility of one or more of these overlapping disorders. Further evaluation of complicated pain in several layers includes imaging of the pelvic organs, PF, and lumbopelvic region.
Body-wide disorders may underlie the development of sexual pain. Three interconnected systems control tissue healing: the endocrine system, the immune system, and the nervous system. Even borderline diabetes can affect sensory nerves in the vulva, just as it causes burning pain in peripheral nerves elsewhere in the body. Consider the possibility of autoimmune disorders, which are common in women, when inflammatory surface changes do not respond quickly to treatment. Conditions such as Sjogren’s, lupus, and connective tissue disorders may affect mucosa, fascia, and small nerve fibers.
Menopause, whether it occurs naturally or is medically or surgically induced, affects all layers in most women to some degree. We now understand more about how declines in estrogen and androgen may disrupt vulvar and pelvic tissues, due to sex hormone receptors in mucosa, myofascia, and sensory neurons. In some women, menopause triggers LPV, resulting in severe sexual pain and vestibular exam findings similar to those in younger patients.24,25 Topical hormone therapy usually benefits menopausal dyspareunia, and testing baseline and follow-up blood hormone levels is not necessary. But for women who do not respond quickly, re-evaluation for LPV and disorders in other layers is key to a complete diagnosis in menopause, too.
Centralized pain may occasionally be present as a component of chronic sexual pain.26 Findings suggesting this condition include systemic allodynia, hyperesthesia, and lowered pain thresholds, and comorbidities such as fibromyalgia and chronic headaches. Assembling a team of specialists in neurology and rheumatology for further evaluation of systemic conditions is crucial. Research and experience continue to show the benefits of integrating complementary mind-body therapies into care of complex and systemic pain disorders.27
Overall treatment principles
Share with patients a written individualized treatment plan addressing each layer. The vulvar surface must be protected and strengthened, abnormal peripheral and central nerve activity suppressed, and the PF normalized with PT. Musculoskeletal abnormalities and pelvic organ pain require focused therapies, and underlying systemic conditions must be appreciated and treated. Depression, anxiety, and hopelessness are improved by supportive and cognitive behavioral therapy. Develop a relationship with a therapist who is knowledgeable about chronic pain and mind-body practices, which calm the ANS and physical consequences of pain and stress.
Anticipate pain flares and have a plan in place before they occur. Re-evaluate persistent or recurrent pain often, layer by layer. Address the side effects of medications preemptively and quickly. Avoid opioid pain relievers, which do not relieve chronic pain, but may cause bowel and bladder symptoms, endocrinopathies, sexual dysfunction, and mood and cognitive disturbances that may lead to overdose.28
Patients trust ob/gyns with the care of chronic sexual pain. Our committed partnership with patients will improve their quality of life and provide an essential component of healing: hope for the real possibility of cure.
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