Proper evaluation of a key muscle group can identify pelvic floor myalgia—an often unsuspected but highly treatable cause of insertional dyspareunia and pelvic pain. An expert tells how to proceed with diagnosis and treatment.
Sexual pain disorders among women are important, widespread, but poorly understood. Sexual dysfunction affects nearly half (43%) of all American women, according to an analysis of data from a 1992 study of sexual behavior. Lack of desire and pain were cited most often in this study (the National Health and Social Life Survey).1 Backing up these findings, a recent large population-based survey in New England showed that 15.7% of women had vulvodynia, and several studies have described the widely diverse ways in which women with vulvar pain manifest that pain.2-4
As you probably know only too well, providing comprehensive care to women complaining of sexual pain is challenging for most busy ob/gyns because most managed care-oriented schedules don't leave you enough time for a detailed evaluation and sensitive discussion. A classification system based upon a careful and orderly evaluation of these complaints provides a framework for treatment and research. Even though idiopathic localized (vestibulodynia, or vulvar vestibulitis syndrome) and generalized (dysesthetic vulvodynia) vulvodynia make up the bulk of vulvar pain disorders, you must also carefully evaluate and discern symptoms that result from anatomic variations, dermatologic conditions, Bartholin gland disorders, infectious diseases, and pelvic floor myalgia.4
The problem of superficial dyspareunia appears to come up frequently when women consult an ob/gyn for unrelated matters. For example, a general ob/gyn practice in Portland, Ore., found that vestibular pain occurred in 15% of patients over a 6-month period, while a more recent prospective observational study of 400 women from West Hertfordshire, UK, found that the prevalence of vestibulitis varied from 2.9% to 9.8%, depending on how stringent the diagnostic criteria and the method of ascertaining pain were.5,6 However, since vulvar vestibulitis is defined by two physical signs (localized erythema and point tenderness) and one symptom (pain with vaginal entry), it is unclear how many of the women in these studies were functionally impacted by insertional pain. Investigators still don't completely understand the relationship between vestibular pain and entry dyspareunia.
Pelvic floor (levator) myalgia is an important and frequently unrecognized condition. But the good news is that it's highly treatable. My goal here is to assist clinicians evaluating women with insertional dyspareunia, pelvic pain-or both-in the proper evaluation of the pelvic floor muscles and to review treatment options.
How do the pelvic floor muscles work?