Philomeen Weijenborg

Vaginismus and dyspareunia : is there a difference in clinical presentation ?

The purpose of this exploratory study was to identify clinical similarities and differences in patients with vaginismus and dyspareunia. Thirty patients who were referred to an outpatient clinic for psychosomatic gynecology and sexology, with either of these two diagnoses, were investigated by means of a standardized interview, physical examination and self-rating questionnaires. Based on the interview, no significant differences were demonstrated between patients with vaginismus and dyspareunia, in the ability to insert a finger into the vagina or to have a gynecological examination. No differences were found in the reported level of pain during coitus (or attempted coitus), inserting one finger into the vagina, or during gynecological examination. Patients with vaginismus, however, more often reported that coitus was impossible. The physical examination and self-rating questionnaires showed no differences at all between patients with vaginismus and dyspareunia in palpated vaginal muscular tension and reported anxiety or tension during the examination. Moreover, in both groups redness and painful areas on the vulva were equally common. Redness and pain on the same location were more frequently present in the dyspareunia group. Patients with dyspareunia reported higher levels of pain during the examination. In conclusion, neither the interview nor the physical examination produced useful criteria to distinguish vaginismus from dyspareunia. A multi-axial description of these syndromes is suggested, rather than viewing them as two separate disorders.

The effect of a group programme on women with the Mayer-Rokitansky-Küster-Hauser Syndrome

Objective To evaluate the effect of a group programme on psychological distress in women with the Mayer‐Rokitansky‐Küster‐Hauser (MRKH) syndrome.

Clinical course of chronic pelvic pain in women.

Abstract A follow‐up study on a cohort of women with chronic pelvic pain (CPP) was conducted, to evaluate the clinical course and to identify factors associated with outcome. Participants were over 18 years of age and had initially visited a multidisciplinary CPP‐team of a Gynaecological Department of a University Hospital. The course of chronic pelvic pain was evaluated using the Life Chart Interview (LCI) method. All participants completed questionnaires covering demographic and clinical characteristics, pain (McGill) and psychological distress (SCL‐90) at baseline and follow up. The response rate was 60%. A survival analysis was conducted. After a mean follow‐up period of 3.4 years, 18 women (25%) of the study sample (N = 72) reported recovery from pelvic pain (i.e. pelvic pain for less than 3 months per year). Eight of these 18 women (11% of the total sample) reported no pain at all at follow up. Relapse of symptoms was not encountered. Not any demographic, clinical or pain related variable measured at baseline, nor any intervention between baseline and follow up, was associated with outcome. Our results indicate that chronic pelvic pain in women in secondary care is a longstanding condition. Further research is recommended to identify risk factors for persistence of symptoms.

Request for operative reduction of the labia minora; a proposal for a practical guideline for gynecologists.

The increase in womens request for labia reduction surgery raises medical and ethical dilemmas for the gynecological surgeon. A bio-psycho-social approach is suggested; the problem is put forward from the perspective of the medical ethical principles and a practical guideline is proposed.

Predictors of outcome in a cohort of women with chronic pelvic pain – A follow‐up study

Background: Chronic pelvic pain (CPP) in women is a long‐lasting condition.

Throwing the Baby Out with the Bathwater: The Demise of Vaginismus in Favor of Genito-Pelvic Pain/Penetration Disorder

Over the past 15 years, there has been ongoing debate about whether vaginismus can be differentiated from dyspareunia categorically, dimensionally, or not at all (Reissing, Binik, & Khalifé, 1999). Despite the fact that the debate on diagnostic distinction continues, a significant change was made in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5; American Psychiatric Association, 2013). The diagnosis of Genito-Pelvic Pain/Penetration Disorder (GPPPD) was introduced to replace the hitherto separate diagnosesofDyspareuniaandVaginismus,previouslyunder thesubcategory of sexual pain disorders (DSM-IV-TR; American Psychiatric Association, 2000). Binik (2005a) argued that the sexual pain disorders were the onlypainconditionsthatwereclassifiedaccordingtotheactivity they interfered with and argued for their removal from the classification of sexual dysfunctions. This was received with broad skepticism from clinicians and researchers alike (Binik, 2005b). The introduction of GPPPD may represent an apparent compromise. The diagnostic criteria for this new category have focused on symptomatology related to pain during sexual activity and/or pain with (anticipated) vaginal penetration. The multidimensional diagnosis of GPPPD is clearly more in line with the outcomes of scientific research and clinical practice than the original categorical classification in DSM-IV-TR as outlined elegantly by Binik’s (2010a, 2010b) summary of the literature. However, GPPPD fails to capture the complexity of sexual difficulties in women who have never been able to experience intercourse (for the purpose of this commentary referred tobythepreviousdiagnostic labelof lifelongvaginismus). Inour opinion, we run the risk that the baby (lifelong vaginismus) is thrown out with the bathwater (sexual pain disorders). By summarizing different aspects of lifelong vaginismus based on the results of recent studies, we will underscore this and offer a temporary solution to assist clinicians and researchers to mediate the omission of lifelong vaginismus from the DSM-5. Vaginismus was first mentioned as a sexual/reproductive problem by the Italian physician Trotula of Salerno in the eleventh century:‘‘On the tightening of the vulva so that even a woman who has been seduced may appear a virgin’’(1940; p. 37). The diagnostic term ‘‘vaginismus’’was coined by the English gynecologist, J. Marion Sims, in 1861. Even in the first description of vaginismus, the confusion between pelvic Charmaine Borg and Symon K. Spoelstra are both second authors.

A New Device for Simultaneous Measurement of Pelvic Floor Muscle Activity and Vaginal Blood Flow: A Test in a Nonclinical Sample

INTRODUCTION Dyspareunia in women, defined as persistent or recurrent genital pain associated with sexual intercourse, is hypothesized to be related to (fear associated) pelvic floor hyperactivity and to diminished sexual arousal. Psychophysiological research to support these hypotheses is scarce and concentrates mostly on the role of either pelvic floor activity or sexual arousal. To investigate both factors, a measurement device that enables simultaneous assessment of pelvic floor muscle activity and genital sexual arousal would be most optimal. AIM The aim of this study was to test a new vaginal device0-a vaginal photoplethysmograph with build-in surface electromyography (EMG)--that allows simultaneous assessment of pelvic floor muscle activity and vaginal blood flow. MAIN OUTCOME MEASURES Genital arousal measured as vaginal pulse amplitude (VPA) and vaginal surface EMG. METHODS Thirty-six sexually functional women participated. To investigate the sensitivity of the device for changes in genital blood flow and involuntary changes in pelvic floor activity, VPA and vaginal surface EMG were monitored during exposure to sexual and anxiety-evoking film clips. In addition, vaginal surface EMG was monitored during voluntary flick and hold contractions. RESULTS VPA increased in response to the sexual film, and EMG values were significantly higher in response to the anxiety-evoking film. Higher EMG values in response to the anxiety film were associated with lower VPA. EMG during the instructed 3-second hold pelvic floor contractions showed, as expected, higher values during pelvic floor contractions with support of surrounding muscle groups, compared with pelvic floor muscles alone. CONCLUSION The device is sensitive to changes in vaginal blood flow in response to sexual stimuli, and it is able to pick up small, involuntary changes in pelvic floor activity associated with anxiety. Also, the device is able to record changes in pelvic floor activity during voluntary pelvic floor contractions. This new device will be a valuable tool in further research on superficial dyspareunia.

Acute abdominal pain in women at an emergency department: Predictors of chronicity

Background: Persistence of pain after acute abdominal pain has been encountered but predictors of chronicity are insufficiently known.

14 Diagnostiek en interventies

In de afgelopen decennia is het onderzoek naar het voorkomen van seksuele problematiek enorm toegenomen.

Sexual response in women with Mayer-Rokitansky-Küster-Hauser syndrome with a non-surgical neo-vagina

BACKGROUND: Sexual dysfunction is prevalent in women with Mayer‐Rokitansky‐Küster‐Hauser syndrome after the creation of a neovagina. Insight into the physiologic response of the neovagina during sexual arousal is lacking, although this would help in the understanding of sexual function of these patients. The physiologic sexual response of the vagina can be measured objectively by vaginal photoplethysmography to assess vaginal blood flow. OBJECTIVE: Testing whether the physiologic and subjective sexual response in women with Mayer‐Rokitansky‐Küster‐Hauser syndrome with a neovagina differs from the response in women with a natal vagina. STUDY DESIGN: Vaginal blood flow (vaginal pulse amplitude) and subjective sexual responses during neutral and erotic film viewing were assessed in premenopausal women with Mayer‐Rokitansky‐Küster‐Hauser syndrome with a nonsurgically created neovagina (n=15) and were compared with responses of an age‐matched control group (n=21). RESULTS: All women with Mayer‐Rokitansky‐Küster‐Hauser syndrome had created their neovagina themselves by dilation. Women with Mayer‐Rokitansky‐Küster‐Hauser syndrome showed a significantly smaller vaginal pulse amplitude compared with control subjects during neutral film viewing (P=.002). In both groups, vaginal pulse amplitude increased significantly during erotic film viewing, but this increase was significantly smaller in the Mayer‐Rokitansky‐Küster‐Hauser syndrome group (P<.005). Levels of subjective sexual arousal did not significantly differ between the 2 groups (P>.2). CONCLUSION: Women with Mayer‐Rokitansky‐Küster‐Hauser syndrome with a nonsurgically created neovagina showed a weaker vaginal blood flow response during visual sexual stimulation and poorer basal blood flow compared with control subjects. The differences in vaginal blood flow may be related to less vascularization and innervation of the neovagina compared with the natal vagina. The weaker vaginal sexual response can play a role in sexual dysfunction; however, despite the weaker vaginal response, women with Mayer‐Rokitansky‐Küster‐Hauser syndrome did not differ in their level of subjective sexual arousal. Future studies may compare vaginal blood flow and subjective sexual response of women with Mayer‐Rokitansky‐Küster‐Hauser syndrome with nonsurgically and surgically created vaginas.