Yitzchak M. Binik

Physical Therapy for Vulvar Vestibulitis Syndrome: A Retrospective Study

This retrospective study evaluated the effectiveness of physical therapy in relieving painful intercourse and improving sexual function in women diagnosed with vulvar vestibulitis. This syndrome is a frequent cause of premenopausal dyspareunia and is characterized by a sharp, burning pain located within and limited to the vulvar vestibule (vaginal entry) and elicited primarily via pressure applied to the area. Participants were 35 women with vulvar vestibulitis who took part in physical therapy treatment for an average of 7 sessions. We conducted telephone interviews to assess whether physical therapy or other subsequent treatments impacted on pain during intercourse and sexual functioning. Length of treatment follow up ranged from 2 to 44 months, with a mean of 16 months. Physical therapy yielded a complete or great improvement for 51.4% of participants, a moderate improvement for 20.0% of participants, and little to no improvement for the other 28.6%. Treatment resulted in a significant decrease in pain experienced both during intercourse and gynecological examinations; it also resulted in a significant increase in intercourse frequency and levels of sexual desire and arousal. Successful patients were significantly less educated than nonsuccessful patients. Findings demonstrate that physical therapy is a promising treatment modality for dyspareunia associated with vulvar vestibulitis.

The surgical treatment of vulvar vestibulitis syndrome: A follow-up study

This study evaluated the effectiveness of vestibulectomy in relieving coital pain and improving sexual function in women diagnosed with vulvar vestibulitis. Vulvar vestibulitis syndrome, a chronic, nonspecific inflammation of the vulvar vestibule, probably represents the most frequent subtype of premenopausal dyspareunia. Participants were 38 women who underwent vestibulectomy at a university hospital between 1986 and 1994. Telephone interviews were conducted to assess whether vestibulectomy or other subsequent treatments affected coital pain and sexual functioning. Length of postoperative follow-up ranged from 1.1 to 10 years, with a mean of 3.3 years. Vestibulectomy yielded a positive outcome for 63.2% of the participants and moderate to no improvement for the other 36.8%. The surgery was linked to a significant increase in intercourse frequency for the entire sample and to an increase in oral and manual stimulation for the women with successful surgical outcomes. No other factors were significantly associated with treatment outcome.

Morphometry of the Pelvic Floor Muscles in Women With and Without Provoked Vestibulodynia Using 4D Ultrasound

INTRODUCTIONnIt has been suggested that pelvic floor muscles (PFMs) play an important role in provoked vestibulodynia (PVD) pathophysiology. Controversy in determining their exact contribution may be explained by methodological limitations related to the PFM assessment tools, specifically the pain elicited by the measurement itself, which may trigger a PFM reaction and introduce a strong bias.nnnAIMnThe aim of this study was to compare PFM morphometry in women suffering from PVD to asymptomatic healthy control women using a pain-free methodology, transperineal four-dimensional (4D) ultrasound.nnnMETHODSnFifty-one asymptomatic women and 49 women suffering from PVD were recruited. Diagnosis of PVD was confirmed by a gynecologist following a standardized examination. All the participants were nulliparous and had no other urogynecological conditions. The women were evaluated in a supine position at rest and during PFM maximal contraction.nnnMAIN OUTCOME MEASURESnTransperineal 4D ultrasound, which consists of a probe applied on the surface of the perineum without any vaginal insertion, was used to assess PFM morphometry. Different parameters were assessed in sagittal and axial planes: anorectal angle, levator plate angle, displacement of the bladder neck, and levator hiatus area. The investigator analyzing the data was blinded to the clinical data.nnnRESULTSnWomen with PVD showed a significantly smaller levator hiatus area, a smaller anorectal angle, and a larger levator plate angle at rest compared with asymptomatic women, suggesting an increase in PFM tone. During PFM maximal contraction, smaller changes in levator hiatus area narrowing, displacement of the bladder neck, and changes of the anorectal and of the levator plate angles were found in women with PVD compared with controls, which may indicate poorer PFM strength and control.nnnCONCLUSIONnUsing a reliable and pain-free methodology, this research provides sound evidence that women with PVD display differences in PFM morphometry suggesting increased tone and reduced strength.

History of Sexual and Physical Abuse in Women with Dyspareunia: Association with Pain, Psychosocial Adjustment, and Sexual Functioning

AIMnDyspareunia is a womens sexual health problem that still often goes undiagnosed despite its high prevalence and its detrimental impact on sexual, relationship, and psychological adjustment. Although sexual and physical abuse may constitute risk factors for the development of dyspareunia, the effects of past abuse on current pain and associated sexual and psychosocial impairments have never been examined. Thus, the aim of this study is to determine the relation between a history of sexual and physical abuse and a series of pain, psychological, dyadic, and sexual functioning variables in a sample of women with dyspareunia.nnnMETHODSnA hundred and fifty-one women took part in the study via health professional referrals and advertisements in local newspapers. Each participant underwent a standardized gynecological examination and a structured interview in order to confirm the diagnosis of dyspareunia. They also completed self-report questionnaires investigating past sexual and physical abuse, in addition to current pain, psychosocial adjustment, and sexual functioning. Dependent measures included: (i) The Brief Symptom Inventory; (ii) the Sexual History Form; and (iii) the Locke-Wallace Marital Adjustment Scale. Pain was assessed via the McGill Pain Questionnaire and a visual analogue scale.nnnRESULTSnResults revealed that a history of sexual abuse involving penetration was associated with poorer psychological adjustment and sexual functioning. Additionally, findings showed that women who perceived a link between their dyspareunia and their past sexual abuse reported worse sexual functioning than those who did not. Finally, the experience of sexual abuse was not associated with pain intensity and physical abuse was not associated with any of the outcome measures.nnnCONCLUSIONSnFindings suggest that the presence of a sexual abuse history in women with dyspareunia is associated with increased psychological distress and sexual impairment, although there is no relation between a history of physical abuse and these outcomes.

Evaluation of Clitoral Blood Flow by Color Doppler Ultrasonography

The feasibility of reliably measuring clitoral blood flow using standard color Doppler ultrasonography was evaluated by two independent assessors in a sample of 40 pre- and post-menopausal women. High positive correlations with no significant mean differences between examiners were found for three major standard blood flow measures including maximum velocity, resistance, and pulsatility indices. With further methodological refinements, ultrasonographic evaluation of clitoral blood flow will be adaptable for clinical and research use and is likely to become the standard physiological measure of female sexual arousal.The feasibility of reliably measuring clitoral blood flow using standard color Doppler ultrasonography was evaluated by two independent assessors in a sample of 40 pre- and post-menopausal women. High positive correlations with no significant mean differences between examiners were found for three major standard blood flow measures including maximum velocity, resistance, and pulsatility indices. With further methodological refinements, ultrasonographic evaluation of clitoral blood flow will be adaptable for clinical and research use and is likely to become the standard physiological measure of female sexual arousal.

In favor of an integrated pain-relief treatment approach for vulvar vestibulitis syndrome.

In their commentary regarding the results of our vulvar vestibulitis randomized treatment outcome study, Weijmar Schultz and van de WieP raise a number of important clinical and scientific issues. We approve of most of their comments but would like to elaborate in an attempt to promote further discussion and research. Weijmar Schultz and van de Wiel suggest on page of this issue that the lowered efficacy of cognitive behavioral therapy in our study as compared to theirs resulted from our shorter duration of treatment (12 weeks versus 1-1.5 years). Although it makes sense that more therapy should result in better outcomes, to our knowledge, there are no data concerning the impact of length of treatment on outcome for pain or sexual dysfunction. How long should therapy last? A12-week duration, as found in our study1, is indeed short but was necessary for scientific and economic purposes. However, our recent two-year follow-up of the initial study participants revealed that although vestibulectomy remained superior to the other two conditions in its impact on vestibular pain (cotton-swab test), i t was equal to group cognitive-behavioral therapy in terms of self-reported pain during intercourse (Bergeron et al, unpublished data). This result corroborates that of Weijmar Schultz and colleagues2, who found no difference between cognitive-behavioral therapy and surgery at 2.5-3 year follow-ups. This suggests that the effects of cognitive-behavioral therapy may be slower to appear, and that if one is patient, surgerycan be avoided. Finally, it may be that the differences between our two studies are due more to the length of follow-up rather than to the length of treatment. Nonetheless, the impact of length of treatment and other relevant variables, such as patient degrees of self-efficacy, need to be further studied if we are to predict treatment outcome with greater accuracy. Weijmar Schultz and van de Wiel state that the positive results of the cognitivebehavioral therapy in their 1996 studyZ has lead them to favour this less invasive, albeit more time-consuming, intervention over surgery. The delivery of the cognitivebehavioral therapy in their study was in fact multidisciplinary and included physical therapy. Interestingly, despite the superior outcome results of the vestibulectomy condition in our randomized study, our overall clinical approach also begins by recommending cogni tive-behavioral therapy and physical therapy. Paradoxically, results of our study seem to have convinced participating gynecologists that cognitivebehavioral therapy and biofeedback were actually efficacious, and in turn convinced psychologists to overcome their biases against vestibulectomy. Overall, the gynecologists on our team report performing far fewer surgeries than they did five years ago. After diagnosing a woman with vulvar vestibulitis, the gynecologists typically recommend that she choose between cognitive-behavioral sex therapylpain management either given in group, couple or individual format, and physical therapy. If one or a combination of these treatments is not effective, i.e. to the satisfaction of the patient, the gynecologist will consider performing a vestibulectomy. The traditional medical approach postulates tha t we should always offer the more conservative treatment first. However, in the case of vulvar vestibulitis, conservative medical treatments such as corticosteroid 3. Bergeron, Department of Sexology, Universite du Quebec a Montreal, and Department of Psychology, McGill University Health Centre, Royal Victoria Hospital, Y. M. Binik, Department of Psychology, McGill University and Department of Psychology, McCill University Health Centre, Royal Victoria1 Hospital, and S. Khalife, Department of Obstetrics and Gynecology, McCill University, Jewish General Hospital, Montreal, Canada

Gender Similarities and Differences in Sexual Arousal, Desire, and Orgasmic Pleasure in the Laboratory

Relatively little is known about gender differences in the orgasm experience. The objectives of this study were to compare mens and womens patterns of sexual arousal and desire before and after orgasm, and the predictors of their orgasmic pleasure. Using their typical technique, where masturbation enjoyment was similar to that experienced at home, 38 men and 38 women masturbated to orgasm in the laboratory. Physiological sexual arousal (genital temperature) and subjective sexual arousal and desire measurements were taken at baseline, after masturbation almost to orgasm, and immediately and 15 minutes after orgasm. In both genders, all measures increased significantly during masturbation, with a greater buildup leading to a more pleasurable orgasm. After orgasm, however, sexual arousal and desire decreased more quickly and consistently in men than in women, thereby replicating Masters and Johnsons (1966) observations. More men than women exhibited resolution of subjective sexual arousal and sexual satiation; their genital temperature also decreased more than womens but did not return to baseline. Womens orgasmic pleasure was related to a postorgasmic decrease in genital temperature but, unexpectedly, the maintenance of subjective sexual arousal and desire. Future studies should explore whether this pattern explains gender differences in the pursuit of additional orgasms.

Using the Dual Control Model to Investigate the Relationship Between Mood, Genital, and Self-Reported Sexual Arousal in Men and Women

Recent findings suggest that there is considerable interindividual variability in how mood affects sexual arousal and that the dual control model may be helpful in explaining this variation. The current research investigated whether mood interacted with sexual excitation and inhibition proneness to predict subjective and genital arousal. In this study, 33 participants (18 men; 15 women), ages 18 to 45, attended three laboratory sessions where they completed questionnaires assessing preexisting mood and propensity for sexual excitation and inhibition, then watched a series of neutral and sexually explicit films. Subjective sexual arousal was continuously indicated during each film, while genital temperature was measured using thermographic imaging. Sexual excitation and inhibition interacted with various mood scores to significantly predict both subjective and genital arousal in men and women. Several gender differences were found. For example, vigor scores interacted with sexual excitation proneness to significantly predict genital but not subjective arousal in women, while the same interaction significantly predicted subjective but not genital arousal in men. The findings supported the hypothesis that the dual control model is an important framework in understanding how mood influences both subjective and genital sexual arousal.