13. Sexual Dysfunction Outcome Measures, Vestibulitis/Vestibulodynia, Dyspareunia, Vulvodynia Flashcards
What is provoked vulvodynia (PVD)?
Pain in the vulvar entry lasting more than 3 months, appearing in the absence of another recognizable vulvar disease
PVD presents as sharp pain or burning sensation localized at the vaginal entry during touch, pressure, and intercourse.
What are the effects of provoked vulvodynia beyond sexual function?
Alters mental health and quality of life (QoL)
Women with PVD experience significant psychological distress due to the condition.
Is there a gold standard treatment for women with PVD?
No gold standard treatment exists for women with PVD
This highlights the complexity and variability of managing the condition.
Which oral medication showed improvement in sexual function and satiffaction for provoked vulvodynia?
Gabapentin- function. Desipramine
sexual satisfaction improved
both with low evidence
This medication demonstrated improvements in the intervention group compared to placebo.
What topical treatment significantly reduced pain during intercourse?
Fibroblast lysate
This treatment showed less pain after 12 weeks but no difference in pain intensity during the cotton-swab test.
What is recommended for decreasing pain sensitivity in the vestibular mucosa?
Repeated application of topical lidocaine gel or cream
Clinical guidelines suggest this, yet RCT reviews show no difference in pain or sexual function.
What was the effect of daily application of vaginal diazepam?
Significantly less pain during intercourse after 2 months
Mild drowsiness was experienced by 10% of participants.
What was the outcome of Botox A injections for treating PVD?
Reported significantly less pain during intercourse or tampon use at 3 months, but effect diminished by 6 months
Other studies found no effect from Botox A injections.
What was the result of 10 weeks of combined physiotherapy techniques?
Significantly better results in the intervention group for pain during intercourse and sexual function
Improvements were observed at the 6 months’ follow-up.
What psychological treatment showed some beneficial outcomes for provoked vulvodynia?
Mindfulness-based CBT (mCBT) or CBT
While not significant, these therapies were noted to help with depressive and anxiety symptoms.
What treatment showed significant differences for pain, sexual satisfaction, anxiety, or depression?
TMS and low-level laser
These treatments were effective in improving various outcomes related to PVD.
True or False: Multimodal physiotherapy had significant evidence supporting its effectiveness compared to lidocaine treatment.
True
The evidence for multimodal physiotherapy was of low certainty but indicated improvements.
What is the key takeaway regarding treatment for women with PVD?
Women benefit from more complex interventions that combine several components. mMultimodal tx was helpful and comparrable to Lidociane for PVD treatment.
This approach helps manage pain and its consequences more effectively.
LIst intervnetions that can be used for PVD
10 weeks of combined PT techniques: education and information, exercises for pelvic floor muscles (PFM) using EMG biofeedback, as well as manual physiotherapy. HEP: instructed to perform home exercises for PFM function and vaginal dilation
* TENS with high frequency
* Psychological Treatments
* EMG biofeedback for pelvic floor rehabilitation or surgery (vestibulectomy)
* Mindfulness-based CBT (mCBT) or CBT
* TMS and low level laser
* Low intensity shock-wave treatment via a vaginal probe (pain reduced but not fxn)
What are the Genetic consideration for vulvodynia
Genetic polymorphisms can increase risk of: * candidiasis or other infections
* allow prolonged or exaggerated inflammatory responses
* increased susceptibility to hormonal changes associated with oral contraceptive pills
What are the hormonal considerations for vulvodynia
Use of combined hormonal contraceptives have been associated with increased risk of developing PVD
What are the inflammatory consideration for vulvodynia
Increases in inflammatory cells within painful regions of vulvar vestibule
Increase in number of mast cells and degranulated mast cells, and increased subepithelial heparanase activity are associated with vestibular hyperinnervation in women with PVD
What are the musculoskeletal consideration for vulvodynia
Pelvic floor hypertonic dysfx/overactivity
May lead to imbalances and functional modifications in the pelvic floor myofascial and neural tissue
What are the neurologic considerations for vulvodynia
Central - women with PVD more sensitive to various forms of stimulation in nongenital areas of the body
Peripheral - an increase in density of nociceptors in the vestibular endoderm that increases sensitivity
What comorbidities can be found in vulvodynia
ICS and oral pain
at least 1 comorbidity is usually found
What are the psyhchosocial considerations for vulvodynia
Anxiety, depression, childhood victimization, and posttraumatic stress increase risk for vulvodynia pain catastrophizing, fear of pain, hypervigilance to pain, lower pian self efficacy, negative attributions about pain, avoidance, anxiety, and depression
What healthcare disparities do sexual minorities face?
Higher rates of mental health disorders, smoking, physical limitations, and poor general health compared to heterosexuals
Which demographic of men has higher rates of hypertension and diabetes?
Gay and bisexual men over 50
What do many health care providers feel regarding their ability to help non-heterosexual patients?
They feel unequipped or not educated enough
What percentage of newly diagnosed HIV infections among adults is accounted for by the MSM population?
69%
Which groups within the MSM population are at an even higher risk for HIV?
Black or Latino MSM
What percentage of MSM reported condom use at last sex?
31%
List the HIV prevention strategies mentioned.
- Behavioral strategies (e.g., condom use, seroadaptive practices)
- Chemoprophylactic strategies (e.g., PrEP, post-exposure prophylaxis, treatment as prevention)
What are the names of the PrEP drugs mentioned?
- Truvada
- Descovy
these are HIV prevention meds
What sexual behaviors are significantly associated with STI prevalence?
- Felching
- Group sex
- Fisting
- Anonymous sex
- Use of sex slings
- Use of insertive sex toys
What sexual behaviors are significantly associated with HIV prevalence?
- Fisting
- Felching
- Use of enemas
- Group sex
How does erectile dysfunction (ED) prevalence compare between men with HIV and HIV-negative men?
ED is more prevalent among men with HIV
What is the relationship between antidepressant use and sexual dysfunction among MSM?
There is a direct correlation between an increase in depression/antidepressant use and the prevalence of sexual dysfunction
Name some substances associated with higher rates of substance use disorders among MSM.
- Alcohol
- Marijuana
- Alkyl nitrites
- Gamma hydroxybutyrate
- Methamphetamine
- Cocaine
- Ecstasy
- Ketamine
What psychological factors predict premature ejaculation (PE) among MSM?
- Negative body image
- Body dissatisfaction
What is the definition of premature ejaculation (PE)?
Ejaculation that occurs sooner than desired, either before or shortly after penetration, causing distress
What physiological factors make receptive anal intercourse more prone to pain?
- Type of epithelium of the anus
- Tightness of the anal sphincter
- Lack of natural lubrication
- Anorectal angle
What are predictors of anodyspareunia?
- Younger age
- Decreased frequency of sex
- Decreased number of partners
- Inadequate lubrication
- Lack of oral/digital stimulation
- Psychological factors (e.g., anxiety, internalized homophobia)
What methods can help diminish or prevent pain with penetration?
- Anal foreplay
- Oral/digital stimulation
- Anal massage
- Anal dilators
- Lubricants
- Alkyl nitrites
What can cause hypogonadism in prostate cancer survivors?
- Gonadal injury
- Hypothalamic injury
- Pituitary injury
- Androgen deprivation therapy
- Chemotherapy
What are common types of sexual dysfunction following prostate cancer treatment?
- Erectile dysfunction
- Anodyspareunia
- Anejaculation
- Decreased libido
- Anatomical penile changes
- Urinary incontinence during sex (climacturia)
What percentage of MSM following prostate cancer treatment had erections sufficient for insertive anal intercourse?
22%−27%
What is Peyronie’s disease?
Penile deformity due to the formation of a fibrous scar within the tunica albuginea
What is a penile fracture?
Rupture of the tunica albuginea of the corpora cavernosa
What is the conclusion regarding sexual health disorders among MSM?
High prevalence of sexual health disorders among MSM
What do healthcare practitioners need to improve when treating MSM patients?
Better education and training in culturally competent care
What are some causes of dyspareunia?
- Pelvic floor injury during vaginal delivery
- Pelvic inflammatory disease
- Infection
- Interstitial cystitis
- Adhesions
- Sexual violence
- Sexual abuse
What is genito-pelvic pain/penetration disorder?
A condition where a woman experiences recurrent genital pain before, during, or after vaginal penetration.
What improvements were noted in women with symptomatic dyspareunia after the pelvic floor rehabilitation program?
- Genito-pelvic pain
- Sexual function
- PFM strength
- Endurance
What techniques were included in the pelvic floor rehabilitation program for dysparunia?
- Digital biofeedback
- Intravaginal manual techniques
- Supervised PFM exercises (PFMEs)
- Electrotherapy
What did Naess and Bø demonstrate regarding pelvic floor muscle contractions?
Maximal voluntary pelvic floor muscle contraction can reduce vaginal resting pressure and resting electromyography activity. - helpful when overactive PFs contribute to pain wiht sex
What can be concluded about maximal contractions in pelvic floor rehabilitation?
Using maximal contractions may help reduce tone in an overactive pelvic floor.
What is TENS and its role in treating pelvic pain? What is the dosage?
Transcutaneous electrical nerve stimulation (TENS) can be used as a first-line treatment to inhibit pain based on the gate control theory.
20–25 min of high frequency TENS with intravaginal electrodes
( 110 Hz for an 80-ms pulse duration and maximal tolerable intensity to relieve pain).
How was TENS used for subjects with increased pain during intravaginal digital exams? In what order can it fall?
TENS was used to reduce genito-pelvic pain initially. 1st line treatment
What effect did pelvic floor muscle exercises (PFME) have on postnatal sexual function?
PFME alone improved postnatal sexual function.
What are the two main subtypes of vulvodynia?
Primary PVD / Secondary PVD- localized provoked pain at the vaginal vestibule
Generalized Vulvodynia (GVD)-Unprovoked, diffuse vulvar pain affecting the entire vulvar area.
Primary PVD (PVD1) is pain present since the first episode of vaginal penetration, while Secondary PVD (PVD2) occurs after a period of pain-free activities.
Define Generalized Vulvodynia (GVD).
Unprovoked, diffuse vulvar pain affecting the entire vulvar area.
What aspects should be included in the assessment of vulvodynia?
- Pain history
- Medical history
- Psychological assessment
- Pelvic floor musculature assessments
What is the purpose of validated self-report questionnaires like FSFI in vulvodynia assessment?
To gather information on pain characteristics, sexuality, and psychosocial factors that accompany the pain.
What does the Pain and psychosocial assessment for vulvodynia include?
Pain characteristics
msk hx, bowel and bladder fx
Sexuality
thoughts , emotions, behaviors, and couple interactions that accompany the pain
Comorbid medical or mental health conditions and txs
Previous tx attempts and outcomes
Current romantic relationship if relevant
Childhood trauma
Validated self report questionnaires - FSFI
What is the Cotton Swab Test used for?
To diagnose PVD by applying a cotton swab to the vestibule.
What does the Vulvalgesiometer measure?
Standardizes the amount of pressure applied to the vestibule to quantify levels of sensitivity.
Assessment and specific outcome measures for vulvodynia
Cotton swab test - cotton swab to vestibule to diagnose PVD
Vulvalgesiometer - standardizes the amount of pressure applied to the vestibule to quantify levels of sensitivity
Tampon test - pain with inserting tampon, easier that testing pain with intercourse
True or False: The FSFI is appropriate for women who have not been sexually active in the preceding 4 weeks.
False.
What medications may contribute to vulvodynia?
- Oral contraceptives- decreasing free circulating testosterone which might be harmful to the glands and endothelium of the vulvar vestibule
- Psychotropic medications- Low desire and arousal
- Long-term antibiotics-predispose women to chronic yeast infections
- Ask about CAM tx like Herbal supplements
What is assessed and should be explained during an educational pelvic exam?
Educate on anatomy and why each step is important as it is performed, use mirror to allow pt to follow along
What findings might indicate vulvodynia during a colposcopic examination?
- Infection
- Trauma
- Atrophy
- Dermatitis
- Neoplasia
magnifying device called a colposcope to visualize the cervix and take biopsies if necessary
What does pain location in the cotton swab test indicate?
- Labia majora, clitoral prepuce, perineum, and intra-labial sulci: Process that is affecting the entire anogenital region (eg, vulvar dermatoses or vulvovaginal infections)
- Pain throughout the entire vestibule: might be associated with an intrinsic pathology within the mucosa of the vestibular endoderm,
- posterior vestibule: pathology extrinsic to the vestibule, most commonly hypertonic pelvic floor muscle dysfunction
what are locations of palpation assessment for the cotton swab test?
The cotton swab should be used to palpate the vestibule gently at five locations (however, non-adjacent palpation of these sites is recommended to decrease sensitization: at the ostia of the Skene glands (lateral to the urethra), at the ostia of the Bartholin glands (4 and 8 o’clock at the vestibule), and at 6 o’clock at the fossa navicularis.
What is the recommended size of the speculum used in a speculum exam for vulvodynia?
Pediatric size Graves speculum.
What should be examined during a manual examination of the pelvic floor?
- Urethra
- Bladder trigone
- Levator ani muscles
- Pudendal nerve
What additional tests may be performed by other providers for vulvodynia?
- Wet prep of vaginal secretions
- pH testing
- Culture for candidiasis and trichomoniasis
- Biopsy if specific findings are noted
- blood tests
- Xray US based on findings
What is commonly found in women with PVD who are on hormonal contraceptives?
Increased SHBG and decreased free testosterone and estradiol.
What is the role of biofeedback in vulvodynia treatment?
To improve pelvic floor muscle strength and control.
Fill in the blank: Women with PVD typically have _______ in pelvic floor tone and poorer PFM strength.
increase
What nerves innervate the perineum and labia?
- Posterior femoral cutaneous nerve (perineum)
- Ilioinguinal nerve (labia)
- Genitofemoral nerve (mons pubis)
treatment of dysparunia
Treatment
* Referral to obgyn or sexual health specialist
* Vaginal estrogen
* PFPT - manual, biofeedback, dilators, HEP
* For the subset of women with provoked vestibulodynia potentially related to hormonal changes, the addition of off-label low dose topical testosterone at the vestibule may improve symptom relief beyond that attained with local estrogen treatment
* Women with provoked vestibulodynia may benefit from topical lidocaine applied to the vestibule before penetration - not rec’d for long term use
Evaluation of Dyspareunia
- Deeper pain = myofascial or pelvic organ origin
- Superficial pain = vulva or vestibule
- ask about hormonal status (postmenopausal, lactating,etc),
- medical, surgical, obstetric hx, trauma (including sexual violence), and social circumstances (
- Nongynecologic chronic health issues: fibromyalgia, ICS, inflammatory bowel disease, and lower back and hip musculoskeletal pain
- Visual inspection of external genitalia, biopsy of vulvar lesions
- sensory assessment of the genital skin can elicit patterns of allodynia and other dx
- Internal digital assessment
What evidence grade does PT have for vulvodynia treatment?
B
What are contributing factors to vulvodynia that PT can help with ?
Altered biomechanics muscular response to stress
* maladaptive guarding
* poor sports training techniques/over training * history of over activation of sport
* constant abdominal activation to appear slimmer * injury or dysfunction
* surgical repeated sensitizing events
* attempting core exercise when core is already over active
what surgical recommendations can be offered to patients with vulvodynia ?
severe vestibulitis who have not responded to conservative management may benefit from vestibulectomy, but noted no difference in sexual outcomes with surgery
How should dilators be used for vulvodynia care?
application should be clinically supported and contextual
rarely used in PVD to gain capacity through stretch, instead offers graded exposure
*provide a stimulus that does not elicit pain, providing an opportunity to learn a new way to respond (without fear or guarding);
what is the difference between vaginismus and PVD?
Vaginismus = significantly higher levels of emotional distress during gynecological examination and avoid significantly more sexual and nonsexual vaginal penetration attempts VS PVD
PVD= superficial dyspareunia
(+) cotton swab test
severe, sharp, burning pain upon vestibular touch or attempted vaginal entry
what is the difference between vaginismus and dyspaunia?
Women with vaginismus report fear of vaginal penetration, high emotional distress with penetration, tampon use (non-sexual)
Unclear if phobia, or a technique to reduce pain as a pain response
Dyspareunia patients : have not been shown to avoid vaginal penetration
Criteria for genito–pelvic pain/penetration disorder
should be used instead of vaginismus
*Inability to have vaginal intercourse/penetration on at least 50% of attempts;
*Marked genito–pelvic pain during at least 50% of vagina intercourse/ penetration attempts;
*Marked fear of vaginal intercourse/penetration or of genito–pelvic pain during intercourse/penetration on at least 50% of vaginal intercourse/penetration attempts;
*Marked tensing or tightening of the pelvic floor muscles during attempted vaginal intercourse/penetration on at least 50% of occasions.
Can vaginismus cause premature ejaculation?
No. erectile and premature ejaculation are generally the result rather than the cause of vaginismus
What are treatment suggestions for vaginismus?
Pelvic floor physiotherapy, pharmacological treatments, general psychotherapy and sex/cognitive behavioral therapy
Does muscle spasm have to be included in the definition of vaginismus?
Although spasm is part of the definition, only 28% demonstrate spasm on evaluation and 24% spasm with intercourse
Vaginal muscle spasm is not a reliable diagnosis, it should be evaluated with surface electromyography (sEMG) or needle electromyography, Yet studies that investigate vaginismus don’t have established protocols for definition; muscle inclusion definitions, assessment type, of definition of cramp/spasm
what are classifications of vaginismus
Classifications
Primary: lifelong problem
Secondary or acquired: if intercourse has been possible in the past and now is impossible
Global: if spasm occurs whenever penetration is attempted regardless of the circumstance
Situational: when it occurs under certain conditions
what is the most common form of vulvodynia
provoked vestibulodynia (PVD)
What do study results show for PVD tone
*Women with PVD showed higher PFM tone
* Altered strength, speed of contraction, coordination, and endurance
* Higher resting forces and stiffness with contribution of active and passive components
* Can be considered TONE because of mix of the active and passive components
Following the understand of tone on PVD, what should treatment consider for passive and active structures?
Modalities should target passive components of tone as well as active
Stretching, dilator, manual techniques to restore viscoelastic alterations
First need adequate muscle relaxation BEFORE effecting passive tone
Decrease pain behaviors (such as protective muscular reactions) that contribute to electrogenic spasm
Correct other potential contributors to electrogenic spasm
Psychological distress, muscle overload or overuse (inadequate posture), inefficient use (failure to fully relax after contraction)
what is a leading cuase of premenopausal vulvodynia
Provoked Vestibulodynia PVD is the leading cause of premenopausal vulvodynia
treatment for Provoked Vestibulodynia
BF, E-stim, dilators,MT,Education, multimodal techniqes
PT is considered the most effective intervention for PVD tx, according to a survey of experts:
Increase muscle awareness and proprioception
Improve muscle relaxation and discrimination
Normalizing muscle tone
Increasing elasticity of muscle and vaginal tissues and desensitizing painful area
Decreasing fear of vaginal penetration
what is the lamont grading scale
Lamont grading
Grade 1 - pt able to relax for pelvic exam
Grade 2 - pt unable to relax for pelvic exam
Grade 3 - buttocks lift off table, early retreat, toes curl upward
Grade 4 - generalized retreat - buttocks lift up, thighs close, pt retreats
Pacik Grade 5 - grade 4 plus visceral reaction which may result in any one or more of the following: Palpitations, hyperventilation, sweating, severe trembling, uncontrollable shaking, screaming, hysteria, wanting to jump off the table, a feeling of going unconscious, nausea, vomiting and even a desire to attack the doctor
what is the recommendation of lidocaine use for Provoked Vestibulodynia
PT group reported higher satisfaction with tx than women in lidocaine group. Lidocaine is often a first line tx, but PT can help with pain quality, sex and distress
treatment for primary vaginismus
Physiotherapy should be considered first-line treatment of vaginismus compared to botox injections.
* there was a greater decrease in sexualdysfunction in PT FES group vs bota group
* Botulinum toxin injections did not improve scores of lubrication and desire, although total sexual function scores improved
* look for main cause of pain and then provide multimodal tx
