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Genitopelvic Pain/Penetration Disorder

By

Allison Conn

, MD, Baylor College of Medicine, Texas Children's Pavilion for Women;


Kelly R. Hodges

, MD, Baylor College of Medicine

Last full review/revision Aug 2021| Content last modified Aug 2021
Click here for the Professional Version

Genitopelvic pain/penetration disorder includes pain during sexual intercourse or other sexual activity that involves penetration and involuntary contraction of muscles around the opening of the vagina (levator ani syndrome, or vaginismus), making sexual intercourse painful or impossible. This disorder also includes anxiety about attempts at penetration and difficulty having sexual intercourse.

  • Most women with genitopelvic pain/penetration disorder cannot tolerate insertion of any object into the vagina.

  • Most of these women fear and are anxious about pain before or during penetration of the vagina.

  • Pain during intercourse or attempted intercourse may result from vaginal dryness or disorders of the genital organs.

  • Doctors diagnose genitopelvic pain/penetration disorder based on symptoms, a pelvic examination, and specific criteria.

  • Anesthetic ointments, lubricants, exercises to relax pelvic muscles, exercises to get women used to touching the opening of their vagina and having their partner touch it, or a change in the position for intercourse may help.

  • The cause, if identified, is treated.

Pain during intercourse may be

  • Superficial (called provoked vestibulodynia): Occurring when pressure is put on the opening to the vagina (genital area or vulva)

  • Deep (called dyspareunia): Occurring when the penis moves deep into the vagina

The pain may be burning, sharp, or cramping. Pelvic muscles tend to become tight, which increases the pain, whether it is superficial or deep.

Pain, including pain during sexual intercourse, is greatly affected by emotions. For example, minor discomfort may feel like severe pain after a traumatic sexual experience, such as rape. Anger toward a sex partner, fear of intimacy or pregnancy, a negative self-image, or a belief that the pain will never go away may make the pain feel worse.

In genitopelvic pain/penetration disorder, muscles around the opening of vagina tighten involuntarily for no apparent physical reason even if the woman wants to have sexual intercourse.

Many women with genitopelvic pain/penetration disorder also have difficulty becoming aroused and/or difficulty reaching orgasm.

Causes

Causes of genitopelvic pain/penetration disorder vary depending on whether the pain is superficial or deep.

Superficial pain

Superficial pain may result from the following:

Genitourinary syndrome of menopause refers to changes in the vagina and urinary tract that occur after menopause. Tissues of the vagina can become thin, dry, and inelastic, and lubrication for intercourse is inadequate. These changes occur because estrogen levels decrease as women age. These changes can make intercourse painful. Urinary symptoms that can occur at menopause include a compelling need to urinate (urinary urgency) and frequent urinary tract infections.

Provoked vestibulodynia may be present the first time something (such as a tampon, speculum, or penis) is inserted into the vagina (penetration). Or it may develop in a woman who has experienced comfortable, pain-free penetration. Vestibulodynia may result from a combination of factors, including the following:

  • Inflammation or an immune reaction (which may result from contact with an irritating substance, a contact irritant, an infection or a drug)

  • An increased number of nerve fibers (which is sometimes present at birth), making the area more sensitive to pain

  • Decreased production of hormones

  • Problems with the pelvic floor muscles (muscles that are located in the low in the pelvis and that support organs in the pelvis, including the vagina)

The hymen is a membrane that encircles or, in a very few women, covers the opening of the vagina. When women have sexual intercourse the first time, the hymen, if not previously stretched (for example, from tampon use or sexual stimulation with a finger inside the vagina), may tear, causing some pain and bleeding. A few women are born with an abnormally tight hymen.

The term levator ani syndrome has largely replaced the term vaginismus because symptoms of vaginismus typically result from levator ani muscle dysfunction. Levator ani syndrome is involuntary contraction of the levator ani, which is the main pelvic floor muscle. It is the muscle that contracts during orgasm. This disorder may result from fear that intercourse will be painful. It often begins when sexual intercourse is first attempted but may develop later after periods of stress. If women fear sex will be painful, their muscles may automatically tighten whenever the area around the vagina is touched.

Deep pain

Deep pain during or after sexual intercourse may result from the following:

Strong unintended (involuntary) contraction of the muscles in the pelvis (called pelvic muscle hypertonicity) can cause or result from deep pain.

Symptoms

The pain of genitopelvic pain/penetration disorder may first occur when something (tampon, speculum, or penis) is inserted into the vagina. Or the woman may never have had pain-free sexual intercourse. For example, the pain may occur after a period of pain-free intercourse. The pain is often described as burning or stabbing.

Women with genitopelvic pain/penetration disorder may have an intense fear of and anxiety about pain before or during penetration of the vagina. When women anticipate that pain will recur during penetration, their vaginal muscles tighten, making attempts at sexual intercourse even more painful. However, most of these women can enjoy sexual activity that does not involve penetration.

The inability to have sexual intercourse can strain a relationship. Women may feel ashamed, embarrassed, inadequate, or depressed. It causes significant stress for women who want to have a baby.

Diagnosis

  • A doctor's evaluation, based on specific criteria

Doctors diagnose genitopelvic pain/penetration disorder based on the woman’s description of the problem, including when and where the pain is felt, and on the results of a pelvic examination Pelvic Examination For gynecologic care, a woman should choose a health care practitioner with whom she can comfortably discuss sensitive topics, such as sex, birth control, pregnancy, and problems related to... read more . The pelvic examination can detect or rule out physical abnormalities. However, the woman's pain and anticipation of pain and involuntary contraction of muscles around the vagina's opening can make the examination difficult. Doctors try to make the examination as tolerable as possible. They are as gentle as possible and often explain what they are doing in detail. Doctors may ask the woman whether she wants to sit up and view her genitals in a mirror during the examination. Doing so may give her a sense of control and ease her anxiety.

The area in and around the opening of vagina is gently but thoroughly examined for possible causes, such as signs of inflammation or abnormalities. If doctors find an abnormal area, they may take a sample to be examined under a microscope (biopsy).

To determine where the pain occurs, a doctor may use a cotton swab to touch different areas around and/or in the vagina.

The doctor assesses the tightness of the pelvic muscles around the vagina by inserting one or two gloved fingers into the vagina. To check the uterus and ovaries for abnormalities, the doctor then places the other hand on the lower abdomen (called a bimanual examination) and presses on these organs.

Doctors also press on the urethra and bladder to check for tenderness.

A rectal examination may also be done.

Doctors diagnose genitopelvic pain/penetration disorder based on criteria from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), published by the American Psychiatric Association. These criteria require the presence of at least one of the following:

  • Significant pain during intercourse or penetration attempts

  • Significant fear or anxiety about pain in anticipation of, during, or because of vaginal penetration

  • Significant tensing or tightening of the pelvic muscles during attempts to penetrate the vagina

These symptoms must have been present for at least 6 months and must cause significant distress in the woman. Also, doctors must rule out any other cause of the symptoms, such as another disorder, sexual abuse, or drug or other substance.

Treatment

  • Anesthetic creams, sitz baths, and lubricants

  • Treatment of the cause if possible

  • Psychologic therapies

  • Pelvic floor physical therapy

  • Desensitization

Treatment may involve a team of clinicians, such as doctors and physical and sex therapists.

Which treatments for genitopelvic pain/penetration disorder are best has not been determined, and treatments vary depending on symptoms. However, some general measures are recommended.

General measures

General measures include wearing cotton underwear during the day, washing with a mild soap (only using soap on the hairy areas of the genitals), and avoiding douching and over-the-counter vaginal deodorants. Using an unscented, unflavored lubricant during sex can reduce vaginal dryness, which causes pain during intercourse.

Vaginal lubricants and moisturizers include food-based oils (such as coconut oil), silicone-based lubricants, and water-based products. Water-based lubricants dry out quickly and may have to be reapplied, but they are preferred over petroleum jelly or other oil-based lubricants. Oil-based lubricants tend to dry the vagina and can damage latex contraceptive devices such as condoms and diaphragms. They should not be used with condoms. Silicone-based lubricants can be used with condoms and diaphragms, as can water-based lubricants. Women can ask their doctor which type of lubricant would be best for them.

When treating genitopelvic pain/penetration disorder, doctors or other team members often do the following:

Sexual activities that do not involve penetration can help couples attain mutual pleasure (including having orgasms and ejaculation). An example is stimulation involving the mouth, hands, or a vibrator.

Spending more time in foreplay may increase vaginal lubrication and thus make intercourse less painful.

For deep pain, using a different position for intercourse may help. For example, being on top can give women more control of penetration, or another position may limit how deeply the penis can be thrust.

Psychologic therapies

Psychologic therapies, such as cognitive-behavioral therapy and mindfulness-based cognitive therapy (MBCT), may benefit some women. Mindfulness involves focusing on what is happening in the moment, without making judgments about or monitoring what is happening. Such therapies help women manage their fear and anxiety about pain during sexual intercourse.

Doctors may refer women to a qualified sex therapist for psychologic therapies.

Pelvic floor physical therapy

Pelvic floor physical therapy can often benefit women with genitopelvic pain/penetration disorder. It includes pelvic floor muscle training, sometimes with biofeedback, to teach women how to consciously relax their pelvic muscles. These exercises teach women to tighten these muscles and then relax them.

Physical therapists may use other techniques to stretch and relax tight pelvic muscles. Techniques include

Levator ani syndrome (vaginismus) can be treated with progressive desensitization (done by hand or with dilators). This technique enables women to gradually get used to the genital area being touched. The next step is taken only when the woman is comfortable with the previous step.

  • The woman touches herself daily as close to the vagina's opening as possible. Once her fear and anxiety due to touching her genitals has decreased, the woman will be more able to tolerate the physical examination.

  • The woman inserts her finger past her hymen. She is instructed to push or bear down as she inserts her finger to enlarge the opening and ease entry into the vagina.

  • She inserts specially designed dilators gradually increasing sizes. Leaving a dilator inside for 10 to 15 minutes helps the muscles get used to gently increasing pressure without automatically contracting. After she can tolerate the smallest size, she inserts the next larger and so on.

  • The woman allows her partner to help her insert a dilator during a sexual encounter to confirm that it can go in comfortably when she is sexually excited.

  • The woman should allow her partner to touch the area around the vagina's opening with his penis or a dildo but without its entering the vagina. Then the woman can get used to feeling the penis or dildo on this area.

  • Eventually, the woman inserts her partner’s penis or a dildo partially or fully in the vagina in the same way that she placed the dilator. She may feel more confident if she is on top during intercourse.

For superficial pain, pelvic floor physical therapy is key because involuntary contraction of the muscles around the vagina's opening is often part of the problem. Applying an anesthetic ointment and taking sitz baths may help, as may liberally applying a lubricant before intercourse.

Specific therapies

More specific treatment depends on the cause, as in the following:

Estrogen can be inserted into the vagina as a cream (with a plastic applicator), as a tablet, or in a ring (similar to a diaphragm). These topical forms of estrogen can relieve symptoms that affect the vagina and urinary tract. If women are also having hot flashes, doctors may instead prescribe estrogen taken by mouth or estrogen patches applied to the skin. If women have a uterus (that is, they have not had a hysterectomy), they are given estrogen plus progestogen (a version of the hormone progesterone) because taking estrogen alone increases risk of cancer of the lining of the uterus Cancer of the Uterus Cancer of the uterus develops in the lining of the uterus (endometrium) and is thus also called endometrial cancer. Endometrial cancer usually affects women after menopause. It sometimes causes... read more Cancer of the Uterus (endometrial cancer). Low doses of estrogen are used. Estrogen patches are usually preferred over tablets for postmenopausal women.

In postmenopausal women, a synthetic form of dehydroepiandrosterone (DHEA) called prasterone, inserted into the vagina, can also relieve vaginal dryness and make sex less painful.

Ospemifene (a selective estrogen receptor modulator, or SERM) and estrogen affect vaginal tissues in a similar way. Like estrogen, ospemifene can be used to relieve vaginal dryness and other symptoms that involve the vagina and/or urinary tract.

Drugs used to treat neuropathic pain Adjuvant Analgesics In some cases, treating the underlying disorder eliminates or minimizes the pain. For example, setting a broken bone in a cast or giving antibiotics for an infected joint helps reduce pain.... read more (pain due to damage of the nervous system) can help lessen the pain in provoked vestibulodynia. They include the antiseizure drugs gabapentin and pregabalin and the antidepressants amitriptyline and nortriptyline.

Various creams that contains gabapentin and amitriptyline can be applied directly to the vagina's opening. These treatments may help relieve the pain and have fewer side effects.

Botulinum toxin type A, injected into the pelvic floor muscles, is usually used only to treat provoked vestibulodynia when no other treatments have been effective. It is used only for a short period of time.

Vestibulectomy (removal of the area around the vagina's opening) is rarely done. It is usually done in women who have never had pain-free sexual intercourse.

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