Genito-Pelvic Pain/Penetration Disorder

The etiology of GPPPD is multifactorial, influenced by a combination of biologic, psychological, interpersonal, and sociocultural factors (see figure Biopsychosocial Model).

Biopsychosocial Model

Data from Parish SJ, Hahn SR, Goldstein SW, et al. The International Society for the Study of Women's Sexual Health Process of Care for the Identification of Sexual Concerns and Problems in Women. Mayo Clin Proc. 2019;94(5):842-856. doi:10.1016/j.mayocp.2019.01.009

Biologic: Medical issues such as pelvic floor dysfunction (1), endometriosis, vaginal infections (eg, yeast infections or bacterial vaginosis) (2), and hormonal changes (eg, menopause, oral contraceptive use) (3) that contribute to inadequate vaginal lubrication and vulvovaginal atrophy may contribute to pain issues.

Psychological: Women diagnosed with GPPPD are more likely to have a history of sexual, emotional, or physical abuse (2). Past painful sexual experiences may lead to anticipatory anxiety at future sexual encounters, resulting in tensing of pelvic muscles, bracing, increased pain, and eventual avoidance of sexual activity, creating a fear-avoidance cycle (4) (see figure Fear-Avoidance Cycle). Cognitive factors such as distracting thoughts, predisposing beliefs about sexual function (eg, unrealistic expectations), hypervigilance of pain symptoms, and catastrophizing can all play a role in anticipation and maintenance of pain (5).

Fear-Avoidance Cycle

Data from Basson R. The recurrent pain and sexual sequelae of provoked vestibulodynia: a perpetuating cycle. J Sex Med. 2012;9(8):2077-2092. doi:10.1111/j.1743-6109.2012.02803.x

Interpersonal: The interpersonal emotion regulation (IER) model proposes that a partner’s response to a woman’s sexual pain can influence the maintenance of pain symptoms (6). For instance, solicitous or negative partner responses may contribute to negative sexual outcomes, whereas facilitative responses are associated with more positive outcomes.

Sociocultural: Limited or inadequate sexual education, misinformation about sex, cultural, or religious education or beliefs that propose negative attitudes toward sexuality, and stress can contribute to development and maintenance of pain symptoms.

Symptoms of GPPPD include persistent or recurrent difficulties with vaginal penetration (intercourse, pelvic examination, or tampon use), often describing any attempt at penetration as painful or uncomfortable, anticipatory anxiety regarding penetration, tensing of the pelvic floor muscles, avoidance of penetration or sexual activity altogether, and psychological or interpersonal distress related to their experience. Women with GPPPD may be able to enjoy nonpenetrative sexual activities or they may have concurrent sexual issues, such as low sexual interest (libido).

• History and pelvic examination

• Clinical criteria

Evaluation of GPPPD is based on an obstetric/gynecologic and other medical history, sexual history, and pelvic examination.

The medical history should focus on determining menopausal status, eliciting gynecologic history or symptoms that can be associated with dyspareunia, and aligning with Diagnostic and Statistical Manual of Mental Disorders, 5th edition, Text Revision (DSM-5-TR) diagnostic criteria utilizing a biopsychosocial framework to identify precipitating, perpetuating, and maintaining factors. (See table Components of the Sexual History for Assessment of Female Sexual Dysfunction.) Standardized measures of sexual function, such as Female Sexual Function Index (FSFI) may be incorporated to support diagnosis (1).

DSM-5-TR criteria for genito-pelvic pain/penetration disorder require persistent or recurrent difficulties with of 1 or more of the following (2):

• Vaginal penetration during intercourse

• Marked vulvovaginal or pelvic pain during vaginal intercourse or penetration attempts

• Marked fear or anxiety about vulvovaginal or pelvic pain in anticipation of, during, or as a result of vaginal penetration

• Marked tensing or tightening of pelvic floor muscles during attempted vaginal penetration

Criteria require that these symptoms have been present for ≥ 6 months, cause significant distress in the individual, and cannot be better explained by another psychiatric or general medical condition, significant relationship stressors, or use of a medication or substance.

The pelvic examination can be especially helpful in detecting or excluding vulvovaginal or pelvic disorders (eg, vulvovaginitis, vaginismus). During the examination, the vulva is inspected, including the skin and mucosa (eg, for fissures typical of chronic candidiasis in the creases between the labia minora and majora, atrophy, signs of inflammation, abnormal skin lesions requiring biopsy), clitoral hood, urethral meatus, hymen, and openings of major vestibular gland ducts (3).

A moist cotton swab can then be used to map out the woman's pain. Provoked vestibulodynia manifests with pain that is reproduced when the vestibule is palpated. The pain may occur throughout the entire vestibule (from 1 to 11 o'clock) or sometimes only posteriorly (from 4 to 8 o'clock). If only the posterior part of the vestibule is affected, pelvic floor dysfunction may also be present.

A digital vaginal examination is then performed to check for pelvic floor hypertonicity, which can be elicited by palpating the levator ani muscles (4). Signs of pelvic floor hypertonicity include inability to relax pelvic floor muscles, involuntary muscle spasm and tenderness. The urethra and bladder should also be palpated anteriorly to identify abnormal tenderness.

A speculum examination can be performed to evaluate the cervix, and bimanual examination to palpate the uterus and ovaries can help identify causes of deeper pain.

Examination can sometimes be difficult because of the patient's pain and/or anticipation of pain. Many women with GPPPD cannot tolerate the speculum, so bimanual part of the examination cannot be performed. Explaining what will occur throughout the examination helps reduce anxiety and increase relaxation throughout the examination. If necessary, the examination can be deferred until the patient is able to tolerate it.

• Treatment of cause when possible

• Education about chronic pain and its effects on sexuality

• Lubricants, sometimes anesthetic (numbing) gels

• Pelvic floor physical therapy

• Progressive desensitization

• Psychological therapies

Management should be comprehensive, focus on biopsychosocial contributing factors, and include referrals to specialists as needed, such as gynecologists or pelvic floor physical therapists for medical interventions and psychologists or sex therapists for psychological interventions.

Medical interventions directed at addressing the underlying physical triggers, if present, such as menopause-related vaginal dryness and dyspareunia, vaginismus, and vulvodynia are the first step in management. Often a combination of pharmacotherapy and pelvic floor muscle training is recommended.

Medications used for vulvodynia include topical lidocaine, gabapentin, and certain antidepressants. Decreasing pelvic muscle hypertonicity with intravaginal diazepam or other muscle relaxant suppositories or botulinum toxin injections has been found to help minimize GPPPD symptoms (1). If vaginal dryness is contributing to dyspareunia, various lubricants (eg, water, silicone, or oil-based) and moisturizers can reduce vaginal dryness. Oil-based lubricants should not be used with condoms, but silicone- and water-based lubricants are safe to use. In postmenopausal women with genitourinary syndrome of menopause (GSM), vaginal atrophy can lead to pain with vaginal penetration; use of vaginal hormone therapy (low-dose estrogen, prasterone inserts) or oral ospemifene can be used to address this.

In addition to pharmacotherapy, pelvic rehabilitation therapies geared towards addressing the hypertonic pelvic floor muscles are often utilized. Pelvic floor physical therapy is a mainstay of treatment of women with GPPPD. Its aim is to teach women to relax the pelvic floor and decrease reflex tightening contributing to pelvic pain. Physiotherapists specializing in pelvic floor issues utilize a wide range of techniques including pelvic floor muscle training, soft-tissue mobilization and myofascial release, trigger-point pressure, electrical stimulation, biofeedback, and therapeutic ultrasound. Prescription and nonprescription devices are available for self-dilation in women with hypertonic pelvic muscles.

Photobiomodulation (TVPBM), a form of near-infrared light therapy, has been found to be effective at reducing chronic pelvic pain due to hypertonic muscular dysfunction in trials (1). Relaxation of smooth and skeletal muscle, along with improved circulation and reduced inflammation results from dissociation of nitric oxide within the muscle. In other chronic musculoskeletal conditions, TVPBM has been shown to improve pain and reduce inflammation.

Psychological interventions, such as psychotherapy approaches like CBT, mindfulness-based therapies, and individual and couples sex therapy, have been shown to improve sexual function in those with GPPPD, with CBT being the most widely studied.

• Genito-pelvic pain/penetration disorder (GPPPD) is ≥ 6 months of difficulty with vaginal penetration, pain with penetration, fear or anxiety about pain, and/or pelvic floor muscle tightening.

• GPPPD may be associated with dyspareunia, provoked vestibulodynia, vaginismus, or vulvodynia.

• Causes are multifactorial and may be biological, psychological, interpersonal, or sociocultural.

• Symptoms include when vaginal penetrative sexual activities are painful or difficult and/or are associated with anticipatory anxiety, pelvic floor muscle tension, avoidance of sexual activity, and distress.

• Diagnosis is based on medical and sexual history and pelvic examination.

• Management targets underlying causes and may include medications, education, pelvic floor physical therapy, desensitization, and psychological therapies.