Female sexual dysfunction is currently classified by the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM 5) into three categories – genito-pelvic pain/penetration disorder (GPP/PD), sexual interest/arousal disorder and female orgasmic disorder.

Symptoms are experienced 75% to 100% of the time for at least 6 months and cause significant distress. It should not be due to substance abuse or medications, a psychiatric condition, the consequence of severe relationship distress (e.g., partner violence) or other significant stressors.¹

GENITO-PELVIC PAIN/PENETRATION DISORDER – A TYPE OF FEMALE SEXUAL DYSFUNCTION

GPP/PD was previously termed sexual pain disorder, and was made up of two separate diagnostic entities in DSM ⁴, namely dyspareunia and vaginismus.

Dyspareunia is defined as persistent or recurrent pain with attempted or complete vagina entry and/or vagina penetration. Vaginismus is described as persistent or recurrent difficulties to allow vaginal entry of a penis, finger or any object, despite the woman’s expressed wish to do so.

In vaginismus, individuals experience fear and anxiety during penetration attempts which cause vagina and pelvic floor muscle contraction, resulting in the experience of genital pain. This pain then results in an increased experience of negative emotions and hypervigilance that perpetuate muscle tension. This leads to a cycle of pain and unsuccessful attempts at penetration, which often ultimately leads to sex avoidance.

The aetiology of GPP/PD is multifactorial (Refer to Table 1), and can be due to physical (Refer to Table 2), psychological, psychosocial, sexual and cultural factors.

INCIDENCE AND PREVALENCE

GPP/PD is under-recognised and under-treated, but a common and distressing complaint that affects women of all age groups.2

Worldwide incidence of GPP/PD is estimated to be highest in women aged 20 to 29 years old, at 22 per 1000 women years. The incidence reduces to 9, 5 and 8 per 1000 women years in the fourth, fifth and sixth decade of life respectively.³

International GPP/PD prevalence rates range from 1% to 20% in adult women. This variability in range may be attributed to age differences among women.⁴

Dyspareunia prevalence ranges from 14% to 34% in younger women and 6.5% to 45% in older women.^{5, 6, 7} Localised provoked vulvodynia is the most common cause of superficial dyspareunia in pre-menopausal women, affecting up to 12% of the fertile population.5 Vaginismus prevalence ranges from 1% to 5% in fertile women and may be higher in subfertile populations.^{8, 9}

A survey study of Singaporean women in the tertiary health setting showed that 38.3% experienced sexual problems and 22% reported genital sexual pain.¹⁰

At KK Women’s and Children’s Hospital, there were 129 new cases of patients with female sexual difficulties who presented to the multidisciplinary sexual health clinic in 2016.

PATIENT PROFILE

Women across all age groups may suffer from GPP/PD. The condition is sub-classified into lifelong or acquired, and generalised or situational.

Acquired GPP/PD can be precipitated by life events such as pregnancy, menopause, infertility and cancer. Pelvic cancer treatment, such as surgery, radiation, and hormones, can cause dyspareunia directly, as well as indirectly, by inducing premature menopause.

GPP/PD is frequently co-morbid with other female sexual dysfunctions, such as reduced sexual interest, orgasm, lubrication and satisfaction (Refer to Table 3).

Women with superficial genital pain (e.g., provoked vulvodynia) have high prevalence of depression and anxiety, and low self and body esteem with specific personality traits, such as neuroticism and harm avoidance.² These intrapersonal characteristics predispose individuals to sexual dysfunction.

Vaginismus patients present with anxiety rather than depression, and exhibit phobic avoidance due to psychosomatic fear of penetration. Associations with a harm avoidance personality trait and catastrophic cognition have been found.²

Fatigue is common in chronic pain patients and can interfere with sexual and non-sexual function.

The male partner’s erectile and ejaculatory dysfunction have also been found to be closely-related.² Severe penile curvatures can also cause dyspareunia.

HOW SHOULD GENERAL PRACTITIONERS APPROACH FEMALE SEXUAL PAIN?

Sexual health concerns frequently surface in conversations with primary care providers and not specialists. A qualitative study by Brooks et al found that patients with vestibulodynia had seen up to 15 physicians before receiving a diagnosis, which delays treatment by an average of 24 months.¹¹

General practitioners can encourage earlier intervention by questioning all patients about their sexual health concerns. The PLISSIT model provides a concise method for integrating sexual enquiry into a clinical consultation, and can be used by all healthcare professionals:

1. Ask for permission: Use of open-ended questions such as “Is there anything about your sexual health you would like to discuss?”


2. Offer limited information: Once the patient has identified a concern, the provider can offer targeted information, such as potential causes of the symptoms or clarify misinformation.


3. Give specific suggestions: Offer differential diagnosis and give specific suggestions to start addressing the problem.


4. Intensive intervention: If necessary, a referral can be made to a sexual health specialist, such as a sex therapist or pelvic floor specialist to provide more comprehensive support and guidance.

If sexual pain has been identified after utilising the PLISSIT model, assessment can proceed in the following manner outlined in Table 4.

1. Specify if symptoms are lifelong or acquired; localised or generalised, and identify if the pain is situational (e.g., only during partnered sex). Elicit the presence of extra-genital pain. Gynaecological, psychiatric and sexual history are especially important. Medications, such as oral contraceptive pills, have also been associated with genital pain in users.²


2. Patients with sexual pain, especially vaginismus patients, are often reluctant to undergo a gynaecological examination, especially during their first visit.
   
   Internal vagina examinations should not proceed against the patient’s wishes. In the primary care setting, internal vagina examinations should not be performed on virgins.
   
   However, external genitalia assessment for vulvovaginal atrophy, dermatoses and infections can usually be performed. Extra-genital manifestations of the disease responsible may be found (e.g., oral mucosa lichen planus).


3. For women of reproductive age, consider the patient’s goals (e.g., trying to conceive or to achieve painfree intercourse) when making a referral.
   
   Use of the PLISSIT model also helps primary care providers route patients with complex sexual health issues to appropriate specialists, by differentiating between psychological and physical causes of pain or dysfunction.

For instance, a woman with depression may not feel pleasure during masturbation or sex. The PLISSIT model can be used to determine whether her sexual difficulties stem from depression, or a physiological cause such as postpartum pelvic floor dysfunction.

SPECIALIST MANAGEMENT

Patients are usually first referred to gynaecologists or dermatologists for confirmation of a pathological diagnosis, to exclude malignancy, or after first-line treatment has failed. GPP/PD can be considered a chronic pain condition as symptoms last more than 6 months. It is also frequently co-morbid with psychological disorders such as anxiety and depression, disturbances in other phases of the sexual response and is also associated with sexual dysfunction in the partner.

Therefore, a multi-systemic and multi-disciplinary assessment approach to the assessment and management of genital sexual pain is recommended, focusing on pre-disposing, precipitating and maintaining factors for treatment and relapse prevention.

Couple assessment is recommended as genital sexual pain affects the sexual function of the couple as a whole. When initiating treatment for sexual pain, Van Lankveld et al has recommended focusing on the following six areas (Refer to Figure 1): mucous membranes, pelvic floor, pain intensity, sexual and relationship function, psychological adjustment and sexual history.¹²

Psychosexual assessment and interventions should be integrated with medical management. The British Society for the Study of Vulval Disease also recommends combination treatment for the management of vulval pain.¹² Not all patients require or are motivated to pursue psychotherapy, but a provision of brief sexological counselling sessions are still helpful for most couples for education and support. Cognitive- behavioural therapy has been found to be effective for vulvodynia.¹³

Pelvic floor assessment by a physiotherapist experienced in pelvic floor dysfunction is important, as women with chronic sexual pain commonly have reduced pelvic floor function and increased tension. Pelvic floor rehabilitation is part of multi- systemic treatment for GPP/PD and can be performed using physical therapy or electromyography biofeedback.

CASE STUDY

A female patient in her late 20s and her husband in his 30s were referred to the subfertility clinic (at KKH) for dyspareunia. The couple had requested for in-vitro fertilisation (IVF) as they had been trying to conceive since getting married a few years ago. Joint consultation was held and sexual history revealed the patient had no prior experience of vagina insertion during masturbation, nor previous tampon use. The couple were each other’s first sexual partners and had no pre-marital sexual activity.

Since marriage, sex had never been successful as the patient always felt a sharp pain on attempted penetration, and was worried that this could be due to her hymen tearing. She had consulted a gynaecologist previously, but was not able to tolerate a speculum examination. Local anaesthetic gel was prescribed for her use when needed, and she was encouraged to try to relax and continue attempting intercourse. Attempts at arousal failed to overcome the problem.

Over time, attempts at intimacy dwindled and her husband developed difficulty in maintaining his erection. He consulted an urologist and was prescribed, but it did not lead to successful consummation of marriage. During a subfertility clinic session, the patient exhibited physical symptoms of heightened anxiety during physical examination and hence, an internal vagina examination was not performed.

In this case study, anatomical and other biological causes of pain were needed to be ruled out before attributing pain to vaginismus. Even though an internal examination was not performed, congenital causes such as an imperforate hymen can be detected by gentle traction of buttocks downwards to inspect the introitus. Internal pelvic examination is not mandatory for vaginismus patients prior to treatment, but may be an end point of therapy. It is important to note that many vaginismus patients are still virgins and a thorough explanation of what is involved in an internal pelvic examination and its possible implications (torn hymen) should be undertaken, and consent should be documented.

The male partner’s sexual difficulties can be the cause or the result of female dysfunction. For vaginismus patients, partners frequently complain of difficulty maintaining erections. However, taking phosphodiesterase type 5 inhibitors does not help partners of vaginismus patients achieve penetration and may in fact worsen sexual pain. Relationship factors are important in sexual pain disorders and couple therapy may be required.

In Singapore, sexual naivety is often seen in vaginismus patients, and vaginismus treatment should include education on sexual response and an understanding of genitalia structures. A combination of approaches, including progressive digital/dilator desensitisation, Kegel’s exercises and cognitive-behavioural therapy are commonly utilised.

Women who experience painful sex are likely to suffer from impaired libido and arousal, as described earlier. Therefore, concentrating more on foreplay and non-penetrative forms of sexual pleasuring can increase enjoyment and reduce pain. Sensate focus may be beneficial. Avoidance of penetration is also recommended during treatment to break the cycle of pain.

IVF is often viewed as a “quick-fix” to conception for couples who are trying to conceive. However, for young couples who are unable to consummate the marriage due to vaginismus, with no obvious subfertility factors, it may be reasonable to start with working towards the goal of pain-free sex first; or at least to aim for tolerance of internal medical examinations required for subfertility work-up and treatment.

GPs can call for appointments through the KKH Central Appointments Hotline at 6294 4050 for more information.

Dr Tan Tse Yeun is a Consultant at the Department of Reproductive Medicine at KK Women’s and Children’s Hospital, and is an accredited IVF Specialist and a Fellow of the European Committee of Sexual Medicine.
Dr Tan is also a clinical lecturer at the Yong Loo Lin School of Medicine, a clinical faculty member of the Lee Kong Chian School of Medicine, and an adjunct instructor at the Duke-NUS Medical School.

References

1. American Psychiatric Association (2013) DSM-5: Diagnostic and Statistical Manual for Mental Disorders. 5th edition. American Psychiatric Press, USA.
2. Standard Operating Procedures for Female Genital Sexual Pain. Fugl-Meyer, Kerstin S. et al. The Journal of Sexual Medicine, Volume 10, Issue 1, 83 – 93
3. Danielsson, I., Sjöberg, I., Stenlund, H., Wikman, M. Prevalence and incidence of prolonged and severe dyspareunia in women: Results from a population study. Scand J Public Health. 2003;31:113–118.
4. Eugl-Meyer, K.S., Lewis, R.W., Corona, G.C., Hayes, R.D., Lauman, E.O., Moreira, E.D. Jr, Rellini, A.H., Segraves, T. Definitions, classification & epidemiology of sexual dysfunction. in: Montorsi F. (Ed.) Sexual medicine sexual dysfunctions in men and women. Health Publication Ltd,; 2010:42–117.
5. Harlow, B.L. and E.G. Stewart, A population-based assessment of chronic unexplained vulvar pain: have we underestimated the prevalence of vulvodynia? J Am Med Womens Assoc, 2003, 58: 82-8.
6. Laumann, E.O., A. Paik, and R.C. Rosen, Sexual dysfunction in the United States: prevalence and predictors. JAMA 1999, 281: 537-44.
7. Oberg, K., A.R. Fugl-Meyer, and K.S. Fugl-Meyer, On categorisation and quantification of women’s sexual dysfunctions: an epidemiological approach. Int J Impot Res 2004, 16: 261-9.
8. Binik, Y.M., The DSM diagnostic criteria for vaginismus. Arch Sex Behav 2010, 39: 278-91.
9. Danielsson, I., et al., Prevalence and incidence of prolonged and severe dyspareunia in women: results from a population study. Scand J Public Health 2003, 31: 113-8.
10. Sexual behaviour of women in Singapore. V Atputharajah 1990
11. Feldhaus-Dahir M. The causes and prevalence of vestibulodynia: a vulvar pain disorder. Urologic Nurs. 2011; 31(1):51-54.
12. Van Lankveld, J. J., Granot, M. , Weijmar Schultz, W. C., Binik, Y. M., Wesselmann, U. , Pukall, C. F., Bohm-Starke, N. and Achtrari, C. (2010), Women’s Sexual Pain Disorders. The Journal of Sexual Medicine, 7: 615-631.
13. 2014 UK national guideline on the management of vulval conditions. Sarah K Edwards, Christine M Bates, Fiona Lewis, Gulshan Sethi, Deepa Grover