Sexual Pain Disorders

Sexual Pain Disorders
Cindy Meston, Ph.D. & Penny Frohlich, Ph.D.

DYSPAREUNIA

The DSM-IV defines dyspareunia as recurrent or persistent genital pain associated with sexual intercourse. The diagnosis of dyspareunia is not given if the pain decreases or is eliminated by adequate vaginal lubrication.

Although dyspareunia is currently classified as a psychiatric disorder, experts contend that it may be better classified as a pain syndrome that results in sexual dysfunction rather than a sexual dysfunction (that involves pain). In a recent review, Binik et al. (2000) suggested that describing genital pain along several dimensions including location, quality, elicitors, course, intensity, and meaning could be useful in identifying the cause of the pain and directing the type and course of treatment. Some women report that the pain is localized, generalized, or wandering while some women are not able to identify the location of the pain. The pain may have a “sharp,” “burning,” “dull,” or “shooting” quality that may reflect the type of pathology. The pain may be specific to intercourse, or may follow other types of stimulation (e.g., oral sex). It may begin before, during, or after stimulation, and may be mild, moderate, severe, or excruciating. Women may attribute meaning to the pain – they may believe it is related to a medical condition or a psychological source.

Dyspareunia may be caused by anatomical, pathological, iatrogenic, or psychological factors. A rigid hymen would be an anatomical factor that could result in genital pain during intercourse. Infections in the genitals could produce genital pain during intercourse, as could endometriosis and nonmalignant and malignant tumors. Surgical procedures (e.g., episiotomy) could also result in dyspareunia. Following menopause, atrophy of the vulva and vaginal tissue can increase the likelihood of dyspareunia. No one disease is associated with dyspareunia and a disease or disorder can be quite extensive without causing sexual pain. A variety of psychological factors may also lead to dyspareunia. For example, it may develop as a result of attitudes and values passed down from parents that lead to fear and anxiety in sexual situations, traumatic events where sexual or nonsexual contact with the genitals was experienced as painful, or emotional or relational factors, such as depression or discord between partners.

Recent evidence suggests that some forms of dyspareunia may be associated with abnormalities in pain sensation. The sense of touch and pain was measured in women with vulvar vestibulitis and control women (vulvar vestibulitis is a condition characterized by severe pain upon attempted intercourse or vestibular touch – the vestibule refers to the area of tissue below the clitoris, between the labia minora, and the vaginal opening). Touch and pain thresholds were obtained by applying small amounts of force to the skin; touch threshold was defined as the minimum amount of force needed for the women to consciously detect the stimulation, and pain thresholds were defined as the minimum amount of force that was experienced as painful. The women with vulvar vestibulitis were more sensitive to light touch and pain then the control women suggesting greater tactile and pain acuity (Pukall et al., 2000). Women with vulvar vestibulitis also had more densely packed sensory nerves in the vestibule, which may account for their increased sensitivity (Westrom & Willen, 1998).

Treatment

Regardless of the cause of dyspareunia, the symptoms are most effectively treated with cognitive-behavioral therapy. Even when the pain is a direct result of a medical condition, the pain often continues after medical intervention (Schover et al., 1982). Psychological treatment typically involves one or more of the following techniques: vaginal exercises, vaginal dilation, systematic desensitization, and couples therapy (education regarding communication and sexuality). The goal is for the woman and her partner to learn, through education and direct experience, that sexual contact and intercourse does not necessarily produce pain. Vaginal exercises involve the voluntary contraction of the vaginal muscles, allowing the women to gain familiarity and greater control over her muscle contractions. Vaginal dilation involves inserting increasingly larger dilators into the vagina until the woman is able to insert one that is a similar size to her partner’s penis, without experiencing pain or anxiety. Vaginal dilation is one form of systematic desensitization but systematic desensitization can also be performed by fantasizing about pain producing activities. The woman is first asked to list activities in order from least painful or anxiety provoking to most painful and anxiety provoking. She is then instructed to fantasize about the least painful activity until she is able to picture it without discomfort. Once she is able to do this, she moves to the next item on the list, until she is able to fantasize about the most painful and anxiety-provoking item on the list without feeling discomfort.

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VAGINISMUS

The DSM-IV defines vaginismus as repeated and persistent involuntary spasm of the vaginal muscles that interferes with intercourse. For many women, this difficulty is not specific to intercourse; they are often unable to insert even tampons into their vaginas and fear and avoid gynecological exams. The condition is not necessarily a generalized sexual problem; many women with vaginismus are able to enjoy sexual stimulation and orgasm that does not involve penetration of the vagina. The prevalence of vaginismus is not known. Laumann et al. (1994) interviewed a random sample of 1,749 women and found that 10-15% of women reported sexual pain, either dyspareunia or vaginismus. Approximately 12-17% of women seeking sexual therapy present with symptoms of vaginismus (Spector & Carey, 1990).

Although the DSM-IV indicates that vaginismus involves spasm of the musculature of the outer third of the vagina, this description is based almost exclusively on self-report rather than physical examination. One study found no difference in vaginal muscular activity (measured via EMG) between women with vaginismus and control women (van der Velde & Everaerd, 1996). No empirical studies have explored what specifically occurs to prevent penetration. It is not clear whether muscle contraction prevents penetration or makes penetration difficult or painful, or whether penetration is not attempted due to anticipatory pain. The DSM-IV does not include pain as a characteristic of vaginismus, yet some experts in the field argue that the pain, or the anticipation of pain, may be central to the disorder (Reissing et al., 1999).

Vaginismus has traditionally been thought to result primarily from psychological factors. A review of the family histories of women with vaginismus reveals similar backgrounds. Often women with vaginismus were raised by parents with oppressive or authoritarian attitudes (Tugrul & Kabakci, 1997) and had parents who were engaged in frequent conflict (Silverstein, 1989). Many women with vaginismus report having fathers who were domineering or threatening, alcoholic, seductive, or overprotective, and mothers who disliked sex or viewed sex as an obligation. Approximately 40% of women with vaginismus report a history of sexual trauma (Silverstein, 1989).

Medical conditions that could lead to vaginismus include: vaginal surgery, prolapse of the uterus, endometriosis, vaginal tumors, vaginal lesions, vaginal atrophy, congenital abnormalities, sexually transmitted diseases, abnormalities of the hymen, and pelvic congestion. In such cases, the condition may produce genital pain that develops over time into vaginismus. Medical conditions are associated with vaginismus in 23-32% of cases (Reissing et al., 1999).

Treatment

Vaginismus is treated with cognitive-behavioral therapy targeted at eliminating the erroneous beliefs and the vaginal spasms. Therapy involves identifying faulty beliefs (e.g., “my vagina is too small to accommodate his penis”) and educating the woman and her partner regarding normal sexual anatomy and physiology (e.g., in the aroused and non-aroused state, the vagina is capable of accommodating even a large penis). Vaginal spasms are treated with vaginal muscle exercises and progressive vaginal dilation. The woman and her partner insert dilators into her vagina, starting with very small sized dilators, progressively increasing the size until she is able to insert a dilator that is as large as an erect penis, and finally, attempting intercourse. Few well-controlled treatment outcome studies have been conducted making it difficult to evaluate the effectiveness of therapy, but estimates suggest that 60-100% of vaginismus cases are successfully treated with this type of intervention (Reissing et al., 1999).

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