gynecology and obstetrics
Genito Pelvic Pain Penetration Disorder
Diagnosis of Genito Pelvic Pain Penetration Disorder
Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR) criteria ( Diagnosis reference ) Diagnosis of genito-pelvic pain/penetration disorder is based on symptoms and results of a pelvic examination, which can detect or rule out physical abnormalities. The examination focuses on inspecting all the vulvar skin (including the creases between the labia minora and majora [eg, for fissures typical of chronic candidiasis]), as well as the clitoral hood, urethral meatus, hymen, and openings of major vestibular gland ducts (for atrophy, signs of inflammation, and abnormal skin lesions requiring biopsy). 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 along 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 examination is then done to check for pelvic floor hypertonicity, which can be elicited by palpating the levator ani muscles. The urethra and bladder should also be palpated anteriorly to identify abnormal tenderness. A speculum examination can be done 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. In many women with levator ani syndrome, the speculum and bimanual part of the examination cannot be done. Clinicians should explain each step of the examination to women to help them relax and to get as much information as possible from the examination. Diagnosis ofgenito-pelvic pain/penetration disorderis based on specific criteria in the DSM-5-TR. The criteria require persistence or recurrence of one or more of the following: Marked vulvovaginal or pelvic pain during intercourse or penetration attempts Marked fear or anxiety about vulvovaginal or pelvic pain in anticipation of, during, or because of vaginal penetration Marked tensing or tightening of pelvic floor muscles during attempted vaginal penetration Symptoms must have been present for ≥ 6 months and must cause significant distress in the woman. Also, the diagnosis of genito-pelvic pain/penetration disorder requires that sexual dysfunction is not better explained by the presence of another disorder, severe relationship distress (eg, intimate violence), or other significant stressors or by use a substance or medication. 1. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 5th ed. Text Revision (DSM-5-TR). Washington, DC, American Psychiatric Association, 2022. 