gynecology and obstetrics
Genito Pelvic Pain Penetration Disorder
Treatment of Genito Pelvic Pain Penetration Disorder
Treatment of cause when possible (eg, topical estrogen for genitourinary syndrome of menopause) Education about chronic pain and its effects on sexuality Pelvic floor physical therapy Progressive desensitization Psychological therapies Management of genito-pelvic pain/penetration disorder frequently includes the following: Encouraging and teaching the couple to develop satisfying forms of nonpenetrative sex Discussing psychological issues contributing to and caused by the chronic pain When possible, treating the primarily physical abnormality that contributes to pain (eg, Treatment , Treating coexisting pelvic muscle hypertonicity Treating comorbid sexual interest/arousal disorder Menopausal Hormone Therapy is helpful for genitourinary syndrome of menopause, atrophic vaginitis, and recurrent posterior fourchette tearing. Topical estrogen, intravaginal prasterone (a preparation of dehydroepiandrosterone, or DHEA), or Data about the optimal treatment of genito-pelvic pain/penetration disorder are limited, and many approaches are currently used depending on the specific presentation. The first approach is always a reminder to practice good vulvar hygiene, including wearing cotton underwear during the day, washing with a mild soap, and avoiding douching and over-the-counter vaginal deodorants. If a lubricant is used during sex, it should be nonscented and water-based. Pelvic floor physical therapy can often benefit women with genito-pelvic pain/penetration disorder; it includes pelvic floor muscle training, sometimes with biofeedback, to teach pelvic muscle relaxation. Other therapies include soft-tissue mobilization and myofascial release, trigger-point pressure, electrical stimulation, bladder and bowel retraining, and therapeutic ultrasonography. Prescription and nonprescription devices are available for self-dilation if women with genito-pelvic pain/penetration disorder have tight pelvic muscles that contribute to painful intercourse. Self-dilation in the presence of a therapist and the woman's partner plus psychotherapy has been shown to enable women with levator ani syndrome to have sexual intercourse more frequently ( Treatment references ). Levator ani syndrome(previously called vaginismus) can be treated with progressive desensitization; women progressively accustom themselves to self-touch near, on, then through the introitus. Each stage in the progression begins only when the woman is comfortable with the previous stage. The woman touches herself daily as close to the introitus as possible, separating the labia with her fingers. (Once her fear and anxiety due to introital self-touch has diminished, the woman will be more able to tolerate the physical examination.) The woman inserts her finger past her hymen; pushing or bearing down during insertion enlarges the opening and eases entry. The woman inserts vaginal cones in gradually increasing sizes progressively; leaving a cone inside for 10 to 15 minutes helps perivaginal muscles become accustomed to gently increasing pressure without reflex contraction. The woman then allows her partner to help her insert a cone during a sexual encounter to confirm that it can go in comfortably when she is sexually excited. The couple includes penile vulvar stimulation during sexual play so that the woman becomes accustomed to feeling the penis on her vulva. Ultimately, the woman inserts her partner’s penis partially or fully, holding it like an insert. She may feel more confident in the woman superior position. Forprovoked vestibulodynia,first-line treatment includes pelvic floor physical therapy because pelvic floor muscle hypertonicity is often present. therapy was effective ( Treatment references ). A topicallidocainegel can also be applied before activities that cause discomfort during sexual intercourse; this gel should be used only for a short time. receptor modulator [SERM]) may be useful in women with dyspareunia due to Menopause . Medications used to treat Treatment (eg, Tricyclic antidepressants, often used to treat chronic pain disorders, are a 2nd-line treatment for provoked vestibulodynia.Amitriptylineandnortriptylineare the tricyclic antidepressants most commonly used and should be started at a low dose and titrated up. Various topical compounds containing combinations ofgabapentinandamitriptylinemay also be effective and, when applied directly to the vaginal vestibule, have fewer systemic adverse effects. Botulinum toxin type A, injected into the pelvic floor muscles, has been used to treat levator ani syndrome and provoked vestibulodynia, but it is normally used only for short-term treatment of refractory cases. Vestibulectomy (removal of the vaginal vestibule) is not done often but can be considered on a case by case basis. Women with primary provoked vestibulodynia are usually the best candidates for this surgical procedure. Referral to a certified sex therapist for psychological therapies such as cognitive-behavioral therapy, and mindfulness-based cognitive therapy can often help women manage their fear of and anxiety about pain and penetration. 1.Ter Kuile MM, Melles R, de Groot HE, et al: Therapist-aided exposure for women with lifelong vaginismus: A randomized waiting-list control trial of efficacy.J Consult Clin Psychol81 (6):1127–1136. 2013. doi: 10.1037/a0034292 2.Burrows LJ, Goldstein AT. The treatment of vestibulodynia with topicalestradiolandtestosterone.Sex Med1(1):30-33, 2013. doi:10.1002/sm2.4 