Vestibular Anatomic Localization of Pain Sensitivity in Women with Insertional Dyspareunia: A Different Approach to Address the Variability of Painful Intercourse

Abstract

The pathophysiology underlying painful intercourse is challenging due to variability in manifestations of vulvar pain hypersensitivity. This study aimed to address whether the anatomic location of vestibular-provoked pain is associated with specific, possible causes for insertional dyspareunia. Women (n = 113) were assessed for “anterior” and “posterior” provoked vestibular pain based on vestibular tenderness location evoked by a Q-tip test. Pain evoked during vaginal intercourse, pain evoked by deep muscle palpation, and the severity of pelvic floor muscles hypertonicity were assessed. The role of potential confounders (vestibular atrophy, umbilical pain hypersensitivity, hyper-tonus of pelvic floor muscles and presence of a constricting hymenal-ring) was analyzed to define whether distinctive subgroups exist. Q-tip stimulation provoked posterior vestibular tenderness in all participants (6.20 ± 1.9). However, 41 patients also demonstrated anterior vestibular pain hypersensitivity (5.24 ± 1.5). This group (circumferential vestibular tenderness), presented with either vestibular atrophy associated with hormonal contraception use (n = 21), or augmented tactile umbilical-hypersensitivity (n = 20). The posterior-only vestibular tenderness group included either women with a constricting hymenal-ring (n = 37) or with pelvic floor hypertonicity (n = 35). Interestingly, pain evoked during intercourse did not differ between groups. Linear regression analyses revealed augmented coital pain experience, umbilical-hypersensitivity and vestibular atrophy predicted enhanced pain hypersensitivity evoked at the anterior, but not at the posterior vestibule (R = 0.497, p < 0.001). Distinguishing tactile hypersensitivity in anterior and posterior vestibule and recognition of additional nociceptive markers can lead to clinical subgrouping.

Clinical Significance of Topical Spermidine Hyaluronate in Vestibulodynia: An Early Appraisal

“…Following this response, cells activate contractile filaments, proteins linking the ECM to the cytoskeleton and membrane. The mechanosensitive sites along these filaments promote a second wave of responses: force-induced membrane tension, compliance or curvature leading to focal adhesion assembly [24] [25], cytoskeleton re-distribution [26] [27], cell movement [5], and ECM remodeling [28]. Mechanosensing can be active or passive.…”

A systematic review of diagnostic tests to detect pelvic floor myofascial pain

“…PFMP may occur either as an isolated diagnosis or in conjunction with other conditions including musculoskeletal [32,33], gastrointestinal [34][35][36], genitourinary [31,[37][38][39], gynaecological [6,40,41] and persistent pelvic pain [20,42] conditions. PFMP may present as primary muscular dysfunction [43,44] or as a consequence of peripheral and central sensitization resulting from other pain conditions, as reflected in studies demonstrating extra pelvic manifestations in women with pelvic pain [6,[45][46][47][48][49], mucosal hypersensitivity [50], enhanced pain sensitivity [51][52][53][54], regional allodynia and hyperalgesia [6]. Assessing for peripheral and central pain mechanisms contributing to PFMP is important to tailor management, which may require multimodal interventions [55] including physical and medical therapy, such as botulinum toxin [56], rather than physical therapy alone [57].…”

Genito Pelvic Pain/Penetration Disorder (GPPPD) in Spanish Women—Clinical Approach in Primary Health Care: Review and Meta-Analysis

“…To establish the diagnosis of GPPPD, the beginning is the clinical interview followed by the physical examination, including a pelvic examination [56], and the performing of complementary studies to determine any organic factors underlying the diagnosis of GPPPD [56,57]. Biological causal and related factors include different illness and associated treatments, including surgical procedures, such as thyroid autoimmune disease [58], endometriosis [59][60][61][62], medical treatments [61], surgical treatment techniques [60,63,64], hidradenitis suppurativa [65], localization of pain sensitivity in insertional dyspareunia [66], and chronic pelvic pain [67]. The collaboration of sexual medicine experts from scientific societies with the ICD-11 provides confidence on its codes for diagnosing and coding sexual dysfunctions, including sexual pain disorders, in worldwide clinical settings and providing sexual medicine experts with a greater understanding of risk factors and etiologies of sexual pain disorders [68].…”