A Guide for Sexual Pain Disorders. The prevalence of female sexual dysfunctions has been known to be as high as 43%, with approximately 26% of women reporting sexual pain disorders, given the high prevalence and major impact on interpersonal relationships and quality of life. Our goal is to develop a plan of care for patients that report sexual pain disorders. Sexual pain disorders was previously diagnosed as two separate entities in the DSM-IV, dyspareunia and vaginismus. However, the DSM-V has now merged these two terms, due to the marked overlap in symptoms, into a new term called genitopelvic pain penetration disorder. Genitopelvic pain penetration disorder is defined by the DSM-V as persistent or recurrent difficulties and one or more of the following criteria that is persistent for a minimum duration of six months. The first three criteria were originally listed under dyspareunia. These criteria are vaginal penetration during intercourse, marked vulvovaginal or pelvic pain during vaginal intercourse or penetration attempts, marked fear or anxiety about vulvovaginal or pelvic pain in anticipation of, during, or as a result of vaginal penetration. The final criteria was originally listed under vaginismus. This criteria is marked tensing or tightening of the pelvic floor muscles during attempted vaginal penetration. To meet the criteria for the DSM-V, the symptoms must cause clinically significant distress in the individual and the sexual dysfunction cannot be better explained by a non-sexual mental disorder or as a consequence of severe relationship distress such as partner violence or other significant stressors that are not attributable to substance or medications or another medical condition. To assist with these new changes, a diagnostic algorithm based on the recent DSM-V has been developed to assist in establishing a diagnosis of female sexual dysfunction. This involves identifying if there is pain or discomfort associated with sexual encounters and determining if the intercourse is painful as in dyspareunia. If there is genital pain associated with sexual stimulation or arousal, known as non-coital pain disorder, or if there is pain or tightness associated with vaginal entry, which is vaginismus. If a patient has any of these symptoms, these symptoms may all be diagnostic of the new DSM-V term, genitopelvic pain, penetration disorder. Despite these new changes, most literature still refers to dyspareunia and vaginismus as separate diagnostic entities. This includes the ICD-10 and ICSM. A thorough history and review of symptoms is important to identify the causes of genitopelvic pain, penetration disorder. It is important to first ask to characterize the pain. A focused medical history is important to identify factors contributing to pain such as urologic, gastrointestinal, and musculoskeletal pain. It is also important to identify a patient's surgical history. Gynecologic surgery and traumatic perineal injury can cause pain as well. A thorough sexual history should be obtained. The brief sexual symptom checklist for women may be used as a primary screening tool. With this form, patients can mark which symptom is the most bothersome to them, such as pain during sex. Third key findings include obstetric and gynecologic history, such as postmenopausal status. Other risk factors include physical or sexual violence and smoking status. Medications associated with sexual dysfunctions include psychotropic medications, antihypertensives, and histamine blockers. For the physical exam, it is important to identify the location of the pain. Sensitivity noted on the external genitalia may be due to vulvodynia, vulvitis or vulvovaginitis, or vulvodermatosis. Pain located at the introitus with entry is identified with genitourinary syndrome and menopause, vaginismus, and inadequate lubrication. Pain upon deep penetration may occur with endometriosis, pelvic inflammatory disorder, and a history of sexual abuse. Examination of the external genitalia consists of visual inspection. This will assist in identifying possible etiologies of genitopelvic pain, such as vulvar lesions. An infection should be ruled out using various tests, including the wet mount, vaginal pH, fungal culture, and gram stain based on patient symptoms. Cotton swab testing can identify areas of pain. Cotton swab testing starts on the thigh, followed by the labia majora and the interlabial sulci. The vestibule is then tested at 2, 4, 6, 8, and 10 o'clock. When pain is present, the patient is asked to quantify the pain as mild, moderate, or severe. Cotton swab testing can help differentiate between generalized and localized pain. When asking a subject with vulvodynia where does it hurt, a patient with generalized vulvodynia will note that it hurts all over, whereas patients with localized vulvodynia may have erythema and pain out of proportion to touch at one vulvar site. Internal atrophy may be identified during speculum exam. A bimanual exam can identify other etiologies that can contribute to sexual pain, such as adnexal masses or cysts and tender utero-sacral nodularities, which may be suggestive of endometriosis. Spasms from the pelvic muscle floor can create lower abdominal pain, back pain, and insertional dyspareunia. An internal pelvic musculature exam is important to identify trigger points. This is performed by applying pressure to muscles to assess localized tenderness and tone. We will now review the most common treatment for genitopelvic pain penetration disorder. Management is based on diagnosis. For vulvodynia, overcare measures can minimize irritation. Other treatment options include topical medications such as local anesthetics, estrogen cream, and tricyclic antidepressants. Oral medications including tricyclic antidepressants and anticonvulsants such as amitriptyline and gabapentin can be used. Additionally, trigger point injections, physical therapy with or without biofeedback, dietary modifications, cognitive behavioral therapy, and sexual counseling may also treat vulvar pain. First-line therapy for genitourinary syndrome and menopause are non-hormonal approaches. Vaginal moisturizing agents with supplemental use of vaginal lubricants for sexual intercourse is recommended. Low-dose vaginal estrogen therapy is recommended for patients who failed first-line therapy. The choice of delivery may be by an insert, ring, or cream based on the patient's preference. Ospemephine can also be used rather than vaginal estrogen for patients who cannot or prefer not to use a vaginal product. There is insufficient data to support the efficacy and safety of using lasers for treatment of genitourinary syndrome and menopause. For management of vaginismus, desensitization techniques such as pelvic floor exercises, physical therapy, and biofeedback may be helpful. Sex therapy and counseling may be helpful as well. In conclusion, we anticipate this video will make practitioners more comfortable with the new DSM-5 criteria, as well as the assessment, workup, and management for genitopelvic pain penetration disorder.

healthcare practitioners

sexual pain disorders

genitopelvic pain penetration disorder

DSM-V

diagnostic algorithm