Vestibular Anatomic Localization of Pain Sensitivity in Women with Insertional Dyspareunia: A Different Approach to Address the Variability of Painful Intercourse
Abstract
:1. Introduction
2. Materials and Methods
2.1. Study Population
2.2. Patient Evaluation Measures
- Medical and gynecological examination: after obtaining a detailed medical, obstetric, and gynecological history, a vulvovaginal examination was performed. This included vaginal pH measurement, saline and 10% potassium hydroxide microscopy, yeast cultures and sexually transmitted infections (STIs) screening. In addition, localized vestibular atrophy, characterized by vestibular (but not vaginal) mucosal thinning, dryness and erythema was assessed. This particular vestibular atrophy is not referred to as “vaginal atrophy”, is often ignored and thus, its description is usually absent from clinical assessment. Patients were asked to provide dyspareunia history (primary/secondary), duration of dyspareunia, and current or prior use of systemic hormonal contraception (HC): oral contraceptives, transdermal patch, or vaginal ring.
- Pain evoked during vaginal intercourse: Self-report of pain intensity ratings experienced during sexual intercourse were assessed using a 0–10 Visual Analogue Scale (VAS), with 0 representing no pain and 10 being the worst possible pain.
- Assessment of vestibular pain [25]: Vestibular tenderness was assessed by the Q-tip test, using a moistened cotton-tip applicator and touching the vestibule in four defined points (2, 4, 8 and 10 o’clock—Figure 1), with an interval of 5 s between each stimulus. The Q-tip test was performed twice, first to localize vestibular tenderness at each point (yes/no) and secondly, to quantify pain intensity using a Numeric Pain Scale (NPS) ranging from 0 to 10 at each point, with 0 corresponding to no pain and 10 being the worst possible pain.
- Pain rating in response to deep muscle palpation: patients were requested to report pain intensity using a 0–10 NPS, in response to pressure applied bilaterally to the puborectalis muscles with the examiner’s index finger.
- Pelvic floor muscle hypertonicity: the physician’s impression of hypertonicity (mild, moderate and severe) of the pelvic floor musculature was measured by applying pressure with the examiner’s index finger bilaterally to the puborectalis muscles.
- Assessment of rigid/constricting hymenal ring: This was done by placing 2 fingers at the introitus and stretching the hymenal ring (Figure 1) laterally [26,27], avoiding pressing or stretching of the underlying muscles. If insertion of two fingers was impossible due to obliterating hymenal tissue (but not contraction of the muscles or vaginismus), or if this hymenal-ring stretching provoked pain similar to the pain experienced by the patient with penetration and the physician identified a thick/rigid hymen, the patient was reported to have a “constricting hymen”.
- Umbilical hypersensitivity: Umbilical tenderness was assessed by a dry cotton-tip applicator by touching it gently and asking the patient to report hypersensitivity (yes or no). Given the common endodermal embryological origin of the vestibular mucosa and the umbilicus, hypersensitivity to touch in this location was considered to be a possible representative of congenital vestibular neuroproliferation [28].
- Level of desire and vaginal lubrication were assessed by calculation of the relevant domains in the Female Sexual Function Index, which was completed by the participants.
2.3. Allocation into the Anterior and Posterior Vestibular Tenderness Groups
2.4. Statistical Analyses
3. Results
3.1. Patients’ Characteristics
3.2. Characteristics of Circumferential Vs. Posterior-Only Vestibular Tenderness Hypersensitivity
3.3. Characteristics of Vestibular-Hypersensitivity in the Circumferential Vestibular Tenderness and the Posterior-Only Vestibular Tenderness Groups
3.4. Construction of the Four Vestibular Tenderness Subgroups
3.4.1. The Distinctive Characteristics of the Four Subgroups
3.4.2. Four Group Comparisons of Experimental Provoked Pain Measures
3.5. Prediction of Augmented Pain Hypersensitivity at the Anterior Vestibule
3.6. Prediction of Augmented Pain Hypersensitivity at the Posterior Vestibule
4. Discussion
5. Conclusions
Author Contributions
Funding
Conflicts of Interest
References
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Mean | Range | |
---|---|---|
Age | 26.2 ± 4.1 | 18–40 |
Married/in a committed relationship | 82 (73.2%) | |
Duration of Dyspareunia symptoms (years) | 4.1 ± 3.4 | 4 months–13 |
Nullipara Para | 105 8 | |
Education (years) | 14.23 ± 2.1 | 11–21 |
Religiosity | Secular 84 (74.3%) Religious 14 (12.4%) Orthodox 15 (13.3%) |
Circumferential Vestibular Sensitivity (n = 41) | Posterior-Only Vestibular Sensitivity (n = 72) | p Value | |
---|---|---|---|
Vestibular mucosal atrophy | 63.4% | 20.8% | <0.001 |
Hormonal Contraceptive use | 14.1% | 13.6% | NS |
Umbilical pain hypersensitivity | 46.3% | 18.1% | 0.001 |
Rigid hymen | 0% | 51% | <0.001 |
Pain intensity during intercourse | 8.2 ± 1.5 | 7.7 ± 1.8 | NS |
Pain evoked by deep muscle palpation | 6.4 ± 2.3 | 6.3 ± 1.7 | NS |
Primary PVD | 13.5% | 13.3% | NS |
Unstandardized Coefficients | Coefficients Std. Error | Coefficients Beta | t | p | |
---|---|---|---|---|---|
Degree of muscle tonus | 0.361 | 0.436 | 0.081 | 0.828 | 0.410 |
Pain during intercourse | 0.359 | 0.123 | 0.276 | 2.914 | 0.004 |
Pain evoked by deep palpation | −0.044 | 0.114 | −0.041 | −0.386 | 0.701 |
Umbilical sensitivity | 1.366 | 0.4192 | 0.283 | 3.262 | 0.002 |
Vestibular atrophy | 1.140 | 0.391 | 0.251 | 2.917 | 0.004 |
Unstandardized Coefficients | Coefficients Std. Error | Coefficients Beta | t | p | |
---|---|---|---|---|---|
Degree of muscle tonus | 0.203 | 0.361 | 0.053 | 0.368 | 0.714 |
Pain during intercourse | 0.497 | 0.102 | .440 | 4.867 | 0.000 |
Pain evoked by deep palpation | 0.162 | 0.094 | 0.173 | 1.719 | 0.089 |
Umbilical sensitivity | 0.608 | 0.347 | 0.145 | 1.753 | 0.083 |
Vestibular atrophy | 0.119 | 0.324 | 0.030 | 0.368 | 0.714 |
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Lev-Sagie, A.; Wertman, O.; Lavee, Y.; Granot, M. Vestibular Anatomic Localization of Pain Sensitivity in Women with Insertional Dyspareunia: A Different Approach to Address the Variability of Painful Intercourse. J. Clin. Med. 2020, 9, 2023. https://doi.org/10.3390/jcm9072023
Lev-Sagie A, Wertman O, Lavee Y, Granot M. Vestibular Anatomic Localization of Pain Sensitivity in Women with Insertional Dyspareunia: A Different Approach to Address the Variability of Painful Intercourse. Journal of Clinical Medicine. 2020; 9(7):2023. https://doi.org/10.3390/jcm9072023
Chicago/Turabian StyleLev-Sagie, Ahinoam, Osnat Wertman, Yoav Lavee, and Michal Granot. 2020. "Vestibular Anatomic Localization of Pain Sensitivity in Women with Insertional Dyspareunia: A Different Approach to Address the Variability of Painful Intercourse" Journal of Clinical Medicine 9, no. 7: 2023. https://doi.org/10.3390/jcm9072023