Sexual Dysfunctions

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INTRODUCTION

Chronic Pelvic Pain (CPP) in women and “Chronic Prostatitis”/ Chronic Pelvic Pain Syndrome (CP/CPPS) in men, is chronic or persistent pain perceived in structures related to the pelvis. It is often associated with negative cognitive, behavioral, sexual and emotional consequences as well as with symptoms suggestive of lower urinary tract, sexual, bowel, pelvic floor or gynaecological dysfunction [38,97,98]. In men, there is considerable overlap between CPP, unexplained genital pain, bladder outlet obstruction and irritable bowel syndrome (IBS), interfering with sexual function [3,36,37,51,60,85]. In women, CPP overlaps with Bladder Pain syndrome/Intersistial Cystitis (BPS/IC), IBS, and with sexual conditions such as dyspareunia and Provoked Vulvodynia (PVD), as defined by the International Society for the Study of Vulvovaginal Disease (ISSVD) [13,30,60,61,69,70]. The IASP taxonomy on female genital pain is based on their general pain term rule: localization-pain-syndrome. Therefore, the term Vulvar Pain Syndrome (VPS) is used instead of vulvodynia. VPS is subdivided into generalized and localized vulvar pain syndrome.

In this chapter, sexual problems comorbid with CPP in women and men will be discussed, focusing on terminology, prevalence, etiology, and treatment.

DESCRIBING THE SUBJECT

Sexual Dysfunction Related to CPP in Women

Terminology and Assessment

Dyspareunia, VPS/vulvodynia, and vaginismus are common pain problems in women interfering with sexuality. Because differentiation between these problems using clinical tools has proven difficult, these disorders were recently merged in the Diagnostic and Statistical Manual of Mental Disorders 5^th edition (DSM-5) under the heading of Genito-Pelvic Pain/Penetration Disorder [2]. The disorder refers to four commonly comorbid symptom dimensions: (1) difficulty with intercourse/penetration; (2) vulvovaginal or pelvic pain during vaginal intercourse/penetration attempts; (3) fear or anxiety about vulvovaginal or pelvic pain or vaginal penetration; and (4) tensing or tightening of the pelvic floor muscles during attempted vaginal penetration. Because difficulty in any one of these symptom dimensions may result in clinically significant distress, a diagnosis can also be made if only one of these dimensions is present. Symptoms should persist for a minimum duration of approximately 6 months and cause clinically significant distress in the individual. Subtypes of Genito-pelvic pain/penetration disorders are early-onset (lifelong) or late-onset (acquired), and symptoms can be generalized (occurring in each and every sexual situation) or situational. To make a diagnosis, somatic explanations for all symptom dimensions should be ruled out.

The first symptom dimension, difficulty with vaginal penetration, is comparable to what was formerly called vaginismus, and can vary from a complete inability to experience vaginal penetration in any situation (generalized) to the ability for vaginal penetration in one situation (e.g., tampon insertion, gynaecological examination, sexual intercourse) but not in another (situational).

Vulvovaginal or pelvic pain during vaginal intercourse or penetration attempts is related to the Diagnostic and Statistical Manual of Mental Disorders 4^th edition (DSM-IV) diagnosis of dyspareunia [1], and to VPS, which is not mentioned in DSM-IV. This symptom dimension refers to pain in different locations in the genito-pelvic area. Pain can be characterized as superficial (vulvovaginal or occurring during penetration) or deep (pelvic; i.e., not felt until deeper penetration). The intensity of the pain is often not linearly related to distress or interference with sexual intercourse or other sexual activities. Some genito-pelvic pain only occurs when provoked (i.e., by intercourse or mechanical stimulation); other genito-pelvic pain may be spontaneous as well as provoked. Genito-pelvic pain can also be characterized qualitatively (e.g., “burning,” “cutting,” “shooting,” “throbbing”). The pain may persist for a period after intercourse is completed and may also occur during urination. The next two symptom dimensions can be considered to be emotional and behavioural consequences of sexual pain that may be more or less salient.

Fear or anxiety about vulvovaginal or pelvic pain, whether in anticipation of, during, or following vaginal penetration is associated with avoidance of sexual situations and is often reported by women who have regularly experienced pain during intercourse, but is also seen in women who have not yet had much experience with painful intercourse.

Tensing or tightening of the pelvic floor muscles can vary from an involuntary, reflex-like reaction of the pelvic floor in response to attempted vaginal entry, to voluntary muscle guarding in response to the anticipated or the repeated experience of pain.

To support diagnosis, a number of associated features should be investigated. First, genito-pelvic pain/penetration disorder is often associated with reduced sexual interest and arousal, but arousal and desire can be preserved in sexual situations that are not painful or in which penetration is not anticipated. Five other factors should be considered during assessment as they may be relevant to etiology and/or treatment: (1) partner factors (e.g., partners sexual problems or health status); (2) relational factors such as poor communication and discrepancies in desire; (3) individual vulnerability factors (e.g., poor body image, a history of sexual or emotional abuse), psychiatric comorbidity or stressors; (4) cultural and religious factors that may restrain sexual activity or pleasure; and (5) medical factors relevant to prognosis, course, or treatment. Each of these factors may contribute differently to the presenting symptoms [2].

For painful orgasm in women, no publications in Pubmed are available, nor is this type of pain acknowledged in DSM 5, even though it is not an uncommon clinical phenomenon [94].

Headaches associated with sexual activity is another type of sexual pain. The International Classification of Headache Disorders (2^nd Ed) differentiates between preorgasmic (sexual arousal related) headaches, and orgasmic headaches, sudden and severe explosive pain as soon as orgasm starts [48].

All sexual pain disorders associated with CPP are frequently comorbid with DSM-IV sexual dysfunctions such as inhibited sexual desire, female arousal disorder and female orgasm disorder [92]. Anticipation of painful intercourse, painful orgasm or headache after sexual activity will seriously impede sexual arousal, which in itself reduces the likelihood of experiencing orgasm [20]. Even though reduced sexual desire is still conceptualized by many as a biological deficit, as a problem of sexual ‘drive’, incentive-motivation models of sexual desire propose that sexual desire is the consequence rather than the cause of rewarding sexual experiences [50]. It is highly unlikely that the prospect of painful sex, whatever its nature, will evoke much sexual desire.

Prevalence

The prevalence of this new genito-pelvic pain/penetration disorder is currently unknown, but sexual pain problems are common. Prevalence estimates for dyspareunia range from 14–34% in younger women to 6.5–45% in older women [53,65,92,99]. Women with VPS vary in ages from 16 to 80 years, with the majority between the ages of 20 to 50 years [44], even though VPS is also seen in children [22]. The incidence of VPS is approximately 10 to 15% [44,75], and the lifetime prevalence of VPS is estimated between 10 and 20% 8,44,52,75]. Prevalence estimates of vaginismus vary between 1–6% [57]. The prevalence of orgasmic pain in women is unknown, the lifetime prevalence of sexual headaches is less than 1%, with prevalence rates in women being one-fourth of that in men (72,89].

Etiology

The etiology of all sexual pain problems in women is much debated. Several monocausal factors and mechanisms have been proposed. However, sexual pain, of whatever kind, is progressively regarded as a multifaceted problem with medical, psychological, sexual, and relational sequalae [40,94], the most important of which are discussed below. Recently, the hypothesis that pelvic floor overactivity may be an integrating causal and/or maintaining mechanism involved in sexual pain as well as CPP is becoming more important [30,62,69,76,94].

• Biomedical mechanisms. Past research has focused predominantly on (genetic vulnerability for) vulvovaginal infections, hormonal influences, tissue abnormalities and immune system function [39,92]. Even though the human papillomavirus, bacterial vaginosis and candida have often been labeled as causal mechanisms underlying chronic vulvar pain, systematic studies have not supported this [92]. The prevalence of candida in the general population may be as high as 75 to 80% [81], but a US study showed that of all women who had bought an over-the-counter antimycotic agent, only one-third were found to actually have candida [83]. Women may have had a history of candida or bacterial vaginosis, but in most cases, treatment of those conditions does not alleviate the chronic pain problems. Even though oral contraceptive use has been associated with the risk for VPS, the most recent study in the largest sample to date found no evidence of an increased risk for VPS in oral contraceptive users [74].

• Psychological mechanisms. Women with vulvar pain report higher rates of depression and anxiety disorders [92]. Evidence is emerging that chronic sexual pain involves problems in information processing, with attentional bias, hypervigilance to pain and catastrophizing thoughts about the pain, and stronger disgust associations being among the most important factors discriminating between women with and without sexual pain [15,43,67]. A history of a sexual abuse in women with dyspareunia is associated with increased sexual impairment [54]. Significant associations have been found between sexual abuse and chronic pelvic pain (OR, 2.73). When the definition of abuse was restricted to rape, the OR for chronic pelvic pain increased (3.27) [66]. Another recent study found the effect between documented childhood victimization and pain in adulthood to be moderated by the presence of posttraumatic stress disorder (PTSD) in adulthood, such that only individuals who had experienced childhood abuse/neglect and who had PTSD in adulthood were at significantly increased risk for adult pain [71].

• Sexual mechanisms. Women with sexual pain are less satisfied with their sex life and experience more negative feelings during sexual activity [e.g.,17]. Dyspareunia is not associated with a reduced capacity to become (genitally) aroused with adequate sexual stimulation [18], but pain-related fear does reduce subjective and genital sexual responding [20]. Often women do not have arousal problems or orgasm problems with masturbation, but become only moderately sexually aroused as of their first coital attempts. Pain during intercourse frequently is associated with a limited non-coital sexual repertoire, adding to the likelihood of sexual arousal being insufficient for pain free intercourse [19].

• Relational mechanisms. Characteristically, women with dyspareunia do not cease sexual activity that is painful for them. They ignore the primary function of pain as signaling damage to the body [30]. While intercourse frequency of women with dyspareunia is lower than that of women without sexual pain [73], not engaging in sexual intercourse is, by definition, not a behavioural choice that women with dyspareunia make [33,34]. The wish to be ‘normal’ seems to be an important underlying mechanism [35]. In heterosexual partnered sex, many women forego their own needs for fear of the negative impact this might have on the male partner’s ego [77]. A very recent study found that women with dyspareunia exhibited more mate-guarding and duty/pressure motives for engaging in intercourse and had more maladaptive penetration-related beliefs than women without sexual pain. The factor that best predicted continuation of painful intercourse (attempts) was the partner’s negative response to pain [19]. Many women with vaginismus, in contrast, avoid any form of vaginal penetration because of negative cognitions and expectations about vaginal penetration. As a consequence, anxiety-inducing penetration related thoughts cannot be disconfirmed and thereby maintain the condition [56,86,87].

• Pain perception. It has been proposed that vulvar pain represents a chronic local inflammatory condition, starting with tissue injury releasing inflammatory mediators, which may lead to neurogenic inflammation and peripheral sensitization with lowered pain thresholds [40]. There is also evidence of a central sensitization mechanism with enhanced systemic pain response [14].

• Pelvic floor overactivity. As also recently acknowledged in DSM 5, pelvic floor overactivity is considered to be an important causal and/or maintaining factor of dyspareunia as well as VPS [30,62,94]. The pelvic floor consists of a deep and a superficial layer [76,95]. The deep layer is stretched over the bones of the pelvis and consists of the puborectalis muscle, musculus pubococcygeus, iliococcygeus muscle, musculus ischiococcygeus and the external urethral sphincter. The main functions of this deep layer are the support of the abdominal organs, sustaining genital vasocongestion during sexual arousal and orgasm, and maintaining a good posture. Underrecognized, but very relevant in sexual pain problems as well as in CPP, is the fact that the pelvic floor also has an emotional function. In situations of imminent physical or mental pain the pelvic floor contracts involuntarily and often unconsciously [16,90]. In a number of psychophysiological studies in which pelvic floor muscle tone was measured using electromyography, exposure to threatening film excerpts resulted in a significant increase in pelvic floor muscle activity relative to neutral film exposure, both in women with [90,91] and without sexual pain problems [16]. Activity in the shoulder muscles was also significantly enhanced during these film excerpts, suggesting that pelvic floor overactivity in threatening situations should be regarded as part of a general defense mechanism [91].

An elevated pelvic muscle tone reduces vasocongestion in sexual situations [16], resulting in a weakened genital response and diminished lubrication. Repetitive friction between the vulvar skin and the penis may cause vulvar tissue damage, irritation of the skin and possibly secondary hypersensitivity [101]. Anticipation of pain in future sexual encounters may further decrease sexual arousal and increase pelvic floor muscle tension, adding to the friction between vulvar skin and penis [20,30]. Repetitive painful intercourse without adequate genital arousal and a tense pelvic floor aggravates vulvar burning [94]. In women with vaginismus, pelvic floor relaxation is absent in sexual situations and there are reflexogenic involuntary contractions of the perivaginal musculature upon attempts of vaginal penetration. Women whose first sexual pain problem consisted of painful intercourse may develop an anticipatory protective vaginistic response (secondary vaginismus). Women who continue with intercourse despite pain may acquire chronic pelvic floor overactivity, with a pattern of obstructive micturition- and defecation consisting of hesitancy and problems with initiating voiding, urgency and frequency, slow or intermittent stream and straining, dysuria and vulvar burning after micturition, feelings of incomplete emptying, nocturia, obstructed defecation, constipation, symptoms of IBS and CPP.

For women with experiences of sexual abuse, even consensual sexual situations can be negative and threatening [90]. Therefore, it is not surprising that chronic pelvic floor overactivity is more common in women with negative sexual experiences, such as rape or incest [10,66,68].

Orgasm pain in women may also be related to pelvic floor overactivity. Van Lunsen and Ramakers depict painful orgasm as being related to the involuntary clonic pelvic floor contractions associated with orgasm, which become painful in women with a chronic overactive pelvic floor [94].

Patients with complaints associated with pelvic floor overactivity often have other stress-related complaints, particularly in the neck/shoulder area, possibly related to (tension) headache [94]. Women with dyspareunia suffer from tension headache more often than women without sexual pain [63

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