Magnesium-Based Trigger Point Infiltrations Versus Local Anaesthetic Infiltrations in Chronic Pelvic Myofascial Pain: A Randomized, Double-Blind, Controlled Study.

OBJECTIVE: To determine if a novel, magnesium-based trigger point infiltration formulation is more effective in treating chronic myofascial pelvic pain than lidocaine-only infiltration. METHODS: This was a single-centre, double-blind, randomized controlled trial of women diagnosed with chronic pelvic myofascial pain associated with trigger points. We compared a novel magnesium-based infiltration formulation with lidocaine infiltration of trigger points and with a control group of participants who were waitlisted for a chronic pain clinic. Treatment groups completed a 12-week program that included 8 trigger point injection treatments and 9 visits during which pain scores were recorded and questionnaires administered. The primary outcome measure was change in mean pain score between baseline and the final visit. Secondary outcomes included pain with function scores, scores on the World Health Organization Quality of Life questionnaire, procedural pain, concomitant medication use, and complications. RESULTS: We assigned 44 women diagnosed with chronic myofascial pelvic pain associated with trigger points to either the magnesium-based infiltrate (n = 15), lidocaine infiltrate (n = 17), or waitlist (n = 12) group. In the intent-to-treat analysis, a clinically relevant decrease in mean pain score out of 10 was observed in the magnesium-based (-2.6 ± 3.2) and lidocaine (-2.9 ± 3.1) infiltration groups, but not in the waitlist group (-0.5 ± 2.3). The per protocol analysis post-hoc tests, adjusted for multiple comparisons, found a significant difference in the average change in pain score between the magnesium-based infiltrate and the waitlist groups (P = 0.045), while differences between the lidocaine infiltrate and waitlist groups approached statistical significance (P = 0.052). Both treatment groups saw improvements in pain with function and quality of life scores. CONCLUSION: While this study is underpowered, it does not support the use of a magnesium-based trigger point infiltrate in the treatment of chronic myofascial pelvic pain over lidocaine-only infiltration. Nonetheless, these results are consistent with current management recommendations and suggest improvements in pain, pain with function, and quality of life scores with either magnesium-based or lidocaine-only infiltration. We outline an approach to assessment and treatment that can be adopted by general gynaecologists.

Healthcare Experiences of Individuals With Persistent Genital Arousal Disorder/Genito-Pelvic Dysesthesia.

INTRODUCTION: Persistent genital arousal disorder/genito-pelvic dysesthesia (PGAD/GPD) is a distressing condition characterized by persistent, unwanted sensations of genital arousal (eg, feelings of being on the verge of orgasm, and of lubrication, swelling, tingling, throbbing) that occur in the absence of sexual desire. Although PGAD/GPD is associated with significant impairments in psychosocial functioning, the healthcare (HC) experiences of affected individuals are not well understood. AIM: The aims of this study were to examine the barriers to HC, the costs of HC, and the associations among HC experiences, symptoms, and psychosocial outcomes in those with PGAD/GPD symptoms. METHODS: One hundred and thirteen individuals with PGAD/GPD symptoms completed an online, cross-sectional self-report questionnaire about their HC history and experiences. MAIN OUTCOME MEASURES: Self-reported HC barriers, and financial costs associated with PGAD/GPD HC. Validated measures of HC experiences (eg, comfort communicating with HC practitioners [HCPs]), and psychosocial (eg, depression, anxiety) and PGAD/GPD symptom outcomes. RESULTS: The majority of participants (56.6%) reported waiting at least 6 months to seek HC for PGAD/GPD symptoms. Those who sought HC approached many HCPs (46.0% approached 6+ HCPs). Several barriers to HC were identified (eg, lack of HCP knowledge of PGAD/GPD), and high costs were reported. A series of multiple linear regression analyses found an association between HC experiences, psychosocial, and symptom outcomes. Specifically, decreased comfort communicating with one's HCP was associated with greater depressive and anxiety symptoms. CONCLUSION: High costs and numerous barriers to seeking HC for PGAD/GPD symptoms were identified, and discomfort communicating with an HCP about PGAD/GPD was associated with increased symptoms of depression and anxiety. These results highlight the need for more awareness of this condition in order to improve care for this population. Jackowich RA, Boyer SC, Bienias S, et al. Healthcare Experiences of Individuals With Persistent Genital Arousal Disorder/Genito-Pelvic Dysesthesia. J Sex Med 2021;9:100335.

An Investigation of Descending Pain Modulation in Women With Provoked Vestibulodynia: Alterations of Brain Connectivity.

Provoked Vestibulodynia (PVD) is the most common vulvodynia subtype (idiopathic chronic vulvar pain). Functional magnetic resonance imaging (fMRI) studies indicate that women with PVD exhibit altered function in a number of pain modulatory regions in response to noxious stimulation, such as in the secondary somatosensory cortex, insula, dorsal midcingulate, posterior cingulate, and thalamus. However, previous neuroimaging studies of PVD have not examined periods of time before and after noxious stimulation or investigated functional connectivity among pain modulatory regions. Fourteen women with PVD and 14 matched Control participants underwent five fMRI runs with no painful stimuli interleaved randomly with five runs with calibrated, moderately painful heat stimuli applied to the thenar eminence. As recent findings indicate that pain processing begins before and continues after painful stimulation, 2-min periods were included in each run before and after the stimulus. Functional brain connectivity was assessed during both trials of Pain and No Pain stimulation for each group using structural equation modeling (SEM). Analyses of variance (ANOVAs) on connectivity values demonstrated significant main effects of study condition, and group, for connectivity among pain modulatory regions. Most of the differences between the Pain and No Pain conditions found only in the PVD group take place before (i.e., thalamus to INS, ACC to S1, thalamus to S1, and thalamus to S2) and after pain stimulation (i.e., INS to amygdala, PPC to S1, and thalamus to S2). Such differences were not observed in the Control group. These findings further support previous results indicating that women with PVD have altered pain processing compared to pain-free women.

An Investigation of Descending Pain Modulation in Women With Provoked Vestibulodynia (PVD): Alterations of Spinal Cord and Brainstem Connectivity.

The most common subtype of vulvodynia (idiopathic chronic vulvar pain) is provoked vestibulodynia (PVD). Previous imaging studies have shown that women with vulvodynia exhibit increased neural activity in pain-related brain regions (e.g., the secondary somatosensory cortex, insula, dorsal midcingulate, posterior cingulate, and thalamus). However, despite the recognized role of the spinal cord/brainstem in pain modulation, no previous neuroimaging studies of vulvodynia have examined the spinal cord/brainstem. Sixteen women with PVD and sixteen matched Control women underwent a spinal cord/brainstem functional magnetic resonance imaging (fMRI) session consisting of five runs with no painful thermal stimuli (No Pain), interleaved randomly with five runs with calibrated, moderately painful heat stimulation (Pain). Functional connectivity was also assessed in periods before, during, and after, pain stimulation to investigate dynamic variations in pain processing throughout the stimulation paradigm. Functional connectivity in the brainstem and spinal cord for each group was examined using structural equation modeling (SEM) for both Pain and No Pain conditions. Significant connectivity differences during stimulation were identified between PVD and Control groups within pain modulatory regions. Comparisons of Pain and No Pain conditions identified a larger number of connections in the Control group than in the PVD group, both before and during stimulation. The results suggest that women with PVD exhibit altered pain processing and indicate an insufficient response of the pain modulation system. This study is the first to examine the spinal cord/brainstem functional connectivity in women with PVD, and it demonstrates altered connectivity related to pain modulation in the spinal cord/brainstem.

Exploring the neural correlates of touch and pain in women with provoked vestibulodynia.

Group differences in touch and pain thresholds-and their neural correlates-were studied in women with provoked vestibulodynia (PVD; N = 15), a common subtype of vulvodynia (chronic vulvar pain), and pain-free control women (N = 15). Results from quantitative sensory testing and self-report measures indicated that, as compared with control participants, women with PVD exhibited allodynia (ie, pain in response to a normally nonpainful stimulus) and hyperalgesia (ie, an increased response to a normally painful stimulus) at vulvar and nonvulvar sites. In addition, brain imaging analyses demonstrated reduced difference scores between touch and pain in the S2 area in women with PVD compared with control participants, supporting previous findings of allodynia in women with PVD. There were no significant reductions in difference scores between touch and pain for regions related to cognitive and affective processing of painful stimuli. The results of this study contribute important information to the general pain and vulvodynia literatures in elucidating the specific sensorimotor neural mechanisms that underlie hyperalgesia in a chronic pain population. These results have implications for differentiating neural processing of touch and pain for women with and without PVD. Future research should attempt to examine alterations related to hyperalgesia in commonly comorbid conditions of PVD.

Is Mode of Delivery Associated With Sexual Response? A Pilot Study of Genital and Subjective Sexual Arousal in Primiparous Women With Vaginal or Cesarean Section Births.

INTRODUCTION: Although postpartum sexual concerns are common, limited data exist on postpartum sexual response. Furthermore, the physiological process of vaginal birth may negatively impact genital response compared with unlabored cesarean section (C-section), but this hypothesis has yet to be tested. AIM: To (i) compare genital and subjective sexual response and sexual concordance by mode of delivery with inclusion of a control group, (ii) compare groups on self-reported sexual function over the past month, (iii) examine the relationship between laboratory measurement of sexual response and self-reported sexual function, and (iv) investigate association between obstetrical factors and breastfeeding and between sexual response and self-reported sexual function. METHODS: 3 groups of cisgender women were recruited from the community: primiparous women who delivered via vaginal birth within the past 2 years (VB group; n = 16), primiparous women who delivered via unlabored C-section within the past 2 years (CS group, n = 15), and age-matched nulliparous women (NP group, n = 18). Laser Doppler imaging was used to assess genital response while participants watched a neutral and erotic film. MAIN OUTCOME MEASURES: The main outcome measures were change in flux units from neural to erotic video as a measure of genital response, subjective sexual arousal rated continuously throughout films, perceived genital response rated after films, and Female Sexual Function Index (FSFI). RESULTS: Women in the VB group had significantly lower change in flux units than women in the CS (P = .005, d = 1.39) and NP (P < .001, d = 1.80) groups. Groups did not differ on their subjective indices of sexual response or in sexual concordance. Women in both postpartum groups reported lower FSFI scores than women in the NP group. No relationship was determined between FSFI scores and sexual response in the laboratory. Results suggested that genital trauma and breastfeeding may negatively impact FSFI scores, but they were not related to genital response or subjective sexual arousal as measured in the laboratory. CLINICAL IMPLICATIONS: Results underscore the importance of balancing objective and subjective indices of sexual response and function, especially considering the biopsychosocial nature of postpartum sexuality. STRENGTHS & LIMITATIONS: The present study is the first to apply modern sexual psychophysiological methodology to the study of postpartum sexuality. Cross-sectional methodology limits the ability to make causal inferences, and the strict inclusion criteria limits generalizability. CONCLUSION: Physiological changes as a result of labor and delivery may have a detrimental impact on genital response; however, these physiological differences may not impact women's subjective experience of postpartum sexuality. Cappell J, Bouchard KN, Chamberlain SM, et al. Is Mode of Delivery Associated With Sexual Response? A Pilot Study of Genital and Subjective Sexual Arousal in Primiparous Women With Vaginal or Cesarean Section Births. J Sex Med 2020; 17:257-272.

Genital Sensations in Persistent Genital Arousal Disorder: A Case for an Overarching Nosology of Genitopelvic Dysesthesias?

INTRODUCTION: Persistent genital arousal disorder (PGAD) is a highly distressing and poorly understood condition characterized by unwanted sensations of genital arousal in the absence of subjective sexual desire. Research has shown that some individuals with PGAD also report orgasm, urinary, and pain symptoms, with 1 recent study specifically comparing a "painful persistent genital arousal symptom" group to a "non-painful persistent genital arousal symptom" group on various indicators given the highly frequent report of comorbid genitopelvic pain in their sample. AIM: To review literature on PGAD focusing on the presence of pain symptoms. METHODS: A literature review through May 2018 was undertaken to identify articles that discuss pain characteristics in individuals with persistent sexual arousal syndrome, persistent genital arousal disorder, symptoms of persistent genital arousal, and restless genital syndrome. MAIN OUTCOME MEASURE: A review of pain/discomfort associated with persistent genital arousal, and the proposal of a new theoretical framework of genitopelvic dysesthesias. RESULTS: PGAD is a distressing condition that is associated with a significant, negative impacts on psychosocial and daily functioning. Although it is clear that unwanted and persistent genital arousal is the hallmark symptom of PGAD, symptoms of pain and discomfort are also frequently reported. Based on the results of this review, a model of genitopelvic dysesthesias is proposed, with subcategories of unpleasant sensations that are based on patients' primary complaint: arousal, arousal and pain, or pain (and other sensations). CONCLUSION: The proposed model can provide an important framework for conceptualizing conditions characterized by unpleasant genitopelvic sensations. A model such as this one can benefit highly misunderstood conditions that are questioned in terms of their legitimacy and severity-such as PGAD-by conceptualizing them as sensory disorders, which in turn can reduce stigma, unify research efforts, and potentially improve access to care. Pukall CF, Jackowich R, Mooney K, et al. Genital Sensations in Persistent Genital Arousal Disorder: A Case for an Overarching Nosology of Genitopelvic Dysesthesias? Sex Med Rev 2019;7:2-12.

Relationships Between 3-Dimensional Transperineal Ultrasound Imaging and Digital Intravaginal Palpation Assessments of the Pelvic Floor Muscles in Women With and Without Provoked Vestibulodynia.

BACKGROUND: Digital intravaginal palpation remains the favored method for clinical assessment of pelvic floor muscle (PFM) function in women; however, there is growing interest in using transperineal ultrasound imaging (TPUSI). TPUSI does not involve vaginal penetration, making it particularly relevant for PFM assessment in women with genito-pelvic pain and penetration disorders. AIMS: To study the relations between measures of PFM morphology and function assessed using 3-dimensional (3D) TPUSI and PFM assessment through intravaginal palpation. METHODS: 77 nulliparous premenopausal women with (n = 38) and without (n = 39) PVD participated. 3D TPUSI was used to measure levator hiatal dimensions at rest, at maximal voluntary contraction (MVC) of the PFMs, and at maximal Valsalva maneuver (MVM). Intravaginal palpation was used to assess PFM strength, PFM tone, PFM relaxation after contraction, and vaginal flexibility; each was scored using an ordinal grading scale. Ultrasound and palpation outcomes were compared using Spearman correlation coefficients and Kruskal-Wallis 1-way analyses of variance by rank. OUTCOMES: Outcomes included ultrasound measures of the levator hiatal area, anteroposterior diameter, and left-right transverse diameter at rest, at MVC, and at MVM; raw and relative changes in hiatal dimensions between rest and MVC and between rest and MVM; and palpation measures of PFM strength, tone, and relaxation after contraction, and vaginal flexibility. RESULTS: Weak to fair correlations were found between ultrasound and palpation measures. A smaller levator hiatus at rest was associated with greater PFM tone, less PFM relaxation, and less vaginal flexibility. Greater levator hiatal constriction and shortening of the hiatal anteroposterior diameter at MVC were associated with greater palpated PFM strength. Greater hiatal distention at MVM was associated with lower PFM tone and greater relaxation. CLINICAL TRANSLATION: 3D TPUSI and intravaginal palpation provide related but distinct information about PFM function in young women with and without PVD with high functioning PFMs. STRENGTHS AND LIMITATIONS: This was the first study to compare PFM assessment using 3D TPUSI and intravaginal palpation in nulliparous premenopausal women. A main strength of the study was the inclusion of women with PVD and asymptomatic controls, which provided a wide range in outcomes because differences in PFM morphology and function exist between women with and without PVD. The lack of inclusion of older women and women with weaker and/or hypotonic PFMs limits the generalizability of the findings. CONCLUSION: Although TPUSI has several advantages, including painless application, it is not recommended as a replacement for digital palpation in the clinical assessment of PFM function. Thibault-Gagnon S, Goldfinger C, Pukall C, et al. Relationships Between 3-Dimensional Transperineal Ultrasound Imaging and Digital Intravaginal Palpation Assessments of the Pelvic Floor Muscles in Women With and Without Provoked Vestibulodynia. J Sex Med 2018;15:346-360.

Provoked Vestibulodynia: Diagnosis, Self-Reported Pain, and Presentation During Gynaecological Examinations.

OBJECTIVE: To explore factors associated with the diagnosis of provoked vestibulodynia (PVD) through (1) self-reported pain characteristics and (2) Friedrich's criteria (vestibular pain during sexual activity/gynaecological examination). We also identified cases in which incorrect diagnoses were assigned and explored group differences in gynaecological examination presentation and associations with self-reported pain. METHODS: Data were extracted from nine studies conducted in our research laboratory. Information obtained during a telephone interview and a standardized gynaecological examination was compiled for 106 participants with vulvar pain and 106 pain-free control participants, matched for age, hormonal contraceptive use, and parity. RESULTS: Cohen's kappa (0.78) indicated substantial agreement (87.3%) between the telephone interview group categorization and diagnosis after the gynaecological examination. A discriminant function analysis yielded one significant function: Friedrich's first two criteria correctly classified 84.2% of cases, accounting for 76.0% of group membership variance. Of note, those in the other genital pain group were most likely to have received an incorrect diagnosis following the telephone interview (P < 0.001). Paired-samples t tests showed that those with pain reported lower pain intensity during the gynaecological examination than during intercourse (P < 0.001) and that intercourse pain was not necessarily related to pain during the examination. However, many participants (72.8%) indicated that the pain elicited during the cotton swab test was similar to the pain they felt with intercourse. CONCLUSION: These results support the use of a targeted clinical interview and the evaluation of vestibular pain during sexual activity and the gynaecological examination for diagnosing PVD. Caution should be exercised when a patient presents with genital pain symptoms other than those typically observed in PVD. Furthermore, the cotton swab test may underestimate the degree of pain regularly experienced.

Differences in Pelvic Morphology Between Women With and Without Provoked Vestibulodynia.

OBJECTIVE: Pelvic morphology has been suggested to reflect increased tone and reduced strength of the pelvic floor muscles (PFMs) in women with provoked vestibulodynia (PVD) compared to healthy controls. We aimed to determine whether there are differences in pelvic morphology in the resting state, on maximum voluntary contraction (MVC), or on maximum effort Valsalva maneuver (MVM) between women with and without PVD. METHODS: While imaged using ultrasound, 38 women with PVD and 39 controls relaxed their PFMs, performed 3 MVCs and performed 3 MVMs. Levator plate length (LPL), levator plate angle (LPA), and anorectal angle (ARA) were determined at rest, at MVC and at MVM. The displacement of the bladder neck (BN) on MVC and on MVM was also determined. Two-way ANCOVAs were used to evaluate the main effects of group and task, the interaction between group and task, and the effect of resting morphology on LPL, LPA, and ARA. A 2-way repeated-measures ANOVA was used to determine whether the groups differed in terms of BN displacement during the tasks. RESULTS: Women with PVD had smaller LPLs and LPAs than controls across all tasks. The significant group differences in LPL and LPA at MVC and MVM were no longer significant once the resting values were included as covariates in the models. Bladder neck displacement differed between the groups at MVM but not at MVC. CONCLUSION: Women with PVD display shorter LPL sand smaller LPAs than controls but their behavior does not differ when MVC and MVMs are performed. Our results do not support the hypothesis that women with PVD demonstrate abnormalities in PFM contractility on MVC or compliance on MVM.

Effectiveness of Cognitive-Behavioral Therapy and Physical Therapy for Provoked Vestibulodynia: A Randomized Pilot Study.

INTRODUCTION: Non-medical and non-surgical treatments for provoked vestibulodynia target psychological, sexual, and pelvic floor muscle factors that maintain the condition. AIM: The goal of the study was to compare the effects of cognitive-behavioral therapy (CBT) and physical therapy (PT) on pain and psychosexual outcomes in women with provoked vestibulodynia. METHODS: In a clinical trial, 20 women with provoked vestibulodynia were randomly assigned to receive CBT or comprehensive PT. Participants were assessed before treatment, after treatment, and at 6-month follow-up by gynecologic examination, structured interviews, and standardized questionnaires measuring pain, psychological, and sexual variables. MAIN OUTCOME MEASURES: Outcome measurements were based on an adaptation of the Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials recommendations. The primary outcome was change in intercourse pain intensity. Secondary outcomes included pain during the cotton swab test, pain with various sexual and non-sexual activities, and sexual functioning and negative pain cognitions. RESULTS: The two treatment groups demonstrated significant decreases in vulvar pain during sexual intercourse, with 70% and 80% of participants in the CBT and PT groups demonstrating a moderate clinically important decrease in pain (≥30%) after treatment. Participants in the two groups also had significant improvements in pain during the gynecologic examination, the percentage of painful intercourse attempts, the percentage of activities resulting in pain, and the ability to continue intercourse without stopping because of pain. Psychological outcomes, including pain catastrophizing and perceived control over pain, also showed improvement in the two groups. Significant improvements in sexual functioning were observed only in participants who completed CBT. Few between-group differences were identified other than the PT group showing earlier improvements in some outcomes. Nearly all improvements were maintained at the 6-month follow-up. CONCLUSION: The results of the study suggest that CBT and PT can lead to clinically meaningful improvements in pain and areas of psychosexual functioning.

Differences in the Biometry of the Levator Hiatus at Rest, During Contraction, and During Valsalva Maneuver Between Women With and Without Provoked Vestibulodynia Assessed by Transperineal Ultrasound Imaging.

INTRODUCTION: Pelvic floor muscle (PFM) involvement is suspected in the pathophysiology of provoked vestibulodynia (PVD); however, the underlying mechanisms are unclear. PFM morphology can be inferred from the biometry of the levator hiatus determined through dynamic ultrasound imaging. AIMS: The aim of this study was to determine the nature of PFM involvement in women with PVD via an evaluation of the biometry of the levator hiatus at rest, upon maximal voluntary contraction (MVC) of the PFMs, and upon maximal Valsalva maneuver (MVM). METHODS: Thirty-eight women with PVD and 39 asymptomatic controls were imaged using 3D transperineal ultrasound. Levator hiatal dimensions (area; left-right [LR] and anteroposterior [AP] diameters) were measured at rest, on MVC, and on MVM. Differences in hiatal dimensions and in relative changes in dimensions from rest to MVC and from rest to MVM were compared between groups using separate 1-way analyses of variance for each measure and task. Analysis of covariance models were used to investigate the impact of levator hiatal dimensions at rest on the relative changes in the levator hiatal dimensions during MVC and MVM. MAIN OUTCOME MEASURES: Levator hiatal area, LR, and AP diameters, at rest, on MVC, and on MVM were the main outcome measures. Relative changes in hiatal dimensions were assessed as the percent change in hiatal area, LR diameter, and AP diameter. RESULTS: In comparison with controls, women with PVD had smaller hiatal areas at rest, on MVC, and on MVM, concurrent with smaller LR diameters on MVM. Women with PVD had a significantly smaller change in hiatal area on MVM than controls, but no differences were evident on MVC. In both groups, smaller levator hiatal dimensions at rest were associated with smaller relative decreases in dimensions on MVC and larger relative increases in dimensions on MVM. CONCLUSION: In comparison to controls, women with PVD appear to have narrower levator hiatus' and less capacity to distend their hiatus on Valsalva. The state of the PFMs at rest appears to significantly influence biometric changes in the PFMs during contraction and Valsalva.

Cognitive, psychophysical, and neural correlates of vulvar pain in primary and secondary provoked vestibulodynia: a pilot study.

INTRODUCTION: Provoked vestibulodynia (PVD) is a common condition characterized by localized, provoked pain that can be present since first vaginal penetration attempt (primary) or can develop after a period of pain-free penetration (secondary). Research has demonstrated psychosocial and psychophysical differences between women with these subtypes of PVD, but the question of whether neural responses to pain also differ remains to be investigated. AIM: This study aims to examine whether cognitive, psychophysical, and neural responses to vulvar pressure pain differ between women with PVD1 and PVD2. METHODS: Women with PVD1 and PVD2 were compared for group differences using multiple modalities, including questionnaires, psychophysical testing, and neuroimaging. Pain ratings were held constant across groups, rather than amount of pressure applied. MAIN OUTCOME MEASURES: Demographics, sexual functioning, four questionnaires examining anxiety and catastrophizing, quantitative sensory testing at the vulvar vestibule using a vulvalgesiometer, and functional and structural magnetic resonance imaging (MRI). RESULTS: Findings suggest that women with PVD1 are more anxious and that they catastrophize more about their vulvar and nonvulvar pain than women with PVD2. Overall, MRI results demonstrated structural and functional similarities to other chronic pain findings for both groups of women. Gray matter (GM) density also differed between groups: women with PVD1 showed significant decreases in GM throughout areas associated with pain processing. Functionally, between-groups differences were found during painful vulvar stimulation despite lower pressures applied to the vulva for women with PVD1 because of their heightened sensitivity; the determination of the level of vulvar pressure to elicit pain was based on subjective ratings. CONCLUSIONS: Findings are limited by sample size and liberal alpha values; however, future research is certainly warranted based on the preliminary findings of this study suggesting both similarities and differences between PVD1 and PVD2. Overall, women with PVD1 seem to fare worse on several pain-related and psychosocial variables compared with women with PVD2.

Sexual and relationship satisfaction and vestibular pain sensitivity among women with provoked vestibulodynia.

INTRODUCTION: Provoked vestibulodynia (PVD) is a common cause of painful intercourse. Despite the fact that PVD is associated with high levels of pain and negative impact on women's sexuality, research has not examined associations between affected women's pain sensitivity and their sexual and relationship satisfaction. AIMS: This study aimed to examine sexual and relationship functioning/satisfaction and vestibular pain sensitivity among PVD-affected women, and potential associations between these variables. METHODS: Participants were 17 women with PVD and 17 matched controls. Women were assessed via a gynecological examination, structured interview, and the Female Sexual Function Index (FSFI), Golombok Rust Inventory of Sexual Satisfaction (GRISS), and Dyadic Adjustment Scale (DAS). Additionally, women completed a quantitative sensory testing session to assess vestibular pain thresholds and associated pain ratings; specifically, vestibular pressure-pain and heat pain thresholds were measured. MAIN OUTCOME MEASURES: Gynecological and intercourse pain ratings; FSFI; GRISS; DAS; vestibular pressure-pain threshold; and vestibular heat pain thresholds. RESULTS: PVD-affected women reported significantly decreased sexual function in comparison with controls. While no differences in relationship satisfaction were found between groups, women with PVD did report less sexual satisfaction on the FSFI. PVD-affected women also reported significantly higher vestibular pain ratings associated with the gynecological examination and heat pain tolerance procedures, and lower pressure-pain threshold, heat pain threshold, and heat pain tolerance at the vestibule in comparison with controls. Among women with PVD, lower heat pain threshold was associated with less sexual satisfaction, and higher pain ratings related to intercourse and heat pain tolerance, respectively, were associated with lower sexual function and satisfaction. CONCLUSIONS: The results indicate that women with PVD experience negative sexual effects and increased pain sensitivity. This study also suggests that some aspects of pain may be related to lower levels of sexual function and satisfaction among affected women.

Sexual arousal in women with provoked vestibulodynia: the application of laser Doppler imaging to sexual pain.

Introduction. Women with provoked vestibulodynia (PVD) report lower sexual arousal than nonaffected women, however, laboratory studies of arousal have reported contradictory results about whether group differences exist in genital and subjective arousal. Aim. To examine genital and subjective sexual arousal in women with and without PVD. Methods. Eligible women with and without PVD (N = 42) attended a laboratory session that included an interview, questionnaire completion, and genital imaging. A direct measure of superficial blood flow-laser Doppler imaging-was used to assess vulvar blood flow levels while participants watched three films, including an erotic film. Participants answered questions about their level of sexual arousal before, during, and after the erotic film. Main Outcome Measures. Average vulvar blood flow levels during the baseline and erotic films, numerical ratings of subjective sexual arousal and anxiety, as well as questionnaire measures of arousal. Results. There was a significant group difference in genital arousal, whereby the PVD group showed a lower genital response to the erotic film, as well as a significant interaction between baseline blood flow and group membership. Separate group regression analyses demonstrated that baseline blood flow explained a substantial amount of the variance in erotic film blood flow in the control group (70%), while only 27% was explained by this variable in the PVD group. There were no differences in subjective sexual arousal or anxiety between the groups. Across questionnaire measures, women with PVD reported lower sexual arousal than the control group. Conclusions. The results suggest that women with PVD show lower genital responsiveness than nonaffected women to sexual stimuli in a laboratory setting and that their genital arousal is likely impacted by a number of biopsychosocial factors. Boyer SC, Pukall CF, and Chamberlain SM. Sexual arousal in women with provoked vestibulodynia: The application of laser Doppler imaging to sexual pain. J Sex Med **;**:**-**.

Diffuse noxious inhibitory control function in women with provoked vestibulodynia.

OBJECTIVES: The objective of the study was to assess diffuse noxious inhibitory control (DNIC) function in women with provoked vestibulodynia (PVD) compared with healthy controls through the use of 2 different methodologies. Furthermore, the study aimed to assess whether pain characteristics correlate with DNIC in women with PVD. METHODS: Twenty-three healthy control women and 23 women diagnosed with PVD by the study gynecologist participated in the study. To assess DNIC, heat pain tolerance, determined through an ascending method of limits and temporal summation of thermal pain were used as test stimuli and a cold water bath was used as the conditioning stimulus. Participants reported on pain characteristics as potential correlates with DNIC function. RESULTS: No significant group differences were found in the number of DNIC responders per group when using heat pain tolerance or temporal summation procedures to examine DNIC. The magnitude of the DNIC response was examined for the overall groups and for positive DNIC responders only. When all participants were included in the analyses with the heat pain tolerance procedure, women with PVD displayed a higher magnitude of DNIC responding. Correlations between pain variables and DNIC responding and magnitude were nonsignificant. DISCUSSION: Results support previous findings of intact DNIC function in women with PVD, using both an ascending method of limits and a temporal summation paradigm. Pain-related variables were not correlated with DNIC function in women with PVD, perhaps this unexpected finding is due to the possibility that central processes other than DNIC, such as descending facilitation, provoke or maintain this chronic pain condition.