Description

• Recurrent and persistent genital or pelvic pain associated with sexual activity, which is not exclusively due to intensity of intercourse, lack of lubrication or vaginismus, an involuntary contraction of vaginal muscles
  • May be superficial, causing pain with attempted vaginal insertion, or deep
  • Complex, multifactorial disorder involving psychosocial and physical conditions (1)
  • Comprised of a marked anxiety or fear of vulvovaginal pain either in anticipation of or resulting from pain with penetration
• Dyspareunia and vaginismus were previously viewed as separate conditions but are now combined into GPPPD as described by the DSM-5 (1).
• Individuals whose sexual activity do not involve penetration can still have this disorder if they have pain interfering with sexual function.

Epidemiology

• Predominant age: all ages
• Predominant sex: female > male

Etiology and Pathophysiology

Female

• Vulva and vagina
  • Dermatologic diseases: Lichen sclerosus, lichen planus, contact dermatitis
  • Inadequate lubrication: premature ovarian failure, bilateral oophorectomy, menopause, pituitary tumors, postpartum status, diabetes mellitus, chemotherapy/radiation therapy, and medications (See “Medication.”)
  • Pelvic floor dysfunction
  • Vaginal atrophy
  • Vaginismus
  • Vaginitis
  • Vulvodynia
• Bladder
  • Interstitial cystitis
• Uterus and adnexa
  • Ovarian masses
  • Uterine retroversion
• Pelvis
  • Adhesions or chronic pelvic inflammatory disease
  • Endometriosis
• Iatrogenic
  • Hysterectomy
  • Dilation and curettage
• Postpartum
  • Obstetric trauma—perineal tears, episiotomy, instrumented delivery, cesarean delivery
  • Breastfeeding atrophy
• Genitourinary syndrome of menopause
• Medications such as gonadotropin-releasing hormone agonists, selective estrogen receptor modulators, tamoxifen, aromatase inhibitors, progestogens, and danazol
• Female genital mutilation
• Trauma
• Psychological disorders
  • Anxiety
  • Depression
  • PTSD
  • History of sexual abuse

Risk Factors

• Demographic risk factors: younger age, minority racial groups (3), lower socioeconomic status, and being in postpartum, perimenopausal, or postmenopausal period
• Psychosocial risk factors: depression, anxiety, low sexual satisfaction, and history of sexual abuse
• Other etiologies: irritable bowel syndrome, musculoskeletal disorders, and fibromyalgia

Pregnancy Considerations

• GPPPD is common in late pregnancy and postpartum.
  • Breastfeeding atrophy, perineal pain, fatigue, and stress can be risk factors in postpartum period.
• Vacuum-assisted or forceps vaginal delivery or history of pelvic floor surgery increases risk.
• Women who experience delivery interventions including episiotomy are at greater risk than women who deliver over an intact perineum or who have an unrepaired laceration.

Commonly Associated Conditions

• Vaginismus: involuntary contraction of pelvic floor muscles with attempted vaginal penetration
• Vulvodynia: chronic genital pain of at least 3 months duration with no known etiology
  • Vestibulodynia: vulvar vestibule pain lasting >3 months unrelated to infection, skin disorders, or other identifiable factors
  • Clitorodynia: Form of vulvodynia localized to the clitoris associated with frequent and intense pain episodes may cause significant impairment.