Brain Processing of Visual Stimuli Representing Sexual Penetration versus Core and Animal-Reminder Disgust in Women with Lifelong Vaginismus

It has been proposed that disgust evolved to protect humans from contamination. Through eliciting the overwhelming urge to withdraw from the disgusting stimuli, it would facilitate avoidance of contact with pathogens. The physical proximity implied in sexual intercourse provides ample opportunity for contamination and may thus set the stage for eliciting pathogen disgust. Building on this, it has been argued that the involuntary muscle contraction characteristic of vaginismus (i.e., inability to have vaginal penetration) may be elicited by the prospect of penetration by potential contaminants. To further investigate this disgust-based interpretation of vaginismus (in DSM-5 classified as a Genito-Pelvic Pain/Penetration Disorder, GPPPD) we used functional magnetic resonance imaging (fMRI) to examine if women with vaginismus (n = 21) show relatively strong convergence in their brain responses towards sexual penetration- and disgust-related pictures compared to sexually asymptomatic women (n = 21) and women suffering from vulvar pain (dyspareunia/also classified as GPPPD in the DSM-5, n = 21). At the subjective level, both clinical groups rated penetration stimuli as more disgusting than asymptomatic women. However, the brain responses to penetration stimuli did not differ between groups. In addition, there was considerable conjoint brain activity in response to penetration and disgust pictures, which yield for both animal-reminder (e.g., mutilation) and core (e.g., rotten food) disgust domains. However, this overlap in brain activation was similar for all groups. A possible explanation for the lack of vaginismus-specific brain responses lies in the alleged female ambiguity (procreation/pleasure vs. contamination/disgust) toward penetration: generally in women a (default) disgust response tendency may prevail in the absence of sexual readiness. Accordingly, a critical next step would be to examine the processing of penetration stimuli following the induction of sexual arousal

Equity in human papilloma virus vaccination uptake?:sexual behaviour, knowledge and demographics in a cross-sectional study in (un)vaccinated girls in the Netherlands

BACKGROUND: In the Netherlands, human papillomavirus (HPV) vaccination is part of a national program equally accessible for all girls invited for vaccination. To assess possible inequalities in vaccine uptake, we investigated differences between vaccinated and unvaccinated girls with regard to various characteristics, including education and ethnicity, (both associated with non-attendance to the national cervical screening program), sexual behaviour and knowledge of HPV. METHODS: In 2010, 19,939 nationwide randomly-selected 16–17 year-old girls (2009 vaccination campaign) were invited to fill out an online questionnaire. A knowledge scale score and multivariable analyses identified variables associated with vaccination status. RESULTS: 2989 (15%) of the selected girls participated (65% vaccinated, 35% unvaccinated). The participants were comparable with regard to education, ethnicity, most sexual risk behaviour and had similar knowledge scores on HPV transmission and vaccination. However, unvaccinated girls lived in more urbanised areas and were more likely to have a religious background. Irrespective of vaccination status, 81% of the girls were aware of the causal relationship between HPV and cervical cancer, but the awareness of the necessity of cervical screening despite being vaccinated was limited. CONCLUSIONS: HPV vaccine uptake was not associated with knowledge of HPV and with factors that are known to be associated with non-attendance to the cervical cancer screening program in the Netherlands. Furthermore, most sexual behaviour was not related to vaccination status meaning that teenage unvaccinated girls were not at a disproportionally higher risk of being exposed to HPV. Routine HPV vaccination may reduce the social inequity of prevention of cervical cancer

A woman with coital pain:new perspectives on provoked vestibulodynia

Provoked vestibulodynia (PVD) is characterized by pain at the vulvar introitus, in particular the vulvar vestibule, provoked by touch, pressure, and vaginal penetration. Although distinct and interesting hypotheses have been put forward, the pathogenesis of PVD still remains largely unknown. In general, the etiology is considered to be multifactorial. Problems arise in PVD when normal protective functions “overreact”: when normal behavior or a psychophysiological state is too extreme, too prolonged, or too intense. This attention to contextual appropriateness is one of the key principles of psychosomatic obstetrics and gynecology. It is therefore the major reason why PVD symptoms should always be put into a biopsychosocial perspective

Dynamic Clinical Measurements of Voluntary Vaginal Contractions and Autonomic Vaginal Reflexes

IntroductionThe vaginal canal is an active and responsive canal. It has pressure variations along its length and shows reflex activity. At present, the prevailing idea is that the vaginal canal does not have a sphincter mechanism. It is hypothesized that an active vaginal muscular mechanism exists and might be involved in the pathophysiology of genito-pelvic pain/penetration disorder. AimThe aim of this study was to detect the presence of a canalicular vaginal sphincter mechanism by measuring intravaginal pressure at different levels of the vaginal canal during voluntary pelvic floor contractions and during induced reflexive contractions. MethodsSixteen nulliparous women, without sexual dysfunction and pelvic floor trauma, were included in the study. High-resolution solid-state circumferential catheters were used to measure intravaginal pressures and vaginal contractions at different levels in the vaginal canal. Voluntary intravaginal pressure measurements were performed in the left lateral recumbent position only, while reflexive intravaginal pressure measurements during slow inflation of a vaginal balloon were performed in the left lateral recumbent position and in the sitting position. Main Outcome MeasuresIntravaginal pressures and vaginal contractions were the main outcome measures. In addition, a general demographic and medical history questionnaire was administered to gain insight into the characteristics of the study population. ResultsFifteen out of the sixteen women had deep and superficial vaginal high-pressure zones. In one woman, no superficial high-pressure zone was found. The basal and maximum pressures, as well as the duration of the autonomic reflexive contractions significantly exceeded the pressures and the duration of the voluntary contractions. There were no significant differences between the reflexive measurements obtained in the left lateral recumbent and the sitting position. ConclusionThe two high-pressure zones found in this study, as a result of voluntary contractions and, even more pronounced, as a result of reflexive contractions on intravaginal stimulation, support the hypothesis that the vaginal canal has an active and passive canalicular sphincter mechanism. Further investigation of this sphincter mechanism is required to identify its role in the sexual response and genito-pelvic pain/penetration disorder. Broens PMA, Spoelstra SK, and Weijmar Schultz WCM. Dynamic clinical measurements of voluntary vaginal contractions and autonomic vaginal reflexes. J Sex Med 2014;11:2966-2975

A woman with coital pain: new perspectives on provoked vestibulodynia

Provoked vestibulodynia (PVD) is characterized by pain at the vulvar introitus, in particular the vulvar vestibule, provoked by touch, pressure, and vaginal penetration. Although distinct and interesting hypotheses have been put forward, the pathogenesis of PVD still remains largely unknown. In general, the etiology is considered to be multifactorial. Problems arise in PVD when normal protective functions “overreact”: when normal behavior or a psychophysiological state is too extreme, too prolonged, or too intense. This attention to contextual appropriateness is one of the key principles of psychosomatic obstetrics and gynecology. It is therefore the major reason why PVD symptoms should always be put into a biopsychosocial perspective

Female genito-pelvic reflexes: an overview

The female reproductive system includes an active and responsive genital tract that shows involuntary activity triggered by sexual arousal, genital stimulation and/or orgasm. This pelvic and perineal somatic and autonomic reflex muscle activity ("genito-pelvic reflexes") may be an important constituent of the female sexual response. The aim of this study was to review the literature critically on female genito-pelvic reflexes. Only a small number of studies (15) have been published on this issue. More neurophysiological research is needed to search for the implications of these genito-pelvic reflexes for female sexual (dys)function

Long-Term Results of an Individualized, Multifaceted, and Multidisciplinary Therapeutic Approach to Provoked Vestibulodynia

Introduction. Although it is highly recommended to use a multifaceted approach to treat provoked vestibulodynia (PVD), the large majority of treatment studies on PVD used a one-dimensional approach. Aim. To evaluate the long-term treatment outcome of a multifaceted approach to vulvar pain, sexual functioning, sexually related personal distress, and relational sexual satisfaction in women with PVD. Methods. Retrospective questionnaire survey 3-7 years after treatment. Main Outcome Measures. Sexual functioning, sexually related personal distress, and relational sexual satisfaction were measured using the Female Sexual Function Index (FSFI), the Female Sexual Distress Scale (FSDS), and the Dutch Relationship Questionnaire (NRV), respectively. An additional questionnaire assessed socio-demographic variables, intercourse resumption, and the level to which the women would recommend the treatment to other women with PVD. Post-treatment vulvar pain scores were obtained using a visual analog scale (VAS). Pretreatment scores were reported in retrospect on a separate VAS. Results. The questionnaires were completed by 64 out of 70 women (91%). Mean follow-up was 5 years (range 3-7). Comparison of the mean pretreatment and post-treatment VAS scores showed a significant reduction in vulvar pain. Pain reduction was reported by 52 women (81%), whereas no change and pain increase were reported by 7 women (11%) and 5 women (8%), respectively. Post-treatment, 80% of the women had resumed intercourse. Only 5 women (8%) reported completely pain-free intercourse. Comparisons with age-related FSFI and FSDS Dutch norm data showed that scores for sexual functioning in the study group were significantly lower, while scores for sexually related personal distress were significantly higher. There were no significant differences in relational sexual satisfaction ratings between the study group and the NRV Dutch norm data. Conclusion. These retrospective data on long-term treatment outcome support the hypothesis that a multifaceted approach to PVD can lead to substantial improvements in vulvar pain and the resumption of intercourse. Spoelstra SK, Dijkstra JR, van Driel MF, and Weijmar Schultz WCM. Long-term results of an individualized, multifaceted, and multidisciplinary therapeutic approach to provoked vestibulodynia. J Sex Med 2011;8:489-496

Transcutaneous Electrical Nerve Stimulation as an Additional Treatment for Women Suffering from Therapy-Resistant Provoked Vestibulodynia:A Feasibility Study

IntroductionThe current approach to women with provoked vestibulodynia (PVD) comprises a multidimensional, multidisciplinary therapeutic protocol. As PVD is considered to be a chronic pain disorder, transcutaneous electrical nerve stimulation (TENS) can be used as an additional therapy for women with otherwise therapy-resistant PVD. AimsThe aims of this study were to evaluate whether TENS has a beneficial effect on vulvar pain, sexual functioning, and sexually-related personal distress in women with therapy-resistant PVD and to assess the effect of TENS on the need for vestibulectomy. MethodsA longitudinal prospective follow-up study was performed on women with therapy-resistant PVD who received additional domiciliary TENS. Self-report questionnaires and visual analog scales (VASs) were completed at baseline (T1), post-TENS (T2), and follow-up (T3). Main Outcome MeasuresVulvar pain, sexual functioning, and sexually-related personal distress were the main outcome measures. ResultsThirty-nine women with therapy-resistant PVD were included. Mean age was 275.6years (range: 19 to 41); mean duration between TENS and T3 follow-up was 10.1 +/- 10.7months (range: 2 to 32). Vulvar pain VAS scores directly post-TENS (median 3.4) and at follow-up (median 3.2) were significantly (P ConclusionThe addition of self-administered TENS to multidimensional treatment significantly reduced the level of vulvar pain and the need for vestibulectomy. The long-term effect was stable. These results not only support our hypothesis that TENS constitutes a feasible and beneficial addition to multidimensional treatment for therapy-resistant PVD, but also the notion that PVD can be considered as a chronic pain syndrome. Vallinga MS, Spoelstra SK, Hemel ILM, van de Wiel HBM, and Weijmar Schultz WCM. Transcutaneous electrical nerve stimulation as an additional treatment for women suffering from therapy-resistant provoked vestibulodynia: A feasibility study. J Sex Med 2015;12:228-237

Subjective evaluation of the stimuli as a function of group.

<p>Y-Axis, the stimuli presented on a visual analogue scale (VAS) off-magnet, X-Axis, emotions elicited on 3 dimensions (i.e., disgust, fear, pleasure) for the three groups (i.e., vaginismus, dyspareunia and healthy controls). DIS, core disgust elicitors, A-R, animal-reminder disgust elicitors; FEA, fear related stimuli; PEN, explicit sexual penetration stimuli; BOD, neutral bodies; NEU, neutral objects. The VAS had a scale of 0 to 100, with high score indicating higher affect (pleasure/disgust/fear).</p

Shared brain responses between PEN-and aversive- brain activity maps.

<p>Shared activity between PEN-related brain responses and brain responses related to aversive stimuli within the three groups. Results are shown from the conjunction analyses (PEN>BOD ∧ CORE>BOD), [(PEN>BOD ∧ A-R>BOD) and (PEN>BOD ∧ FEAR>BOD). A-R, animal-reminder disgust; CORE, core disgust; PEN, penile-vaginal penetration; k, number of voxels; lm, local maximum. All clusters are p<0.05, FWE corrected for multiple comparisons.</p