The Genito-Pelvic Pain/Penetration Disorder Paradigm and Beyond: Theoretical and empirical perspectives

In the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5)the female sexual pain disorders vaginismus and dyspareunia have been merged into the genito-pelvic pain/penetration disorder (GPPPD). The major reason behind this merging is that in clinical practice it always has been difficult to make a categorical distinction between dyspareunia and vaginismus.
In this thesis the role of pelvic floor muscles in GPPPD is explored. Does the vaginal canal, in analogy to the anal and urethral canal, also has a sphincter mechanism? We hypothesize that vaginal reflexive contractions play a role in the pathogenesis of GPPPD and postulate the genito-pelvic reflex hypothesis, i.e. in acute dyspareunia, primarily voluntary contractions or inadequate relaxation of the pelvic floor muscles predominate to guard against the pain due to vaginal trauma/infection and/or stress/anxiety. In chronic dyspareunia, these voluntary contractions induce increasingly (sub)mucosal vaginal damage: contact- and pain receptors become more sensitive. The increased sensitivity of the contact receptors induces powerful autonomic reflexive contractions. These autonomic contractions provoke vulvar pain, which causes overreactive pelvic floor muscles. In lifelong vaginismus, autonomic reflexive contractions of the pelvic floor muscles predominate the entire disease process.
In the thesis it is also shown that a multidimensional is a precondition for an optimal treatment outcome. Transcutaneous electrical neuro stimulation (TENS) as additional treatment of this multidimensional approach is very effective in reducing vulvar pain and the need of an operative intervention.
However, even after a ‘successful’ multidimensional treatment, coitus remained a sensitive act in the majority women.