Introitus Vulval disease involving introitus (e.g., lichen sclerosis). Recurrent splitting of the posterior fourchette manifest as just visible white lines perpendicular to fourchette edge. Abnormalities of the hymen (e.g., hymenal band across the introitus). Adhesions of the labia minora. Swellings in the area of the major vestibular glands. Allodynia (pain sensation from touch stimulus) of the crease between the outer hymenal edge and the inner edge of the labia minora +/− allodynia of the Skene’s duct openings (all typical of provoked vestibulodynia). Presence of cystocele, rectocele, or prolapse interfering with the woman’s sexual self-image. Inability to tighten and relax perivaginal muscles (often associated with hypertonicity of pelvic muscles and midvaginal dyspareunia). Abnormal vaginal discharge associated with burning dyspareunia.
Internal examination Pelvic muscle tone. Presence of tenderness or trigger points on palpating deep levator ani as a result of underlying hypertonicity.
Full bimanual examination Presence of nodules and/or tenderness in the cul-de-sac or vaginal fornix, or along uterosacral ligaments. Retroverted fixed uterus as causes of deep dyspareunia. Tenderness palpating posterior bladder wall from anterior vaginal wall suggestive of bladder pathology.
The PLISSIT Model Gynecologists may sometimes need to provide detailed management for certain conditions (e.g., for the chronic dyspareunia of provoked vestibulodynia [PVD]), frequently the first two levels of a model, known by its acronym as PLISSIT, are sufficient to address women’s sexual problems. The model is as follows: 1.
Permission. The concept of permission is the validation of the patient’s concerns and confirmation that the gynecologist’s office is an appropriate setting to address them.
2.
Limited Information. The patient is provided with information about sexual physiology and behavior so misunderstandings, myths, lack of knowledge, and inadequate sexual skills can be addressed.
3.
Specific Suggestions. This stage may involve altering the problematic sexual context, reeducating patients about specific attitudes and practices, advising different forms of sexual stimulation, screening for mental health issues, identifying interpersonal issues and prescribing hormones and medications.
4.
Referral for Intensive Therapy. Examples where this step may be necessary include (i) intrapsychological issues stemming from childhood that impair women’s ability to be aroused and experience sexual pleasure and satisfaction including past traumas and abuse, (ii) for couples who need more specialized help in sexual communication, and (iii) for male sexual dysfunctions.
As an example of a PLISSIT approach, a woman with chronic dyspareunia from PVD is first given validation of her pain and is provided with the information that PVD is common and many women find that the pain precludes intercourse. The patient and her partner are encouraged to focus on nonpenetrative aspects of lovemaking. The next level is the provision of limited information about chronic pain mechanisms, the role of psychological stress, and genetic and possible immune factors. Specific suggestions could include ongoing encouragement to remove intercourse as one of the ways the couple interact sexually, explanation of basic cognitive behavioral therapy (CBT)
Table 11.7 Revised DSM-IV Definitions of Women’s Sexual Dysfunction
Absent or diminished feelings of sexual interest or desire, absent sexual thoughts or fantasies and a lack of responsive desire. Motivations (here defined as reasons/incentives) for attempting to become sexually aroused are scarce or absent. The lack of interest is beyond a normative lessening with life cycle and relationship duration.
Minimal spontaneous sexual thinking or desiring of sex ahead of sexual experiences does not necessarily constitute disorder. Additional lack of responsive desire is integral to the diagnosis.