Genito-Pelvic Pain/Penetration Disorder is a condition where the pelvic floor muscles involuntarily contract during any attempted penetration, causing pain. It was previously called vaginismus. Symptoms include pain during penetration, inability to use tampons, and fear of penetration. Causes may include past trauma, infections, or relationship issues. Treatment involves education, cognitive behavioral therapy, relaxation techniques, vaginal dilators, medications, and physical therapy. The goal is to reduce anxiety, relax muscles, and gradually increase tolerance for penetration.

1. Genito-Pelvic Pain/Penetration
Disorder
PRESENTED BY: SAHAR AFRIDI

3. Introduction
 Genito-Pelvic Pain or Penetration Disorder is a condition in which the pelvic floor
muscles around the vagina contract or tighten whenever an attempt is made to
penetrate
 This is an involuntary action, wherein, the partner has no control over the muscle
contraction.
 The tightening of the muscles prevents any possible penetration of foreign object
such as tampons, instruments used for gynecological tests, and the phallus.
 During any attempt to penetrate, a reflex action triggers tension in the muscles,
resulting in pain

5.  This disorder also varies in degree from person to person.
 This disorder was earlier referred to as Vaginismus, and is now called Genito-
Pelvic Pain/Penetration Disorder by DSM5 in its latest edition (American
Psychiatric Association, 2013).
 Painful intercourse or painful sex can be experienced as pelvic pain, vaginal pain,
or pain in the labial or vulvar areas during sex.
 Pain may be experienced as deep pain, sharp pain, or a burning sensation.

6.  Genito-Pelvic Pain Disorder includes what was formerly termed as:
 vaginismus (tightening of the vaginal muscles),
 vulvodynia (pain in the vulva),
 vestibulodynia (pain around the area of the vaginal opening) and,
 dyspareunia (painful intercourse) depending on the location and intensity of pain.

8. Symptoms of Genito-Pelvic Pain/Penetration Disorder
 There is no evidence to show that every woman suffering from this disorder
should experience the same symptoms.
 The DSM-5 criteria for Genito-Pelvic Pain/Penetration Disorder include one or
more symptoms of this condition:
 Tightening of the vaginal muscle resulting in the inability to penetrate
 A feel of tension, pain or a burning sensation felt when penetration is attempted

9.  A decrease in or no desire to have intercourse
 Voluntary avoidance of sexual activity
 An intense phobia or fear of pain

10. Causes
Though it is difficult to state and point out the exact causes for Genito-Pelvic Pain,
 it has been suggested that inflammation in the vaginal muscles or an injury in the
vulva could be causal factors.
 Traumatic past experience. That experience may well be intense pain during
childbirth.
 Victims of child abuse or women whose experience with intercourse has always
been painful are both ideal candidates.

11.  According to the National Health Services (2013), even the fear of getting
pregnant or
 being told in childhood that “sexual desire is wrong or sex is painful” could be
factors that result in this condition.
 Vaginal infections
 Vaginal atrophy or dryness after menopause.
 Relationship conflict.

12.  Poor communication with partner.
 Poor body image.
 Past sexual abuse.
 Fear of pain
 Lack of sexual education and other sociocultural factors

13. Subtypes
 Genito-Pelvic Pain/Penetration Disorder can be classified into early-onset, late-
onset and situational.
 Early-Onset
This is a case in which the pain in the pelvic muscles has persisted and continues to
do so. This may be a natural disorder’.
 Late-Onset
In this classification, the pain is usually experienced after vigorous physical activity of
any sort.
The pain may also be triggered after penetration is attempted with a penis, tampon or
other objects.

14.  Situational
In this condition, the intensity of pain varies by situation –
it may be felt under certain conditions or with some particular objects.
For instance, a woman may not able to feel the pain when inserting a tampon, but
may experience an intense and shooting pain when attempting penetration during
intercourse.
Strangely, the pain may occur only during intercourse with one person and not
another.

15. Genito-Pelvic Pain and Personal life
 This disorder has a tremendous impact on personal life.
 Women with this disorder often have strained relationships because of the
inability to have sexual intercourse, and because it prevents them from having a
child and raising a family.
 As psychological stress builds up over time, it may even lead to depression.
 The inability to get penetrated is likely to cause a deep psychological influence in
a person's mind.
 The person may begin to feel ashamed, shocked, embarrassed or even inferior.
The chances of this person coming to a conclusion of being “defective” are also
high after repeated failures and unbearable pain.

16. Treatment
 Psychoeducation
 The participants will be provided with psychoeducational information on GPPPD
and the multifactorial causes of its development.
 The participants will be introduced to the fear-avoidance model and thereby learn
more about the causal and maintaining factors of GPPPD and the rationale
behind the treatment.
 Participants are given the opportunity to individualize their own fear-avoidance
model by including their cognitions, emotions, physical reactions, and behaviors.
 Participants also learn about the function of emotions and their influence on
GPPPD symptoms.

17.  Cognitive Restructuring
 In the first step, participants identify negative cognitions and distorted beliefs
about sexual intercourse, genital pain, and sexuality in general, and learn how
cognitions can influence emotions and behavior.
 In the second step, they restructure and replace these cognitions with more
helpful and encouraging ones. These cognitions are also rehearsed as coping
self-statements during the exercises.

18.  Non-Judgmental Awareness
 By learning about and practicing non-judgmental awareness, participants might
be able to interrupt automatic processes of negative cognitions.
 They are instructed to observe their cognitions and emotions in response to
sexual situations without interpreting, judging, reacting to or suppressing them.
 Muscle and Breathing Relaxation

19.  Attention-Focusing for Pain Management
 Participants are also introduced to the relationship between vaginal pain and
anxiety, and the consequences of pain and fear of pain on sexual arousal and
muscle tension.
 Body Exposure and Genital Self-Exploration
 The internal and external female genitals and the anatomy of pelvic floor are
introduced and illustrated with drawing. This treatment component also addresses
the physiological processes during arousal and sexual intercourse.

20.  Sensate Focus
 The aim of the sensate focus exercises is to promote physical intimacy and
reduce associated stress, pressure, and anxiety by emphasizing the experience
of sensual pleasure by the couple over intercourse or orgasm.
 Electromyographic Biofeedback
 In this mode of treatment, a sensor is attached to the vagina, detecting parts of
muscles where pain originates due to muscle contraction.
 The therapist then trains the person to relax using breathing exercises

21.  Cognitive Behavioral Therapy
 Maladaptive cognitive schemas are addressed.
 These maladaptive schemas typically affect catastrophizing, where the person
thinks about the worst possible outcome of the situation and engages in
avoidance behaviors.
 Demystifying pain
 Even seemingly inexplicable pain has its patterns.
 One way of transforming the pain from a mysterious tormentor to a more
controllable force is to train the client to explore the conditions under which the
pain is minimized and maximized.

22.  Demystifying anxiety
 Anxiety is not an inevitable reaction to the pain problem.
 It can be targeted and reduced or eradicated.
 Starting to do so using relaxation therapy techniques (e.g., imaging, breathing
exercises, progressive muscle relaxation, and mindfulness), cognitive re-
structuring, and de-catastrophization can be important steps.

23. Medications:
 Blood flow, lubrication, and tissue thickness and elasticity respond directly to
hormone replacement. The most rapid relief of atrophy comes from applying
topical estrogen vaginal cream directly to the vagina and its opening.
 An oral drug taken once a day, ospemifene (Osphena), makes vaginal tissue
thicker and less fragile, resulting in less pain for women during sex.
 Another drug to relieve painful intercourse is prasterone (Intrarosa).
 It's a capsule you place inside the vagina daily and relieve vaginal dryness and
make sex less painful.

24.  Tricyclic antidepressants
 Amitriptyline and
 Nortriptyline
 Glycerine-free lubricants that are water-based.
 Water-based lubricants can be applied for 2-3 days.
 Application of topical estrogen directly in the vagina.
 Oral estrogen.

25.  Estrogen releasing rings that can be put in the vagina to release hormones for
change.
 Vaginismus Physical Therapy
 1. Breathing Technique
 2. Deep Squat
 3. Pelvic Floor Drop

27. Home care
 Talk about it – talk to your partner about what makes you feel good and what doesn’t.
 If you need to, then ask him to be patient and slow, so that you are lubricated enough
to enjoy the act.
 Don’t rush – A longer time for foreplay can do wonders for a woman’s body.
 So be patient and take as long as it needs.
 Change positions – If a woman feels sharp pain when the partner is thrusting, then a
change in position might help.
 The woman on top position can also regulate the depth of penetration without facing
too much pain.

28.  Other – Try taking a warm bath before sex and empty your bladder.
 Can also apply an ice pack to the vulva for relief