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BACKGROUND: A set of enduring conditions have been reported in the literature involving persistent sexual dysfunction after discontinuation of serotonin reuptake inhibiting antidepressants, 5 alpha-reductase inhibitors and isotretinoin.OBJECTIVE: To develop diagnostic criteria for post-SSRI sexual dysfunction (PSSD), persistent genital arousal disorder (PGAD) following serotonin reuptake inhibitors, post-finasteride syndrome (PFS) and post-retinoid sexual dysfunction (PRSD).METHODS: The original draft was designed using data from two published case series (Hogan et al., 2014 and Healy et al., 2018), which represent the largest public collections of data on these enduring conditions. It was further developed with the involvement of a multidisciplinary panel of experts.RESULTS: A set of criteria were agreed upon for each of the above conditions. Features of PSSD, PFS and PRSD commonly include decreased genital and orgasmic sensation, decreased sexual desire and erectile dysfunction. Ancillary non-sexual symptoms vary depending on the specific condition but can include emotional blunting and cognitive impairment. PGAD presents with an almost mirror image of unwanted sensations of genital arousal or irritability in the absence of sexual desire. A new term, post-SSRI asexuality, is introduced to describe a dampening of sexual interest and pleasure resulting from a pre-natal or pre-teen exposure to a serotonin reuptake inhibitor.CONCLUSIONS: These criteria will help in both clinical and research settings. As with all criteria, they will likely need modification in the light of developments.

Background Persistent genital arousal disorder (PGAD), a condition of unwanted, unremitting sensations of genital arousal, is associated with a significant, negative psychosocial impact that may include emotional lability, catastrophization, and suicidal ideation. Despite being first reported in 2001, PGAD remains poorly understood. Aim To characterize this complex condition more accurately, review the epidemiology and pathophysiology, and provide new nomenclature and guidance for evidence-based management. Methods A panel of experts reviewed pertinent literature, discussed research and clinical experience, and used a modified Delphi method to reach consensus concerning nomenclature, etiology, and associated factors. Levels of evidence and grades of recommendation were assigned for diagnosis and treatment. Outcomes The nomenclature of PGAD was broadened to include genito-pelvic dysesthesia (GPD), and a new biopsychosocial diagnostic and treatment algorithm for PGAD/GPD was developed. Results The panel recognized that the term PGAD does not fully characterize the constellation of GPD symptoms experienced by patients. Therefore, the more inclusive term PGAD/GPD was adopted, which maintains the primacy of the distressing arousal symptoms and acknowledges associated bothersome GPD. While there are diverse biopsychosocial contributors, there is a common underlying neurologic basis attributable to spontaneous intense activity of the genito-pelvic region represented in the somatosensory cortex and its projections. A process of care diagnostic and treatment strategy was developed to guide the clinician, whenever possible, by localizing the symptoms as originating in any of five regions: (i) end organ, (ii) pelvis/perineum, (iii) cauda equina, (iv) spinal cord, and (v) brain. Psychological treatment strategies were considered critical and should be performed in conjunction with medical strategies. Pharmaceutical interventions may be used based on their site and mechanism of action to reduce patients’ symptoms and the associated bother and distress. Clinical Implications The process of care for PGAD/GPD uses a personalized, biopsychosocial approach for diagnosis and treatment. Strengths and Limitations Strengths and Limitations: Strengths include characterization of the condition by consensus, analysis, and recommendation of a new nomenclature and a rational basis for diagnosis and treatment. Future investigations into etiology and treatment outcomes are recommended. The main limitations are the dearth of knowledge concerning this condition and that the current literature consists primarily of case reports and expert opinion. Conclusion We provide, for the first time, an expert consensus review of the epidemiology and pathophysiology and the development of a new nomenclature and rational algorithm for management of this extremely distressing sexual health condition that may be more prevalent than previously recognized. Goldstein I, Komisaruk BR, Pukall CF, et al. International Society for the Study of Women’s Sexual Health (ISSWSH) Review of Epidemiology and Pathophysiology, and a Consensus Nomenclature and Process of Care for the Management of Persistent Genital Arousal Disorder/Genito-Pelvic Dysesthesia (PGAD/GPD). J Sex Med 2021;18:665–697.

Transgender individuals face many barriers to healthcare access, including providers’ lack of knowledge on transgender-specific healthcare needs. Physicians and medical students report a lack of tr...

Background Persistent genital arousal disorder (PGAD) is a highly distressing, understudied condition characterized by persistent genital arousal (eg, genital sensations, sensitivity) in the absence of sexual desire. Currently, there is limited information about the prevalence of PGAD based on its proposed diagnostic criteria (“PGAD criteria”). Aim This study sought to assess the prevalence of PGAD criteria in 2 North American samples: a large, non-clinical sample of Canadian undergraduate students (Study 1), and a nationally representative sample from the U.S. (Study 2). Methods The incoming class of undergraduate students (N = 1,634) enrolled in the Introduction to Psychology course at a Canadian university and a nationally representative sample of U.S. participants (N = 1,026) responded to questions about each PGAD criterion, and distress associated with these experiences. Outcomes 5 self-report questions were developed based on each of the Leiblum and Nathan 2001 PGAD criteria, and a measure of associated distress was included. The U.S. sample (Study 2) also responded to questions about medical comorbidities and their knowledge of the term “PGAD.” Results 1.1% (n = 4; Study 1) to 4.3% (n = 22; Study 2) of men and 0.6% (n = 7; Study 1) to 2.7% (n = 14; Study 2) of women reported experiencing all 5 PGAD criteria at a moderate to high frequency. Even greater proportions of participants reported experiencing all 5 criteria at any frequency (6.8–18.8%). Although ratings of associated distress varied, participants who were distressed by these symptoms most frequently endorsed the first PGAD criterion: physiological genital arousal in the absence of sexual excitement or desire. These results are similar to previously reported rates of PGAD. Clinical Implications A non-trivial number of individuals may experience PGAD, and it should be screened for by healthcare practitioners. Strengths & Limitations This study is the first to use 2 large, non-clinical samples to assess the prevalence of PGAD symptoms. However, barriers to reporting symptoms, such as shame or embarrassment, may have resulted in underestimates of prevalence in the present sample. Conclusion The prevalence of the 5 PGAD criteria in 2 large non-clinical samples ranged from similar to higher than rates reported in previous research. However, distress ratings associated with each of the 5 criteria varied, with most respondents describing them primarily as neutral or non-distressing.

Purpose of Review Persistent genital arousal disorder (also referred to as genitopelvic dysesthesia or PGAD/GD) is a distressing and largely underrecognized condition characterized by persistent, unwanted genital arousal (sensations, sensitivity, vasocongestion) in the absence of subjective/cognitive arousal and sexual desire. The purpose of this review is to summarize recent findings on biological and psychosocial factors in PGAD/GD as they pertain to the assessment and treatment of this condition. These findings will be considered within a biopsychosocial framework, for the purposes of considering next steps for clinical and research efforts. Recent Findings A small number of studies have recently examined potential biological aetiologies for PGAD/GD: pharmacological agents, spinal pathology and peripheral nerve involvement. Recent studies have also found that PGAD/GD is associated with a significant negative impact on psychosocial wellbeing and daily functioning as compared to symptom-free individuals. In addition, these results highlight cognitive/affective responses to symptoms (e.g. catastrophizing of symptoms) that may influence outcomes. However, biological and psychological research are rarely integrated in these studies, despite the interrelationship between these factors. Summary Although PGAD/GD was first described in the scientific literature almost two decades ago, most research on PGAD/GD is presented in the form of case studies. Prospective treatment trials that integrate biopsychosocial factors are needed in order to provide effective and efficient care to this population. This research would be facilitated by the development of a patient-reported outcome measure, as well as greater education/awareness among healthcare providers and the public about this distressing condition.

To review recently published literature on vulvodynia classification, comorbidities, chronicity, and interpersonal factors, and to outline critical gaps between research findings and clinical practice. The classification of vulvodynia varies in terms of its specificity and degree of focus on pain and psychosocial correlates, with recent conceptualizations supporting a biopsychosocial framework. The presence of comorbidities in those with vulvodynia is associated with poorer symptom outcomes and psychosocial wellbeing, as well as longer-term symptom presentation. Longitudinal research has indicated that the course of vulvodynia can vary, with some women experiencing complete pain remission, pain remission with relapse, or pain persistence. There has been a significant increase in psychosocial research in vulvodynia, with much attention on the role of interpersonal factors in the experience of pain and in sexual and relationship satisfaction. Partner dynamics and sexual motivation have figured prominently in this area of research. The field of vulvodynia research has grown exponentially over the past few years, with an increase in attention to factors and issues outside pathophysiological processes in the vulva. Despite empirically-based recommendations for treatment options, treatment algorithms remain inconsistent and are based on poorly supported treatment options.

Introduction Although postpartum sexual concerns are common, limited data exist on postpartum sexual response. Furthermore, the physiological process of vaginal birth may negatively impact genital response compared with unlabored cesarean section (C-section), but this hypothesis has yet to be tested. Aim To (i) compare genital and subjective sexual response and sexual concordance by mode of delivery with inclusion of a control group, (ii) compare groups on self-reported sexual function over the past month, (iii) examine the relationship between laboratory measurement of sexual response and self-reported sexual function, and (iv) investigate association between obstetrical factors and breastfeeding and between sexual response and self-reported sexual function. Methods 3 groups of cisgender women were recruited from the community: primiparous women who delivered via vaginal birth within the past 2 years (VB group; n = 16), primiparous women who delivered via unlabored C-section within the past 2 years (CS group, n = 15), and age-matched nulliparous women (NP group, n = 18). Laser Doppler imaging was used to assess genital response while participants watched a neutral and erotic film. Main Outcome Measures The main outcome measures were change in flux units from neural to erotic video as a measure of genital response, subjective sexual arousal rated continuously throughout films, perceived genital response rated after films, and Female Sexual Function Index (FSFI). Results Women in the VB group had significantly lower change in flux units than women in the CS (P = .005, d = 1.39) and NP (P Clinical Implications Results underscore the importance of balancing objective and subjective indices of sexual response and function, especially considering the biopsychosocial nature of postpartum sexuality. Strengths & Limitations The present study is the first to apply modern sexual psychophysiological methodology to the study of postpartum sexuality. Cross-sectional methodology limits the ability to make causal inferences, and the strict inclusion criteria limits generalizability. Conclusion Physiological changes as a result of labor and delivery may have a detrimental impact on genital response; however, these physiological differences may not impact women's subjective experience of postpartum sexuality.

Background Persistent genital arousal disorder (PGAD) is characterized by symptoms of distressing physiological sexual arousal (Persistent genital arousal [PGA] symptoms such as genital vasocongestion, sensitivity, or both) that occur in the absence of sexual desire. There continues to be a lack of systematic research on this condition. Little is known about the common medical comorbidities and psychological, sexual, or relationship well-being of individuals who experience PGA symptoms. Aims To compare these biopsychosocial factors in an age-matched sample of women with and without symptoms of PGA. A secondary aim was to examine what symptom factors (associated distress, symptom severity) and cognitive factors (eg, catastrophizing of vulvar sensations) were associated with psychosocial outcomes in women with symptoms of PGA. Methods Age-matched samples of women with (n = 72) and without (n = 72) symptoms of PGA completed a comprehensive online survey. Main Outcome Measures Participants self-reported their medical histories and completed validated measures of psychosocial functioning (depressive and anxiety symptoms, catastrophizing of vulvar sensations, sexual functioning and distress, and relationship functioning). Results Women with symptoms of PGAD reported significantly greater depressive and anxiety symptoms, sexual distress, and suicidal ideation, as well as significantly poorer relationship functioning than women without PGA symptoms. Catastrophizing of vulvar sensations was related to PGA symptom ratings (greater severity, distress) and psychosocial outcomes (greater depression, anxiety, and sexual distress). Clinical Implications The results of this study highlight medical and psychosocial difficulties associated with PGA symptoms, which should be assessed and addressed as essential components of treatment. Strengths & Limitations This study seeks to address the paucity of research on the well-being of women with PGA symptoms by undertaking a comparison of age-matched samples using validated questionnaires. This study is limited by its self-report, cross-sectional design. Conclusion PGA symptoms are associated with significant health and psychological difficulties. These results highlight the need for continued research in this area to improve identification and treatment for this population.

OBJECTIVE The aim of the study was to document treatment-seeking experiences of women with chronic vulvar pain, comfort communicating about pain, and test the clinical utility of the screening version of the Vulvar Pain Assessment Questionnaire, screening version (VPAQscreen). MATERIALS AND METHODS Patients scheduled for an appointment with the Program in Vulvar Health at Oregon Health and Science University were invited to complete the VPAQscreen and answer descriptive questions about previous treatment-seeking experiences and communication with health care providers. Clinicians provided provisional diagnoses based on VPAQscreen summaries, final diagnoses based on gynecological examination, and commented on alignment with clinical observations. Patients gave feedback on the accuracy and helpfulness of the VPAQscreen summary, characteristics of the questions asked, and whether their comfort communicating increased. RESULTS Participants reported previously seeing approximately 5 medical doctors and 2 other health care providers and perceived them as lacking knowledge of vulvar pain syndromes. Providers indicated that VPAQscreen summaries aligned with clinical presentations and suggested provisional diagnoses with more than 80% accuracy. Participants reported that VPAQscreen summaries were helpful and accurate in summarizing symptoms. Most reported that the number, range, and readability of VPAQscreen questions were good or excellent. More than half reported that completing the VPAQscreen increased comfort when speaking with their Oregon Health and Science University physician. CONCLUSIONS Patients with vulvar pain often endure a lengthy process of consulting multiple clinicians before securing care. The VPAQscreen was more than 80% accurate in predicting diagnosis at this specialty clinic and was useful in assisting patients with expressing symptoms. The applicability of the VPAQscreen in general practice is unknown, although it shows promise.

Genital lubrication and blood flow are theoretically related outcomes of women’s sexual response that prepare the genitals for sexual activity. Despite its importance for sexual function, few experimental studies have directly assessed genital lubrication or empirically demonstrated how genital lubrication and blood flow relate during sexual arousal. In this study, 36 women viewed stimuli that varied by sexual activity intensity (nonsexual, low-intensity sexual, and high-intensity sexual) while their genital responses were assessed using concurrent measures of genital lubrication (using litmus test strips) and genital blood flow (using laser Doppler imaging). Both measures detected a genital response to high-intensity sexual stimuli relative to nonsexual; however, only the laser Doppler imager was sensitive to varying degrees of genital response elicited by stimuli of different sexual activity intensities. The two measures of genital response were suitable for repeated measurement within a single session. Genital lubrication and blood flow were positively correlated for the high-intensity sexual stimuli. Implications for the assessment of women’s genital response and understanding women’s sexual arousal are discussed.

The most common subtype of vulvodynia (idiopathic chronic vulvar pain) is provoked vestibulodynia (PVD). Previous imaging studies have shown that women with vulvodynia exhibit increased neural activity in pain-related brain regions (e.g., the secondary somatosensory cortex, insula, dorsal midcingulate, posterior cingulate, and thalamus). However, despite the recognized role of the spinal cord/brainstem in pain modulation, no previous neuroimaging studies of vulvodynia have examined the spinal cord/brainstem. Sixteen women with PVD and sixteen matched Control women underwent a spinal cord/brainstem functional magnetic resonance imaging (fMRI) session consisting of five runs with no painful thermal stimuli (No Pain), interleaved randomly with five runs with calibrated, moderately painful heat stimulation (Pain). Functional connectivity was also assessed in periods before, during, and after, pain stimulation to investigate dynamic variations in pain processing throughout the stimulation paradigm. Functional connectivity in the brainstem and spinal cord for each group was examined using structural equation modeling (SEM) for both Pain and No Pain conditions. Significant connectivity differences during stimulation were identified between PVD and Control groups within pain modulatory regions. Comparisons of Pain and No Pain conditions identified a larger number of connections in the Control group than in the PVD group, both before and during stimulation. The results suggest that women with PVD exhibit altered pain processing and indicate an insufficient response of the pain modulation system. This study is the first to examine the spinal cord/brainstem functional connectivity in women with PVD, and it demonstrates altered connectivity related to pain modulation in the spinal cord/brainstem.

Provoked Vestibulodynia (PVD) is the most common vulvodynia subtype (idiopathic chronic vulvar pain). Functional magnetic resonance imaging (fMRI) studies indicate that women with PVD exhibit altered function in a number of pain modulatory regions in response to noxious stimulation, such as in the secondary somatosensory cortex, insula, dorsal midcingulate, posterior cingulate, and thalamus. However, previous neuroimaging studies of PVD have not examined periods of time before and after noxious stimulation or investigated functional connectivity among pain modulatory regions. Fourteen women with PVD and 14 matched Control participants underwent five fMRI runs with no painful stimuli interleaved randomly with five runs with calibrated, moderately painful heat stimuli applied to the thenar eminence. As recent findings indicate that pain processing begins before and continues after painful stimulation, 2-min periods were included in each run before and after the stimulus. Functional brain connectivity was assessed during both trials of Pain and No Pain stimulation for each group using structural equation modeling (SEM). Analyses of variance (ANOVAs) on connectivity values demonstrated significant main effects of study condition, and group, for connectivity among pain modulatory regions. Most of the differences between the Pain and No Pain conditions found only in the PVD group take place before (i.e., thalamus to INS, ACC to S1, thalamus to S1, and thalamus to S2) and after pain stimulation (i.e., INS to amygdala, PPC to S1, and thalamus to S2). Such differences were not observed in the Control group. These findings further support previous results indicating that women with PVD have altered pain processing compared to pain-free women.

Background Persistent genital arousal disorder/genito-pelvic dysesthesia (PGAD/GPD) is a highly distressing yet poorly understood condition characterized by persistent genito-pelvic sensations, often described as “genital arousal,” which occur in the absence of sexual desire. PGAD/GPD is associated with significant impairment in psychosocial and daily functioning; however, there are currently no empirically validated treatment algorithms for PGAD/GPD. Pelvic floor physical therapy exercises have been found to be effective at reducing other forms of genito-pelvic discomfort, such as vulvodynia, and may also be beneficial to those experiencing PGAD/GPD. Many individuals with PGAD/GPD report difficulty finding a health care provider who is knowledgeable about PGAD/GPD; therefore, pelvic floor education and exercises in an online format may have the potential to reach more individuals in need. Objective This study examined the feasibility of an online pelvic floor group education program; descriptively assessed outcomes related to distress, discomfort, catastrophizing, and mood; and obtained feedback from participants in order to inform the development of improved online group programs. Methods Fourteen women with current symptoms of PGAD/GPD attended an online, 8-session pelvic floor group education program. Participants completed questionnaires of symptoms (ie, symptom distress, discomfort) and psychosocial well-being (ie, depression, anxiety, symptom catastrophizing) prior to the group sessions (Time 1), immediately after the final group session (Time 2), and 6 months following the final group session (Time 3). Participants also completed an anonymous feedback questionnaire immediately following the group program. Results Overall, participants who attended a larger number of the group sessions (>5 sessions, n=7) appeared to report lower baseline (Time 1) symptoms and psychosocial impairment than those who attended fewer sessions ( Conclusions Online interventions provide an opportunity to reach international participants who may otherwise struggle to access a knowledgeable provider for their PGAD/GPD symptoms. Addressing barriers may help to increase participants’ abilities to engage in the program. Future programs may seek to integrate a greater focus on relaxation strategies and cognitive-affective strategies for managing PGAD/GPD symptoms.

As a rite of passage to womanhood, 2 million girls undergo female genital circumcision (FGC)-the tradition of cutting, and often removing parts of the vulva-every year. The current study is the first to focus on the connection between peripheral nerve damage and chronic neuropathic pain in women with FGC. We used mixed methods-quantitative, qualitative, and physiological-to study chronic pain in Somali-Canadian women (N = 14). These women have the most extensive form of FGC, which includes removal of the glans clitoris, labia minora, medial portion of the labia majora, and stitching together the remaining parts of the labia majora. Our results indicate a multifaceted pain experience in women with FGC. Although they report good overall health and very low pain levels on the short form of the McGill Pain Questionnaire, pressure-pain quantitative sensory testing of the vulvar region applied through vulvalgesiometers shows pain thresholds consistent with those reported by women with chronic vulvar pain. Furthermore, qualitative interviews reveal a considerable amount of often debilitating pain in daily life. These results challenge the use of assessment tools offering elicited verbal pain language and highlight the importance of culturally sensitive ways of conceptualizing, measuring, and managing pain.

Introduction Persistent genital arousal disorder (PGAD) is a highly distressing and poorly understood condition characterized by unwanted sensations of genital arousal in the absence of subjective sexual desire. Research has shown that some individuals with PGAD also report orgasm, urinary, and pain symptoms, with 1 recent study specifically comparing a “painful persistent genital arousal symptom” group to a “non-painful persistent genital arousal symptom” group on various indicators given the highly frequent report of comorbid genitopelvic pain in their sample. Aim To review literature on PGAD focusing on the presence of pain symptoms. Methods A literature review through May 2018 was undertaken to identify articles that discuss pain characteristics in individuals with persistent sexual arousal syndrome, persistent genital arousal disorder, symptoms of persistent genital arousal, and restless genital syndrome. Main Outcome Measure A review of pain/discomfort associated with persistent genital arousal, and the proposal of a new theoretical framework of genitopelvic dysesthesias. Results PGAD is a distressing condition that is associated with a significant, negative impacts on psychosocial and daily functioning. Although it is clear that unwanted and persistent genital arousal is the hallmark symptom of PGAD, symptoms of pain and discomfort are also frequently reported. Based on the results of this review, a model of genitopelvic dysesthesias is proposed, with subcategories of unpleasant sensations that are based on patients' primary complaint: arousal, arousal and pain, or pain (and other sensations). Conclusion The proposed model can provide an important framework for conceptualizing conditions characterized by unpleasant genitopelvic sensations. A model such as this one can benefit highly misunderstood conditions that are questioned in terms of their legitimacy and severity—such as PGAD—by conceptualizing them as sensory disorders, which in turn can reduce stigma, unify research efforts, and potentially improve access to care. Pukall CF, Jackowich R, Mooney K, et al. Genital Sensations in Persistent Genital Arousal Disorder: A Case for an Overarching Nosology of Genitopelvic Dysesthesias? Sex Med Rev 2019;7:2–12.

Group differences in touch and pain thresholds-and their neural correlates-were studied in women with provoked vestibulodynia (PVD; N = 15), a common subtype of vulvodynia (chronic vulvar pain), and pain-free control women (N = 15). Results from quantitative sensory testing and self-report measures indicated that, as compared with control participants, women with PVD exhibited allodynia (ie, pain in response to a normally nonpainful stimulus) and hyperalgesia (ie, an increased response to a normally painful stimulus) at vulvar and nonvulvar sites. In addition, brain imaging analyses demonstrated reduced difference scores between touch and pain in the S2 area in women with PVD compared with control participants, supporting previous findings of allodynia in women with PVD. There were no significant reductions in difference scores between touch and pain for regions related to cognitive and affective processing of painful stimuli. The results of this study contribute important information to the general pain and vulvodynia literatures in elucidating the specific sensorimotor neural mechanisms that underlie hyperalgesia in a chronic pain population. These results have implications for differentiating neural processing of touch and pain for women with and without PVD. Future research should attempt to examine alterations related to hyperalgesia in commonly comorbid conditions of PVD.

Three scientific societies, the International Society for the Study of Vulvovaginal Disease (ISSVD), the International Society for the Study of Women Sexual Health (ISSWSH), and the International Pelvic Pain Society (IPPS) developed the "2015 ISSVD, ISSWSH, and IPPS Consensus Terminology and Classification of Persistent Vulvar Pain and Vulvodynia" (referred to as the "2015 consensus terminology").The terminology included 11 descriptors of vulvodynia. However, the definitions of the descriptors were not included in the 2015 consensus terminology publications. The objective of this article was to provide these definitions.The ISSVD led a discussion on the definitions for the 11 vulvodynia descriptors, with participation from the ISSWSH and IPPS. The definitions were created through a consensus process.The definitions are described and the rationale for their choice is elucidated.The definitions of vulvodynia descriptors were determined by a multistaged process of discussion among health care providers with expertise in the pathophysiology, evaluation, and treatment of vulvodynia. The definitions were approved by the ISSVD, ISSWSH, and IPPS. It is recommended that these definitions of vulvodynia descriptors as well as the 2015 consensus terminology be used for the classification of vulvodynia.

Physicians play a critical role in addressing sexual health in medical practice, including pain during intercourse. Vulvodynia is a prevalent cause of pain, however, related training is limited and variable. In addition, physician attitudes toward pain and sexuality may affect behaviour and therefore patient outcomes. This study's objectives were to: 1) determine whether post-graduate trainees hold more positive attitudes toward women presenting with vulvovaginal pain with (versus without) an identifiable cause; and 2) examine attitudinal predictors of comfort treating vulvodynia and attitudes toward patients with this presentation. Residents in Canadian Obstetrics and Gynecology (OBGYN) and Family Medicine (FM) programs participated in an online survey (N=99). Respondents completed questionnaires related to demographics, sexuality-related training, sexual attitudes, and comfort treating and attitudes toward vulvovaginal pain and its symptoms. Residents reported significantly more positive attitudes toward patients with visible pathology versus no identifiable cause for vulvovaginal pain, regardless of medical specialty, p

Background Media representations of sexuality after childbirth depict vaginal birth as harmful and cesarean delivery as protective, although research does not support these depictions. The objective of the current study was to investigate perceptions of the effects of mode of delivery on sexuality. Methods Nulliparous participants who were able to and interested in giving birth (N = 1428) completed an online survey about their preferences for mode of delivery and their perceptions of childbirth as they specifically relate to sexuality. Participants provided demographic information, rated how influential different sources of information about childbirth were, and completed the Attitudes Toward Women's Genitals Scale. Results Up to half (16-48%), the participants agreed with different statements about vaginal birth as harmful to, and cesarean delivery as protective of, future sexuality. Participant characteristics that were independently predictive of endorsing these beliefs were: self-identifying as heterosexual, holding negative attitudes toward women's genitals, and reporting that reality media, nonreality media, and online media sources are influential sources of childbirth information. Participants who rated health care professionals as an influential source of information were less likely to endorse these beliefs. Conclusion Given that there is no clear evidence in the empirical literature to support the claim that vaginal births are harmful and cesarean delivery is protective to one's future sexual life, it is important to dispel the existing misconceptions. Various media sources likely play a role in the perpetuation of this misinformation.

Provoked vestibulodynia (PVD) is an idiopathic vulvar pain condition characterized by burning pain at the vaginal opening in response to contact or pressure. Previous research has established some of the psychosocial difficulties experienced by these patients, but direct comparisons with other pain conditions are needed. The purpose of this study was to compare women with PVD to those with postherpetic neuralgia and pain-free control participants.Participants were invited to complete an anonymous online survey consisting of sociodemographic questions and a range of validated measures.Women with PVD and postherpetic neuralgia (PHN) did not differ in terms of pain catastrophizing or pain anxiety, but women with PHN reported greater pain disability than those with PVD. Participants in both pain groups reported significantly more symptoms of stress, depression, anxiety, and sleep disturbances than pain-free controls; women with PHN reported more symptoms of depression than those with PVD, with no other differences between pain groups. Groups did not differ on relationship adjustment, but participants with PVD reported poorer sexual functioning than the other groups.These results indicate that women with PVD and PHN experience similar mental health difficulties, but women with PHN experience more severe impact on their day-to-day functioning and mood. These results support the classification of PVD as a chronic pain condition, as both the pain groups differed from pain-free control participants on a range of measures. Finally, the presence of mental health difficulties and poorer sexual functioning highlights the importance of conducting biopsychosocial pain assessments.

Objectives: Vulvodynia (idiopathic chronic vulvar pain) is a prevalent condition associated with significant and negative impacts in many areas of function. Despite the increased research interest in vulvodynia in recent years, recommendations for outcome measures for use in clinical trials are missing. The purpose of this paper, therefore, was to provide recommendations for outcome measures for vulvodynia clinical trials so that consistent measures are used across trials to facilitate between-study comparisons and the conduct of large multicenter trials, and to improve measurement of the multiple dimensions of vulvodynia. Methods: Given that provoked vestibulodynia (PVD)—characterized by provoked pain localized to the vaginal opening—is the most common subtype of vulvodynia and the current main focus of clinical trials, this paper focused on recommended outcome measures in PVD clinical trials. The framework used to guide the selection of outcome measures was based on the one proposed by the Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials (IMMPACT). Results: The IMMPACT framework provided a well-suited guideline for outcome measure recommendations in PVD clinical trials. However, given the provoked presentation of PVD and the significant impact it has on sexuality, modifications to some of the IMMPACT recommendations were made and specific additional measures were suggested. Discussion: Measures that are specific to vulvovaginal pain are ideal for adoption in PVD clinical trials, and many such measures currently exist that allow the relevant IMMPACT domains to be captured.

Objective* the primary aim was to describe the pain characteristics of persistent genito-pelvic postpartum pain (PPP) and compare these characteristics by mode of delivery. The secondary aim was to incorporate psychosocial variables into the conceptualization of PPP by exploring the relationship among postpartum depressive symptoms, fatigue, and PPP. Design cross-sectional study design. Setting online survey. Participants 106 women recruited from the community who gave birth within twelve months prior to completing the survey. Measurements and findings questionnaire regarding sociodemographic information, pregnancy and childbirth variables, depressive symptoms (Edinburgh Postnatal Depression Scale), and fatigue (Fatigue Symptom Checklist). Women who were ≥3 months postpartum and indicated they were still experiencing any genito-pelvic pain from childbirth were provided questions about their current pain experience. Twenty-seven (25.5%) women were between 3–12 months postpartum and currently experiencing PPP. The intensity of pain was mild, and had multiple locations and triggers. Compared to women whose acute pain resolved after childbirth, women with PPP were more likely to have had a Caesarean section (15.2% versus 33.3%). Other birth-related (i.e., epidural/spinal anesthesia use during vaginal birth) and psychosocial variables (income) also differentiated women with PPP from women whose gentio-pelvic pain resolved. Postpartum fatigue independently predicted PPP (Odds ratio=4.7), while postpartum depressive symptoms did not. Key conclusions PPP was quite prevalent in this sample, and while the intensity of pain was on average, mild, the pain was widespread in terms of location and triggers. Multiple biopsychosocial factors differentiated women with persistent postpartum pain from those women whose pain resolved. Implications for practice PPP is a common health concern for new mothers in the first year postpartum, and may be best addressed by health care professionals using a multidimensional approach, which focuses on the psychosocial aspects of pain.

Introduction Prostate cancer (PCa) is the most commonly diagnosed cancer among males globally, and it has one of the highest 5-year net survival rates of all cancers. Most diagnosed individuals, therefore, must live with the consequences of the disease and its treatments, including sexual side effects. Unfortunately, little is known about the sexual outcomes of PCa in individuals who identify as gay or bisexual. Objectives To highlight the unique concerns, experiences, and needs of gay and bisexual men with PCa by reviewing the literature on sexual outcomes in this patient population. Methods A literature review through June 2019 was conducted, with a focus on sexual outcomes in gay and bisexual men with PCa; comparisons of sexual outcomes between heterosexual and gay and bisexual men with PCa; and the health care experiences of gay and bisexual men with PCa, specifically with regards to discussing sex with health care providers. Results Gay and bisexual men with PCa report a number of unique sexual concerns compared to their heterosexual counterparts. They face heteronormative biases and homophobia in the health care system and are frequently dissatisfied with the information they receive with regards to PCa and sexuality. Conclusion There has been limited research on the experiences of gay and bisexual men with PCa; additional research to replicate and extend upon the findings of previous studies is warranted. Research on the experiences of PCa patients and survivors should be inclusive of participants of all sexual orientations and gender identities. Research results must be translated into clinical practice, so that health care providers can communicate specific and relevant information to their gay and bisexual patients. McInnis MK, Pukall, CF. Sex After Prostate Cancer in Gay and Bisexual Men: A Review of the Literature. Sex Med Rev 2020;8:466–472.

Introduction The etiology and consequences of chronic vulvar pain are multidimensional, resulting in highly variable clinical presentations and no established treatment algorithm. Inconsistent use of measurement tools across studies is a significant barrier to drawing conclusions regarding etiology and treatment. In a companion paper, we review additional methodological challenges to the study of chronic vulvar pain and potential solutions. Aim To review and recommend assessment and measurement tools for vulvar pain and associated key outcomes. Methods The authors reviewed the scientific evidence related to measurement of vulvar pain and made decisions regarding recommendations via discussion and consensus. Main Outcome Measure We assessed measurement tools for vulvar pain and related outcomes and considered advantages and disadvantages of their use. Results Empirically validated measurement tools are available and should be used uniformly across studies to support comparisons and pooling of results. There is, at times, a trade-off between advantages and disadvantages when selecting a particular tool, and researchers should be guided by their specific research aims, feasibility, and potential to gain further knowledge in the field. Researchers should incorporate a biopsychosocial assessment of vulvar pain and its consequences. Clinical Implications This review provides a comprehensive list of measurement tool recommendations for use in clinical research, and in some cases, clinical practice. Strengths & Limitations This expert review can guide study design and decision-making for those researching vulvar pain and its consequences. The review content and recommendations are based on expert knowledge of the literature rather than a formal systematic review. Conclusion A thorough consideration of vulvar pain assessment tools is essential for continued progress toward identifying factors involved in the development and maintenance of vulvar pain and developing empirically supported treatments.

Background Chronic pelvic pain with various etiologies and mechanisms affects men and women and is a major challenge. Monotherapy is often unsuccessful for chronic pelvic pain, and combinations of different classes of medications are frequently prescribed, with the expectation of improved outcomes. Although a number of combination trials for chronic pelvic pain have been reported, we are not aware of any systematic reviews of the available evidence on combination drug therapy for chronic pelvic pain. Objective We have developed a protocol for a systematic review to evaluate available evidence of the efficacy and safety of drug combinations for chronic pelvic pain. Methods This systematic review will involve a detailed search of randomized controlled trials investigating drug combinations to treat chronic pelvic pain in adults. The databases searched will include the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, and EMBASE from their inception until the date the searches are run to identify relevant studies. The primary outcome will be pain relief measured using validated scoring tools. Secondary outcomes, where reported, will include the following: adverse events, serious adverse events, sexual function, quality of life, and depression and anxiety. Methodological quality of each included study will be assessed using the Cochrane Risk of Bias Tool. Results The systematic review defined by this protocol is expected to synthesize available good quality evidence on combination drug therapy in chronic pelvic pain, which may help guide future research and treatment choices for patients and their health care providers. Conclusions This review will provide a clearer understanding of the efficacy and safety of combination pharmacological therapy for chronic pelvic pain. Trial Registration PROSPERO International Prospective Register of Systematic Reviews CRD42020192231; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=192231 International Registered Report Identifier (IRRID) PRR1-10.2196/21909

Introduction Persistent genital arousal disorder/genito-pelvic dysesthesia (PGAD/GPD) is a distressing condition characterized by persistent, unwanted sensations of genital arousal (eg, feelings of being on the verge of orgasm, and of lubrication, swelling, tingling, throbbing) that occur in the absence of sexual desire. Although PGAD/GPD is associated with significant impairments in psychosocial functioning, the healthcare (HC) experiences of affected individuals are not well understood. Aim The aims of this study were to examine the barriers to HC, the costs of HC, and the associations among HC experiences, symptoms, and psychosocial outcomes in those with PGAD/GPD symptoms. Methods One hundred and thirteen individuals with PGAD/GPD symptoms completed an online, cross-sectional self-report questionnaire about their HC history and experiences. Main Outcome Measures Self-reported HC barriers, and financial costs associated with PGAD/GPD HC. Validated measures of HC experiences (eg, comfort communicating with HC practitioners [HCPs]), and psychosocial (eg, depression, anxiety) and PGAD/GPD symptom outcomes. Results The majority of participants (56.6%) reported waiting at least 6 months to seek HC for PGAD/GPD symptoms. Those who sought HC approached many HCPs (46.0% approached 6+ HCPs). Several barriers to HC were identified (eg, lack of HCP knowledge of PGAD/GPD), and high costs were reported. A series of multiple linear regression analyses found an association between HC experiences, psychosocial, and symptom outcomes. Specifically, decreased comfort communicating with one's HCP was associated with greater depressive and anxiety symptoms. Conclusion High costs and numerous barriers to seeking HC for PGAD/GPD symptoms were identified, and discomfort communicating with an HCP about PGAD/GPD was associated with increased symptoms of depression and anxiety. These results highlight the need for more awareness of this condition in order to improve care for this population.

Though a large number of women suffer from vulvar pain and dyspareunia, many clinicians feel that they lack the knowledge to adequately evaluate, diagnose, and treat women with vulvovaginal pain. This review examines the new International Society for the Study of Vulvovaginal Disease (ISSVD)/International Society for the Study of Women’s Sexual Health (ISSWSH)/International Pelvic Pain Society (IPPS) terminology of vulvar pain and vulvodynia, reviews a diagnostic algorithm that can help to differentiate between different types of vulvar pain, and discusses non-medical, medical, and surgical treatment options for provoked vestibulodynia (PVD; vulvodynia confined to the vestibule). The combination of this new terminology, diagnostic algorithm, and potential treatments will allow for more appropriately targeted treatments for women with PVD.

Introduction Vulvodynia constitutes a highly prevalent form of chronic genital pain in women, and current information regarding its definition, prevalence, impact, and pathophysiologic factors involved is needed. Aim To update the scientific evidence published in 2010 from the Third International Consultation of Sexual Medicine pertaining to the definition, prevalence, impact, and pathophysiologic factors of women's sexual pain. Methods An expert committee, as part of the Fourth International Consultation of Sexual Medicine, comprised of researchers and clinicians from biological and social science disciplines, reviewed the scientific evidence on the definition, prevalence, impact, and pathophysiologic factors related to chronic genital pain. Main Outcome Measures A review of the definition, prevalence, impact, and pathophysiological factors involved in vulvodynia. Results Vulvodynia is a prevalent and highly impactful genital pain condition. Numerous factors have been implicated in its development and maintenance. Conclusion What is becoming increasingly apparent is that it likely represents the end point of different factors that can differ from patient to patient. Longitudinal research is needed to shed light on risk factors involved in the expression of vulvodynia, as well as in potential subgroups of affected patients, in order to develop an empirically supported treatment algorithm.

Background Previous findings from our group show that in the acute (ie, 6–10 weeks) post-injury period, women with concussions have a 70% greater risk of sexual dysfunction than those with extremity injuries. There are currently limited treatment options for the clinical management of concussions. Resilience is a protective, modifiable psychological construct that has been shown to improve concussion-related sequelae. To date, however, no research has evaluated how resilience impacts sexuality outcomes after concussion in women. Aim Evaluate if resilience offers protection against negative sexuality outcomes in a cohort of reproductive, aged women with a concussion, seeking care in the Emergency Department of a Level-1 Trauma Center. We hypothesized that women with low resilience will be more likely to experience negative impacts on sexuality and that increasing levels of resilience will be associated with more positive sexuality outcomes. Methods Secondary data analyses. Measures Resilience was evaluated with the Resilience Scale (RS), and the Brain Injury Questionnaire for Sexuality (BIQS) was used for sexuality. Results Of the 299 participants recruited for the parent study, 80 with concussion had complete follow-up data and were included in these secondary analyses. Less than half (42.5%; n = 34) had low resilience (score≤130 on the RS), and the remaining 46 (57.5%) had high resilience (score>130 on the RS). In crude linear regression models, 1-unit increase in resilience was associated with a 4% increase in sexuality outcomes (β = 0.04, 95% CI:0.01, 0.05; P = .008). The effect estimate remained similar in post-concussion-symptom-adjusted models (β = 0.03, 95% CI:0.002, 0.06; P = .03). Mood-adjusted models showed a statistically significant interaction term (P Conclusion Longitudinal studies are needed to evaluate how these improvements in resilience translate to patient recovery measures following concussion.

Background Although promoting sexual health should be an integral part of midwifery practice, little is known about midwives’ preparation to address their clients’ sexual health concerns. Aims To assess the formal and self-directed training on sexual health topics relevant to midwifery practice of Canadian midwives as well as the association between training and various practice outcomes. Methods Forty midwives registered in the Province of Ontario, Canada completed an online survey assessing their formal and self-directed sexual health training, knowledge, comfort, and practice related to 10 sexual health issues. Findings In terms of formal training, three of the 10 topics were coved in-depth and seven were covered in general terms only or not at all. Participants had received an average of 26.0 hours of formal training related to sexual health. Almost all (90%) participants had engaged in self-directed learning on at least one topic. Participants had asked at least one client about only 5 of the 10 topics and been asked by at least one client about 4.5 of them. Participants who reported more extensive formal training had been asked about more sexual health topics by their clients. More self-directed learning was associated with more positive attitudes toward midwives’ role in addressing sexual health concerns, feeling more knowledgeable, and being asked about and asking about more sexual health topics. Conclusion The midwives in this sample had limited training in some important sexual health issues relevant to midwifery practice. Likely as a result, they often did not address these issues in practice.

Introduction The current study aims to validate a new imaging tool to assess men’s sexual psychophysiological responding: laser Doppler imaging (LDI), which directly measures subcutaneous genital blood flow. In this study, we concurrently assessed genital sexual arousal in a sample of men using the LDI and the current gold standard of male sexual psychophysiology, the penile strain gauge (PSG). Aim To (i) assess the validity of the LDI as a measure of male sexual arousal, (ii) evaluate the relationship between the LDI and PSG, and (iii) compare sexual concordance produced by the LDI and PSG. Methods A total of 25 male participants (Mage = 24.28 years, SD = 6.10, range 18–37) watched 4 experimental films (ie, anxiety-provoking, humorous, erotic, neutral nature content) while their sexual arousal was assessed. Genital sexual arousal was assessed using the LDI (blood perfusion) and PSG (penile tumescence) concurrently. Subjective sexual arousal was assessed using continuous and discrete self-reported measures. Main Outcome Measure Results demonstrate the validity of the LDI as an imaging-based measure of male genital arousal, and one that is comparable to the PSG. Results Significant increases in genital blood flow assessed via the LDI were observed for erotic, but not anxiety-provoking, humorous, or neutral films (F[1.65, 39.57] = 18.23, P < .001, ηp2 = .43). A moderate, positive correlation between genital arousal measured via the LDI and PSG concurrently was observed (r = .40), despite considerable across-participant variability. In the current sample, the LDI and PSG both produced strong sexual concordance estimates (r = .51 and r = .46, respectively). When all LDI and PSG concordance estimates were correlated, a moderate relationship was revealed (r = .37). Clinical Implications As a new imaging tool for male sexual psychophysiological arousal, the LDI holds promise for improving our understanding of issues related to men’s sexual health. Strength & Limitations Movement artifacts produced by penile engorgement were a limitation to the LDI as an imaging technique. Further, the LDI used in the current study was a discrete measure of arousal, whereas the PSG was continuous; future research would benefit by using continuous measurement capabilities of contemporary LDI systems. Conclusion As a valid measure of genital sexual arousal in men, the LDI holds promise as a tool that can be used to explore more nuanced questions about human sexuality, including cross-gender comparisons and real-time exploration of genital arousal patterns.

Introduction A common subtype of vulvodynia is provoked vestibulodynia (PVD), characterized by severe pain upon contact to the vaginal entrance. Some researchers have further delineated the PVD group based on pain onset (primary vs secondary PVD, referred to as PVD1 and PVD2, respectively). Aim This study aims to review available evidence regarding sociodemographic variables, pain characteristics, medical history and examination findings, quantitative sensory testing, genetic markers, psychosocial/sexual/relationship function, treatment outcome, and brain imaging in women with PVD1 and PVD2. Methods All available data related to PVD1 and PVD2 were reviewed. Main Outcome Measures There is mixed evidence supporting the assumption that women with PVD1 fare worse on all variables investigated. Results The review indicated that although women with PVD1 seem to fare worse on many variables examined (eg, pain severity, genetic markers), many studies also indicated no significant group differences or—less commonly—that women with PVD2 fare worse on some variables (eg, sexual function). Conclusion Although it has been suggested that different pathophysiologic processes are involved in the development and maintenance of PVD1 and PVD2, the data reviewed were mixed. While most studies indicated that women with PVD1 have higher pain intensity, higher sensitivity, more genetic influence, more evidence of inflammation, lower successful treatment outcomes, and different neural activation patterns and structural findings, these results were not consistently reported. In addition, the data for subgroup differences in psychosocial, sexual, and relationship variables were not convincing. A more precise definition of primary and secondary PVD is needed, and importantly, prospective, longitudinal studies are essential for clarifying any differences within these PVD subgroups.

Although social support for relationships is a commonly studied topic, the literature is divided upon whether social support from parents versus friends plays a more important role in predicting relational and health outcomes. Using a sample (N=698) of heterosexual and lesbian, gay, bisexual, transgender and queer (LGBTQ) participants, the current study examined differences in past experiences of relationship disapproval from friends and family, as well as self-reported levels of importance assigned to various sources of social approval for relationships. In addition, participants read hypothetical scenarios in which they were told that their parents, heterosexual friends or LGBTQ friends disapproved of their current dating partner and suggested that they end the relationship. Participants responded by indicating whether or not they would end the hypothetical relationship based on the disapproval. Results indicate that individuals in same-sex relationships often perceive less social support for their relationships from parents than friends, that they place more value on relationship approval from friends, or chosen family, and that they are less likely to end a relationship based on parental disapproval, compared to those in mixed-sex relationships. A ‘currency’ model of parental disapproval for relationships is introduced, whereby parents are seen to have a finite amount of ‘relationship disapproval currency’ available to spend on an adult child's relationships. Inaccurately disapproving of their children's relationships is shown to reduce the likelihood of children considering their parents' opinions, while accurately disapproving of relationships significantly increases the likelihood of their adult children considering their opinions in the future.

This study was an exploration of the impact of men's circumcision status on their sexual partners, focusing on sexual functioning, sexual satisfaction, general preferences for circumcision status, and beliefs about circumcision status. A total of 196 individuals (168 women, 28 men) currently in a sexual relationship with a man were recruited for an online survey. Sexual functioning for female or male participants (assessed by the FSFI or IIEF-MSM, respectively) was not impacted by circumcision status, but women with intact partners reported higher levels of sexual satisfaction, while no differences were observed in the male sample. Women's responses indicated that circumcision status minimally impacted satisfaction with partner's genitals, while men with intact partners indicated significantly higher levels of satisfaction than those with circumcised partners. Overall, women and men rated high levels of satisfaction with their partner's circumcision status and did not wish for it to change. Women indicated a slight preference for circumcised penises for vaginal intercourse and fellatio, and held more positive beliefs about circumcised penises, while men indicated a strong preference toward intact penises for all sexual activities assessed and held more positive beliefs about intact penises. The current study demonstrates distinct gender differences in attitudes toward circumcision status but minimal impact of circumcision status on sexual functioning. Future research should further explore sexual correlates of circumcision status, with a focus on directionality of said correlates and the impact on couples, as well as replicating the findings with a larger sample, specifically with respect to the male sample.

Background Persistent genital arousal disorder (PGAD) is an understudied condition characterized by unwanted physiologic genital arousal in the absence of subjective sexual arousal. Markos and Dinsmore (Int J STD AIDS 2013;24:852–858) theorized that PGAD shares a number of similarities with vulvodynia (unexplained chronic vulvar pain [CVP]), including symptom characteristics and comorbidities. Aim To compare medical histories, symptom characteristics, pain characteristics, and daily functioning among women with persistent genital pain (PGA) (n = 42), painful PGA (n = 37), and CVP (n = 42) symptoms. Methods An online cross-sectional survey was conducted from October 2015 through April 2016. Outcomes Self-report measures of symptoms, diagnosed medical conditions, pain characteristics (McGill Pain Questionnaire), catastrophizing (Pain Catastrophizing Scale), and daily functioning (Functional Status Questionnaire) were collected. Results All 3 groups reported similar medical diagnoses and high frequencies of other chronic pelvic pain conditions. Women in all 3 groups reported comparable ages at symptom onset and timing of symptom expression (ie, constant vs intermittent). Women in the 2 PGA groups reported significantly greater feelings of helplessness than women in the CVP group. Women in the painful PGA and CVP groups endorsed significantly more sensory terms to describe their symptoms compared with women in the PGA group, whereas women in the painful PGA group reported significantly more affective terms to describe their symptoms compared with women in the CVP group. Women in the 2 PGA groups reported that their symptoms interfered significantly with most areas of daily functioning. Clinical Implications Given the similarities between PGA and CVP symptoms, women with PGA may benefit from similar assessment, treatment, and research approaches. Strengths and Limitations Limitations of the present study include its sole use of self-report measures; the presence of PGA or CVP symptoms was not confirmed by clinical assessment. However, the anonymous design of the online survey could have resulted in a larger and more diverse sample. Conclusion The results of this study provide some initial support for the conceptualization of persistent genital arousal as a subtype of genital paresthesias/discomfort. These results also further highlight the negative impact that PGA symptoms have on many domains of daily living and the need for further research on this distressing condition.

Background Digital intravaginal palpation remains the favored method for clinical assessment of pelvic floor muscle (PFM) function in women; however, there is growing interest in using transperineal ultrasound imaging (TPUSI). TPUSI does not involve vaginal penetration, making it particularly relevant for PFM assessment in women with genito-pelvic pain and penetration disorders. Aims To study the relations between measures of PFM morphology and function assessed using 3-dimensional (3D) TPUSI and PFM assessment through intravaginal palpation. Methods 77 nulliparous premenopausal women with (n = 38) and without (n = 39) PVD participated. 3D TPUSI was used to measure levator hiatal dimensions at rest, at maximal voluntary contraction (MVC) of the PFMs, and at maximal Valsalva maneuver (MVM). Intravaginal palpation was used to assess PFM strength, PFM tone, PFM relaxation after contraction, and vaginal flexibility; each was scored using an ordinal grading scale. Ultrasound and palpation outcomes were compared using Spearman correlation coefficients and Kruskal-Wallis 1-way analyses of variance by rank. Outcomes Outcomes included ultrasound measures of the levator hiatal area, anteroposterior diameter, and left-right transverse diameter at rest, at MVC, and at MVM; raw and relative changes in hiatal dimensions between rest and MVC and between rest and MVM; and palpation measures of PFM strength, tone, and relaxation after contraction, and vaginal flexibility. Results Weak to fair correlations were found between ultrasound and palpation measures. A smaller levator hiatus at rest was associated with greater PFM tone, less PFM relaxation, and less vaginal flexibility. Greater levator hiatal constriction and shortening of the hiatal anteroposterior diameter at MVC were associated with greater palpated PFM strength. Greater hiatal distention at MVM was associated with lower PFM tone and greater relaxation. Clinical Translation 3D TPUSI and intravaginal palpation provide related but distinct information about PFM function in young women with and without PVD with high functioning PFMs. Strengths and Limitations This was the first study to compare PFM assessment using 3D TPUSI and intravaginal palpation in nulliparous premenopausal women. A main strength of the study was the inclusion of women with PVD and asymptomatic controls, which provided a wide range in outcomes because differences in PFM morphology and function exist between women with and without PVD. The lack of inclusion of older women and women with weaker and/or hypotonic PFMs limits the generalizability of the findings. Conclusion Although TPUSI has several advantages, including painless application, it is not recommended as a replacement for digital palpation in the clinical assessment of PFM function.

Introduction. Male circumcision is one of the most commonly performed surgical procedures worldwide and a subject that has been the center of considerable debate. Recently, the American Association of Pediatrics released a statement affirming that the medical benefits of neonatal circumcision outweigh the risks. At present, however, the majority of the literature on circumcision is based on research that is not necessarily applicable to North American populations, as it fails to take into account factors likely to influence the interpretability and applicability of the results. Aims. The purpose of this review is to draw attention to the gaps within the circumcision literature that need to be addressed before significant changes to public policy regarding neonatal circumcision are made within North America. Methods. A literature review of peer-reviewed journal articles was performed. Main Outcome Measures. The main outcome measure was the state of circumcision research, especially with regard to new developments in the field, as it applies to North American populations. Results. This review highlights considerable gaps within the current literature on circumcision. The emphasis is on factors that should be addressed in order to influence research in becoming more applicable to North American populations. Such gaps include a need for rigorous, empirically based methodologies to address questions about circumcision and sexual functioning, penile sensitivity, the effect of circumcision on men's sexual partners, and reasons for circumcision. Additional factors that should be addressed in future research include the effects of age at circumcision (with an emphasis on neonatal circumcision) and the need for objective research outcomes. Conclusion. Further research is needed to inform policy makers, health-care professionals, and stakeholders (parents and individuals invested in this debate) with regard to the decision to perform routine circumcision on male neonates in North America. Bossio JA, Pukall CF, and Steele S. A review of the current state of the male circumcision literature. J Sex Med 2014;11:2847-2864.

Introduction Although pelvic examinations (PEs) are an important component of women's health, some women experience difficulty during PEs due to anxiety and pain. These difficulties may be heightened in women with chronic pain during sexual intercourse. Some evidence suggests that this population experiences pain and distress during PEs, but their experiences in this context have not been empirically investigated from a multidimensional perspective. Aims The aims of this study were to compare the PE experiences of women with and without pain during intercourse and to examine predictors of negative experiences in each group. Method Women with vulvovaginal pain (n = 90), pelvic pain (n = 89), and women without current intercourse pain (n = 207) completed an online survey including sections assessing demographics, gynecological and medical history, and PE experiences. Respondents completed questionnaires assessing vaginal penetration cognitions and body image. Main Outcome Measures Participants rated their most recent PE on numerical scales for pain, embarrassment, anxiety, and the overall quality of the experience. Results Women with pelvic and vulvovaginal pain during intercourse reported significantly more pain and anxiety during their most recent PE compared with the no pain group, and women with a higher number of lifetime gynecological diagnoses reported significantly more pain. Multiple regression analyses indicated that various predisposing, examination‐related, and psychological factors predicted specific PE ratings in each group. Conclusions The results provide empirical support that PEs are more physically and emotionally difficult for women who experience chronic pain during intercourse. These findings have important clinical implications, as PEs are a critical part of complete reproductive care and play an essential role in the assessment/management of sexual pain, including Genito‐Pelvic Pain/Penetration Disorder. Boyer SC and Pukall CF. Pelvic examination experiences in women with and without chronic pain during intercourse. J Sex Med 2014;11:3035–3050.

Provoked Vestibulodynia (PVD) is the most common subtype of vulvodynia. Functional MRI studies have indicated that women with PVD exhibit increased BOLD responses in pain modulation regions2-4. However, few neuroimaging studies have examined either the periods of time before and after a noxious stimulus is applied, nor compared fMRI responses between participants experiencing a noxious stimulus versus no stimulus5. The present study filled this gap in knowledge and was the first to apply network connectivity analysis to identify the coordination across brain regions involved with pain processing in PVD. A total of 28 women with PVD and healthy women first underwent quantitative sensory testing to determine the temperature that evoked a moderate pain rating in response to the thermal stimulus to be used for subsequent fMRI studies. This was followed by an MRI session which consisted of 5 fMRI runs with no stimulus, interleaved randomly with 5 runs with stimulation. The stimulation paradigm included 2-minute-long “baseline” periods before and after stimulation. The results showed consistent significant connectivity between brain regions which was relatively similar between the groups, although there were significant differences in connectivity strengths. Despite the similarities in connected regions, the groups differed at what point of the study paradigm they exhibited significant BOLD response variations and the direction of differences varied by region. Despite similarities in regions of connectivity between groups, this study adds to a body of research that confirms alterations in the fMRI response of brain regions both before and during a noxious stimulus in PVD. Supported by the National Vulvodynia Association. 1Hampson, Reed, Clauw, Bhavsar, Gracely, Haefner, & Harris, Journal of Pain, 2013; 2Pukall, Strigo, Binik, Amsel, Khalife, & Bushnell, Pain, 2005; 3Pazmany, Ly, Aerts, Kano, Bergeron, Verhaeghe, ... & VanOudenhove, NeuroImage, 2017; 4Stroman, Ioachim, Powers, Staud, & Pukall, Pain, 2018

Millions suffer from chronic vulvar pain (ie, vulvodynia). Vulvodynia represents the intersection of 2 difficult subjects for health care professionals to tackle: sexuality and chronic pain. Those with chronic vulvar pain are often uncomfortable seeking help, and many who do so fail to receive proper diagnoses. The current research developed a multidimensional assessment questionnaire, the Vulvar Pain Assessment Questionnaire (VPAQ) inventory, to assist in the assessment and diagnosis of those with vulvar pain. A large pool of items was created to capture pain characteristics, emotional/cognitive functioning, physical functioning, coping skills, and partner factors. The item pool was subsequently administered online to 288 participants with chronic vulvar pain. Of those, 248 participants also completed previously established questionnaires that were used to evaluate the convergent and discriminant validity of the VPAQ. Exploratory factor analyses of the item pool established 6 primary scales: Pain Severity, Emotional Response, Cognitive Response, and Interference with Life, Sexual Function, and Self-Stimulation/Penetration. A brief screening version accompanies a more detailed version. In addition, 3 supplementary scales address pain quality characteristics, coping skills, and the impact on one's romantic relationship. When relationships among VPAQ scales and previously researched scales were examined, evidence of convergent and discriminant validity was observed. These patterns of findings are consistent with the literature on the multidimensional nature of vulvodynia. The VPAQ can be used for assessment, diagnosis, treatment formulation, and treatment monitoring. In addition, the VPAQ could potentially be used to promote communication between patients and providers, and point toward helpful treatment options and/or referrals.

Background Provoked vestibulodynia (PVD) is a common chronic genital pain condition affecting approximately 12% of premenopausal women. Although parallels have been drawn between PVD and neuropathic pain (NP), no studies have examined self-reported NP characteristics in PVD. Aim To explore pain symptoms that resemble NP reported by those with PVD and compare responses with those with an established NP condition. Methods Women with provoked vulvar pain (PVP; n = 65) completed online questionnaires designed to assess characteristics of NP. Responses were compared with those of women with postherpetic neuralgia (PHN; n = 30). Outcomes In addition to a range of descriptive questions, participants completed the McGill Pain Questionnaire, the Self-Complete Leeds Assessment of Neuropathic Signs and Symptoms (S-LANSS), the Neuropathic Pain Symptom Inventory (NPSI), and the Pain Quality Assessment Scale (PQAS). Results PVP exhibits some neuropathic characteristics, typically evoked pain (as opposed to the more constant pain of PHN) indicative of allodynia and hyperalgesia. Specifically, women with PVP scored, on average, higher than the NP cutoff on the S-LANSS, and there were no significant differences between women with PVP and those with PHN on some NPSI subscales. However, women with PHN reported more NP symptoms on the PQAS, S-LANSS, and other NPSI subscales. Clinical Implications Validated NP questionnaires could be of particular use for health care professionals who need a more efficient way to assess symptoms of patients with PVP and should be included in future studies investigating the mechanisms and treatment of this pain. Strengths and Limitations This study takes a unique approach to the examination of PVP by using multiple validated NP measures to compare pain characteristics with those of a group of participants with PHN, an established NP condition. However, it is limited by self-reported data not confirmed with clinical examination, small size of the PHN group, and the severity of the pain experienced in the PVP group. Conclusion Women with PVP report some symptoms suggestive of NP characteristics, and future research should use NP measures in addition to physical examinations to further investigate the mechanisms that maintain this pain condition.

To explore factors associated with the diagnosis of provoked vestibulodynia (PVD) through (1) self-reported pain characteristics and (2) Friedrich's criteria (vestibular pain during sexual activity/gynaecological examination). We also identified cases in which incorrect diagnoses were assigned and explored group differences in gynaecological examination presentation and associations with self-reported pain.Data were extracted from nine studies conducted in our research laboratory. Information obtained during a telephone interview and a standardized gynaecological examination was compiled for 106 participants with vulvar pain and 106 pain-free control participants, matched for age, hormonal contraceptive use, and parity.Cohen's kappa (0.78) indicated substantial agreement (87.3%) between the telephone interview group categorization and diagnosis after the gynaecological examination. A discriminant function analysis yielded one significant function: Friedrich's first two criteria correctly classified 84.2% of cases, accounting for 76.0% of group membership variance. Of note, those in the other genital pain group were most likely to have received an incorrect diagnosis following the telephone interview (P0.001). Paired-samples t tests showed that those with pain reported lower pain intensity during the gynaecological examination than during intercourse (P0.001) and that intercourse pain was not necessarily related to pain during the examination. However, many participants (72.8%) indicated that the pain elicited during the cotton swab test was similar to the pain they felt with intercourse.These results support the use of a targeted clinical interview and the evaluation of vestibular pain during sexual activity and the gynaecological examination for diagnosing PVD. Caution should be exercised when a patient presents with genital pain symptoms other than those typically observed in PVD. Furthermore, the cotton swab test may underestimate the degree of pain regularly experienced.

In 2014, the executive council of the International Society for the Study of Vulvovaginal Disease, the boards of directors of the International Society for the Study of Women's Sexual Health, and the International Pelvic Pain Society acknowledged the need to revise the current terminology of vulvar pain, on the basis of the significant increase in high-quality etiologic studies published in the last decade.The new terminology was achieved in the following 4 steps. The first involved a terminology consensus conference with representatives of the 3 societies, held in April 2015. Then, an analysis of the relevant published studies was used to establish a level of evidence for each factor associated with vulvodynia. The terminology was amended on the basis of feedback from members of the societies. Finally, each society's board accepted the new terminology.In 2015, the International Society for the Study of Vulvovaginal Disease, International Society for the Study of Women's Sexual Health, and International Pelvic Pain Society adopted a new vulvar pain and vulvodynia terminology that acknowledges the complexity of the clinical presentation and pathophysiology involved in vulvar pain and vulvodynia, and incorporates new information derived from evidence-based studies conducted since the last terminology published in 2003.

OBJECTIVES: The objective of the study was to assess diffuse noxious inhibitory control (DNIC) function in women with provoked vestibulodynia (PVD) compared with healthy controls through the use of 2 different methodologies. Furthermore, the study aimed to assess whether pain characteristics correlate with DNIC in women with PVD. METHODS: Twenty-three healthy control women and 23 women diagnosed with PVD by the study gynecologist participated in the study. To assess DNIC, heat pain tolerance, determined through an ascending method of limits and temporal summation of thermal pain were used as test stimuli and a cold water bath was used as the conditioning stimulus. Participants reported on pain characteristics as potential correlates with DNIC function. RESULTS: No significant group differences were found in the number of DNIC responders per group when using heat pain tolerance or temporal summation procedures to examine DNIC. The magnitude of the DNIC response was examined for the overall groups and for positive DNIC responders only. When all participants were included in the analyses with the heat pain tolerance procedure, women with PVD displayed a higher magnitude of DNIC responding. Correlations between pain variables and DNIC responding and magnitude were nonsignificant. DISCUSSION: Results support previous findings of intact DNIC function in women with PVD, using both an ascending method of limits and a temporal summation paradigm. Pain-related variables were not correlated with DNIC function in women with PVD, perhaps this unexpected finding is due to the possibility that central processes other than DNIC, such as descending facilitation, provoke or maintain this chronic pain condition.