The distinct impact of voluntary and autonomic pelvic floor muscles on genito-pelvic pain/penetration disorder

ABSTRACT

While the debate on diagnostic distinction continues, the DSM-5 combined dyspareunia and vaginismus into the genito-pelvic pain/penetration disorder. Recent research into the pathophysiology of dyspareunia and vaginismus has focused mainly on general pelvic floor pathology, the experience of pain, and cognitive-affective factors, while ignoring female genito-pelvic reflexes. It has not been taken into account that the vaginal canal, with its surrounding musculature, is an active canal capable of genito-pelvic reflexes, and that several of these reflexes might be triggered separately and/or simultaneously during sexual activity. We hypothesize that vaginal reflexive contractions play a substantial role in the pathogenesis of genito-pelvic pain/penetration disorder and postulate the genito-pelvic reflex hypothesis, i.e. in acute dyspareunia, primarily voluntary contractions or inadequate relaxation of the pelvic floor muscles predominate to guard against the pain due to vaginal trauma/infection and/or stress/anxiety. In chronic dyspareunia, these voluntary contractions induce increasingly submucosal vaginal damage: contact and pain receptors become more sensitive. The increased sensitivity of the contact receptors induces powerful autonomic reflexive contractions. These autonomic contractions provoke vulvar pain, which causes overreactive pelvic floor muscles. In lifelong vaginismus, autonomic reflexive contractions of the pelvic floor muscles predominate the entire disease process.

KEYWORDS:

• Genito-pelvic pain/penetration disorder (GPPPD)
• female sexual pain disorders
• vaginismus
• dyspareunia
• pelvic floor muscle contractions

Disclosure statement

The authors have no conflict of interest relating to the topics discussed in this manuscript.

Additional information

Funding

No financial support or grants were received relevant to the writing of this manuscript.

Notes on contributors

Symen K. Spoelstra

Symen K. Spoelstra, MD, PhD is a psychiatrist and specialized in female sexual pain disorders. He followed specialized courses in Sexual Medicine in Groningen, Amsterdam, and Oxford, UK.

Willibrord C. M. Weijmar Schultz

Willibrord C. M. Weijmar Schultz, MD, PhD is professor emeritus of Psychosomatic Obstetrics and Gynecology/Sexology at the University Medical Center Groningen, The Netherlands. He has 35 years of experience treating, teaching, researching, and publishing, dealing with women's sexual dysfunctions related to disease or handicap and on gender dysphoria.

Elke D. Reissing

Elke D. Reissing, PhD, CPsych is a professor at the School of Psychology, University of Ottawa, Canada and director of the Human Sexuality Research Laboratory. Her research program is aimed at investigating sexuality at midlife and in older women, and the interface of pelvic floor health and sexuality. Dr. Reissing practices clinical psychology with a focus on vaginismus, teaches sexuality at the undergraduate level and sex therapy at the graduate level, and she is the supervisor for sex therapy services at the Centre for Psychological Services and Research at the University of Ottawa.

Charmaine Borg

Charmaine Borg, MSc, PhD is a researcher and lecturer at the University of Groningen in the Department of Clinical Psychology and Experimental Psychopathology. Her work focuses on the dynamics between negative emotions (i.e. disgust) and sexual arousal. In 2015, she was accredited from the European Society of Sexual Medicine as a Psycho-Sexologist.

Paul M.A. Broens

Paul M. A. Broens, MD, PhD is a pediatric surgeon and also director of the Anorectal Physiology Laboratory at the University Medical Center Groningen, The Netherlands. He has 25 years of experience in treating and functional measuring of disorders of the anorectum, which did lead to the discovery of some new regulatory systems in the pelvic region.