Female Genital Pain

Vulvodynia is a chronic pain condition of unknown cause that is associated with sexual inactivity or dysfunction, depression, anxiety, and obsessive behavior.

Vestibulitis is characterized by painful penetration during coitus. It is more common in white females and is resistant to most medical treatment. Some success with tricyclic antidepressants and antihistamines has been reported. Heat treatment (sitz bath) is also helpful.

Chronic dysmenorrhea is a severe pain-producing condition caused by the hypercontractility of uterine muscles during menstruation. Ovulation suppression and the use of NSAIDs are effective because of the antiprostaglandin effect. A 1987 study by Helms^[239] found that acupuncture is effective in resistant cases. Presacral neurectomy can be considered as a last resort after other options have been tried and failed.

Uncoordinated contraction of the muscles of the pelvic floor (levator ani, pubococcygeus, and deep transverse perineal) causes vaginismus. It produces extreme spasms and painful sexual dysfunction. Psychological factors such as rigid sexual upbringing and traumatic sexual experience inadvertently reinforce the vaginal spasm. Treatment involves correction of any physical conditions and then behavior modification that includes desensitization techniques.

Dyspareunia is defined as recurrent and persistent genital pain before or after intercourse; it may be due to infection, trauma, or lack of lubrication. Treatment includes psychotherapy and systemic desensitization.

Chronic pelvic pain is also known as pelvic congestion, pelvic fibrosis, pelvic neurodynia, and pelvic sympathetic syndrome. The pain is often multifactorial and requires multidisciplinary pain management involving psychotherapy, medications, and trigger point injections. In selected cases, nerve root blocks and neuraxial opioid therapy are promising. Metastatic disease of the cervix and uterus can cause severe vulvovaginal pain syndrome and requires aggressive opioids and adjuvant pain treatment.^[240]

Role of Sympathetic Blocks (also see Chapter 73 )

The pelvic viscera in men and women—the urogenital organs, the colon, and the rectum—are supplied by afferent fibers from the lumbar sympathetic chain. The pelvic pain caused by either inflammatory diseases or cancer can be relieved by interruption of bilateral sympathetic pathways,^{[241] [242]} which can be achieved with a superior hypogastric plexus block. The superior hypogastric plexus is a retroperitoneal structure that is formed by confluence of the bilateral lumbar sympathetic chains; it is situated between the body of the L5 and S1 vertebrae. Interruption of the ganglion impar is targeted to mixed somatic and sympathetic pain arising from the distal end of the urethra, the vulva, the perineum, and the distal third of the vagina.