Understanding Genito-Pelvic Pain/Penetration Disorder

By: Angelique Montano-Bresolin, PT

Pelvic pain conditions come in a variety of forms and presentations and the terminology within the pelvic health world related to these conditions continues to evolve over time. The term genito-pelvic pain/penetration disorder (GPPPD) is one of those terms that is not very well known. In the most recent update of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) in 2013, ‘genito-pelvic pain/penetration disorder’ (GPPPD) was introduced as a new diagnostic category of female sexual dysfunction. GPPPD is described as ‘recurrent difficulty/pain on sexual intercourse or penetration attempts’ ¹. GPPPD is the amalgamation of two previous categories of female sexual dysfunction in the DSM-4: dyspareunia and vaginismus.

The current criteria for the diagnosis of GPPPD under the DSM-5 includes ^2,3:

• At least six months duration and the presence of clinically significant distress
• Marked vulvovaginal or pelvic pain during vaginal intercourse or penetration attempts
• Marked fear or anxiety about vulvovaginal or pelvic pain in anticipation of, during, or as a result of vaginal penetration
• Marked tensing or tightening of the pelvic floor muscles during attempted vaginal penetration

Individuals may be more familiar with the terms 1) dyspareunia: pain with intercourse ⁴ and 2) vaginismus: now defined as a transient condition of increased tone and inability to maintain relaxation with attempted vaginal penetration ⁵. This more recent definition of vaginismus may include one or more of these findings: pain, tight, tense, narrow or constricted ⁵.

But regardless of the changes and updates in terminology, it is important to acknowledge that 1) GPPPD can present with symptoms of tension and/or pain and 2) addressing the psychosocial components of GPPPD is essential when it comes to best symptom management and treatment outcomes.

As you can imagine, it can be quite distressing to an individual experiencing symptoms of GPPPD, and it can significantly affect their quality of life, more specifically their personal relationships. Other commonly reported dysfunctions from clients struggling with GPPPD may include:

• having difficulty or pain with tampon insertion
• having unsuccessful or very painful PAP exams or other internal vaginal medical tests

Since GPPPD often presents with pain, it is so important to have a good understanding of pain. The International Association for the Study of Pain (IASP) revised their definition of pain in July 2020 to ‘an unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage’ ⁶.

This ‘sensory AND emotional experience’ will differ from one person to the next and is often highly influenced by unique personal experiences. Factors such as a history of trauma, pain catastrophizing, level of fear and avoidance, positive/negative affect, and self-reports of stress, anxiety and depression can all influence and contribute to pain.

An example that may help put this into context is to consider an individual that struggles with GPPPD. The patterning of physical attempts at intercourse is repetitively associated with significant pressure and exquisite pain and reported ‘spasm’. On medical/pelvic physiotherapy examination, there is an inability to fully assess this individual due to fear and hypersensitivity. On subsequent treatment sessions, this individual presents with significant pelvic floor tenderness and increased tone. A history of this sort of repetitive painful attempts at sexual activity can unsurprisingly give rise to ongoing negative emotions with respect to the genito-pelvic region and sexual activity. These negative emotions could then influence the pain that is experienced as studies have shown that higher pain intensity is associated with less joy, less laughter and higher negative affect ⁷.

The second part of the definition of pain is also quite important as it speaks to the idea of pain being a result of either ‘actual OR potential tissue damage’. A person struggling with GPPPD may not present with actual tissue damage however it is not uncommon to find that even the slightest touch over the individuals vulva/genitals, elicits a protective response such as clenching of the buttocks, increased distress/increased rate of breathing or actual reports of pain (stabbing, sharp etc.). In this circumstance, just the threat or thought of potential tissue damage alone can bring on pain symptoms. Even without injury present, the body and mind will attempt to protect itself by manifesting pain if it senses that it is in danger or if it doesn’t feel safe.

The repeated attempts at penetration without success continues to train our nervous system to automatically respond in ways to protect the individual from this ‘negatively perceived’ activity by outputting more pain, leading to more tension. And thus the negative cycle continues.

GPPPD is often a very frustrating, painful and constricting experience with many physical, emotional and social factors at play. However, a slowly graded, gentle, non-threatening approach to treatment for symptom management can help ‘break down the walls’ of GPPPD.

References:

1. Conforti, Celine (2017). Genito-Pelvic Pain/Penetration Disorder (GPPPD): An Overview of Current Terminology, Etiology, and Treatment. University of Ottawa Journal of Medicine. 7(2):48. DOI:18192/uojm.v7i2.2198
2. American Psychiatric Association. (2013). Genito-pelvic pain/penetration disorder. In: Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Arlington VA: American Psychiatric Association; 437-440.
3. Rogers, R et al. (2018). An International Urogynecological Association (IUGA)/International Continence Society (ICS) joint report on the terminology for the assessment of sexual health of women with pelvic floor dysfunction. Neurourol Urodyn. Apr;37(4):1220-1240.doi: 10.1002/nau.23508.
4. Doggweiler, R et al. (2017). A Standard for Terminology in Chronic Pelvic Pain Syndromes: A Report From the Chronic Pelvic Pain Working Group of the International Continence Society. Neurourology and Urodynamics 36:984–1008.
5. Frawley, H. et al (2021). An International Continence Society (ICS) report on the terminology for pelvic floor muscle assessment. Neurourol Urodyn. 2021;1–44.
6. https://www.iasp-pain.org/PublicationsNews/NewsDetail.aspx?ItemNumber=10475
7. Dunbar et al. (2011) Proc R Soc B. 1373
8. Frasson, E. et al. (2009). Central nervous system abnormalities in vaginismus. Clin Neurophysiol. Jan;120(1):117-22. doi: 10.1016/j.clinph.2008.10.156.