Review Question - QID 108621

This patient presents with vaginal pain with attempted penetration or speculum exam and likely has genito-pelvic pain/penetration disorder (GPPD, formerly known as vaginismus). GPPD is thought to be a disorder of pelvic muscle spasm, and risk factors include generalized anxiety disorder, depression, history of sexual trauma, and strict religious upbringing.

Pelvic pain is a broad and complicated diagnosis, and underlying causes include urinary tract infections, urogenital atrophy, pelvic inflammatory disease or STDs, vulvar dermatitis and cancer, traumatic delivery, endometriosis and interstitial cystitis, and GPPD. The pain in GPPD is generally in the vaginal area as opposed to in the pelvis, and patients often experience pain with tampon or finger insertion, speculum exam, and attempted penetration. In addition, the diagnosis of GPPD requires that no organic cause is present, and symptoms should last at least 6 months, as in this patient. It can be difficult to differentiate GPPD from other causes of pain on exam, but in a patient without an intact hymen as well as no signs of dermatitis or discharge and history of pelvic/urinary infection, GPPD is the most likely diagnosis. Of note, many women do not have an intact hymen despite never having had intercourse; the hymen may be disrupted by everyday activities. GPPD causes significant distress in patients and should be treated with pelvic floor physical therapy and dilators.

Illustration A shows an ulcerated lesion on the vulva, suggestive of vulvar squamous cell carcinoma. Illustration B shows lichen sclerosus, with tissue paper (or “cigarette paper”) whitening and thinning of the vulvar skin with a figure 8 configuration around the introitus and the anus.

Incorrect Answers:
Answer 1: A low estrogen state may occur perimenopausally or from hypothalamic insufficiency (e.., functional hypothalamic amenorrhea). Estrogen is required to maintain elasticity and lubrication of the vaginal and urothelial tissues, and urogenital atrophy can result in pain with intercourse as well as postcoital bleeding. Treatment includes lubricants and vaginal estrogen. This patient’s exam shows no signs of atrophy, and there is no reason to believe that she has low estrogen based on her age and healthy body weight.

Answer 2: Endometriosis is a risk factor for deep dyspareunia, not vaginal pain with intercourse. Endometrial implants in the uterosacral ligaments or rectovaginal septum are associated with pain in the pelvis with penetration. Patients most likely also have other symptoms of endometriosis such as bowel changes and dysmenorrhea. Treatment may include laparoscopic laser ablation of implants.

Answer 4: Squamous cell carcinoma of the vulva can cause external pain and pruritis, but there is usually a visible skin lesion (Illustration A). Vulvar cancer occurs mostly in postmenopausal women and is associated with smoking and human papillomavirus, and lichen sclerosus can be a precursor to carcinoma (Illustration B). Colposcopy with acetowhite application and biopsy are indicated for evaluation. Treatment is wide local excision. This patient is young, has no risk factors, and does not have visible lesions on her vulva, making vulvar cancer highly unlikely.

Answer 5: Body dysmorphic disorder involves the skewed assessment of one's body or a specific body part resulting in significant distress. It is associated with eating disorders and frequent cosmetic procedures, but GPPD is not known to be associated.

Bullet Summary:
Genito-pelvic pain/penetration disorder (formerly vaginismus) presents with painful contraction of the vaginal muscles with penetration, insertion of tampons, or speculum exam. Anxiety, depression, history of sexual trauma, and strict religious upbringing are risk factors, and treatment is with pelvic floor physical therapy or dilators.