{"paper_id":"b080e596-7e97-4cbd-92e4-2959beeb6fba","body_text":"Dyspareunia and sexual dysfunction are common among women with chronic pelvic pain, affecting between 50% and 90% of patients with pelvic pain conditions such as endometriosis, interstitial cystitis/bladder pain syndrome, and vulvodynia. 1 – 4  Sexual dysfunction contributes to decreased quality of life, relationship distress, and negative impact on general life course trajectory demonstrated in women with chronic pelvic pain. 1 , 5 – 7  Dyspareunia and restriction of sexual activity are often multifactorial, with anatomic, functional, relationship, and psychological contributions. 8 – 10\nThe relationship between dyspareunia and endometriosis is well documented 6 , 11  and dyspareunia is now recognised as one of the symptoms that may prompt a presumptive diagnosis of endometriosis. 12  While medical and surgical treatment of endometriosis is associated with a decrease in dyspareunia, ~50% of patients report less than satisfactory long-term improvement in symptoms despite complete surgical excision or effective medical suppression. 13  In addition, dyspareunia and sexual dysfunction are frequently reported in patients who have chronic pelvic pain but do not have endometriosis. It is essential for healthcare providers to expand clinical assessment of dyspareunia beyond endometriosis alone in order to adequately identify all contributing factors and facilitate successful treatment.\nPelvic myofascial pain, also called high tone pelvic floor dysfunction, is highly prevalent in patients with chronic pelvic pain. 14  There appears to be a high degree of overlap between presence of pelvic myofascial pain and other pelvic pain conditions, with at least 50% of patients with endometriosis or interstitial cystitis/bladder pain syndrome demonstrating pelvic myofascial tenderness on examination. 15 , 16  Despite this, pelvic myofascial pain is often overlooked and underdiagnosed in clinical assessment of pelvic pain. 17  The overlap in both prevalence and symptoms likely contributes to the clinical ambiguitiy and underdiagnosis of this condition. Presence of pelvic myofascial tenderness on examination has been associated with dyspareunia in patients with endometriosis in a few studies. 18 , 19  However, much of the existing literature has considered pelvic myofascial tenderness as a binary factor rather than a continuous scale or has evaluated only a single pelvic floor muscle group, limiting the ability to fully evaluate the impact of this condition on various symptoms including dyspareunia. Additionally, existing literature has not evaluated the independent association between pelvic myofascial pain and the degree to which dyspareunia leads to restriction of sexual activity. Understanding how each of these factors may be contributing to symptoms can facilitate prompt and effective treatment, inform patient-centred counselling, and ultimately improve patient satisfaction and quality of life.\nThe objective of this study was to explore factors associated with restriction of sexual activity due to dyspareunia in women with chronic pelvic pain. We hypothesised that severity of pelvic myofascial tenderness on examination would be strongly associated with restriction of sexual activity, even after accounting for other clinical, functional, and psychological factors associated with sexual dysfunction.\n\nThis study is a cross-sectional analysis of data prospectively collected from the Endometriosis Centre and Chronic Pelvic Pain Consultative Clinic at the University of Michigan. This cohort includes all consecutive patients who presented to the clinic between January 2013 and December 2015. Patients completed a detailed questionnaire prior to their first visit, which collects information regarding medical and surgical history, prior treatments utilised for pelvic pain conditions, pelvic pain symptoms, and quality of life. This referral clinic is staffed by fellowship trained gynaecologists with expertise in minimally invasive gynaecologic surgery and chronic pelvic pain. Patients undergo a standardised pain-focused pelvic examination by a gynaecologist at their initial clinic visit.\nThe primary outcome of interest was the degree of restriction of sexual activity due to pain. We used a subjective, patient-reported assessment of sexual activity to explore the relationship between dyspareunia and restriction of sexual activity. Patients were asked to indicate which of the following best described their sexual activity: (1) My sex life is normal and causes no extra pain; (2) My sex life is normal but causes extra pain; (3) My sex life is normal but is very painful; (4) My sex life is severely restricted by pain; (5) My sex life is nearly absent because of pain; (6) Pain prevents any sex life at all; or (7) I am not sexually active, but this is not because of my pain. Rationale for using this subjective assessment method included several considerations. First, most validated measures of female sexual function are not intended for use or validated in patients who have not been sexually active with the prior month. 20  Second, many people may be sexually active despite moderate to severe dyspareunia and we wanted to capture the degree the which they felt that dyspareunia impacted their ability to be sexually active. Finally, many people are not sexually active for reasons unrelated to dyspareunia, which are typically not captured in most validated measures of sexual function. Patients who indicated Response 7 were not included in this analysis. We consolidated the remaining patients into four groups in order to facilitate statistical comparison: Normal activity without pain (indicated Response 1); Normal activity but painful (Response 2 or 3); Severely restricted by pain (Response 4 or 5); and Absent due to pain (Response 6).\nHistory of endometriosis was assessed by asking: (1) whether patients have been diagnosed with endometriosis; and (2) whether diagnosis was surgically confirmed. This simple screening method strongly correlates with surgically confirmed endometriosis on review of operative reports. 21  History of endometriosis was considered a binary outcome in this analysis because we had limited ability to evaluate stage of endometriosis as most patients had undergone surgery at outside facilities. We also asked about other co-occuring chronic pain diagnoses, such as interstitial cystitis/bladder pain syndrome or irritable bowel syndrome, and prior surgery for pelvic pain or prior hysterectomy.\nPain-related measures included self-reported dysmenorrhoea (range 0–10), pain with urination (range 0–10), pain with full bladder (range 0–10), pain with bowel movement (range 0–10), deep dyspareunia (range 0–10), and insertional dyspareunia (range 0–10). Patients indicated average number of days per month (range 0–30) with bothersome pain. Validated measures of pain included Brief Pain Inventory (BPI) and we analysed pain severity and pain interference separately. 22  Pain severity scores range from 0 to 10 (higher score denotes worse severity) and pain interference scores from 0 to 10 (higher score denotes worse interference). Degree of nociplastic pain, also known as central sensitisation, was evaluated with the American College of Rheumatology 2011 Fibromyalgia Survey Score (range 0–31, higher score denotes worse nociplastic pain), which is comprised of the Widespread Pain Index (assesses pain across 19 discrete areas of the body) and the Symptoms Severity scale (assesses non-pain symptoms such as fatigue, sleep, headache, depression, and memory/cognition). 23\nAdditional measures of psychological and functional symptoms included Patient-Reported Outcomes Measurement Information System (PROMIS) 24  depression SF (short form) 8a (range 8–40, higher score denotes more depression), PROMIS anxiety SF 7a (range 7–35, higher score denotes more anxiety), PROMIS sleep disturbance 8b (range 8–40, higher score denotes more sleep disturbance), PROMIS fatigue SF 7a (range 7–35, higher score denotes more fatigue), and PROMIS physical function SF 10a (range 10–50, higher score denotes better function).\nPatients undergo a comprehensive standardised examination during this visit, which includes detailed assessment of pelvic floor muscles in addition to pelvic visceral structures. Pelvic myofascial pain is assessed using single digit transvaginal palpation (applying adequate pressure to cause blanching of the upper portion of the nailbed of the index finger) of the bilateral anterior levator ani (pubococcygeus), posterior levator ani (iliococcygeus), and obturator muscles. Patients indicate pain severity (range 0–10) for each muscle and scores are summed for all six sites (range 0–60, higher score denotes more pelvic myofascial tenderness). This technique has been utilised for assessment of pelvic myofascial pain across multiple chronic pelvic pain conditions. 15 , 16 , 25  The pelvic visceral structures, including the base of the bladder, uterus, and bilateral adnexa are then examined in a similar fashion with a single digit. Patients indicate pain severity (range 0–10) for each structure and scores are summed across all four sites (range 0–40, higher score denotes more pelvic visceral tenderness).\nPatients who had missing questionnaire data or who did not undergo a complete pelvic examination on the day of their appointment were excluded. However, patients were able to skip questions regarding dysmenorrhoea if they were amenorrheic or dyspareunia if they were not sexually active. Patients who had prior hysterectomy or oopherectomy were not assigned scores for uterine or adnexal pain. Therefore, the uterine and adnexal components of the visceral exam have missing data. The number of patients that contributed to these analyses are noted in the tables.\nFor descriptive analyses, the four groups were compared by one-way analysis of variance or chi-squared analyses as appropriate. We performed multiple comparison testing using Sidak adjustments. Multinomial logistic regression was performed with ‘normal activity without pain’ group as reference category. All models included the following covariates, which were selected based on both prespecified study hypotheses and group differences in unadjusted analyses: age, PROMIS depression, history of endometriosis, and pelvic myofascial score. History of endometriosis did not differ across the groups but was included a priori given study hypotheses.\nThis study was approved by the Institutional Review Board of the University of Michigan (IRB# HUM00003797). The IRB deemed this study as minimal risk as the questionnaire is part of the medical record and the database is deidentified, and therefore written consent was not required. STROBE guidelines were followed in study reporting. SPSS ver. 28.0 and R ver. 3.6 were used for data analyses.\n\nA total of 302 new patients were evaluated between January 2013 and December 2015. After excluding for incomplete responses for endometriosis history ( n  = 34) and demographic questions ( n  = 3), indicating ‘I am not sexually active, but this is not because of my pain’ ( n  = 41), and missing pelvic floor exam ( n  = 37), 187 patients were included in this analysis ( Fig. 1 ).\nPatients were categorised into the following sexual activity groups as described above, including 28 (14.9%) as normal activity without pain, 63 (33.7%) as normal activity but painful, 75 (40.1%) as severely restricted by pain, and 21 (11.2%) as absent due to pain. No differences were noted across clinical characteristics, including prior surgery for pelvic pain and history of endometriosis ( Table 1 ).\nGroups differed significantly across multiple pelvic pain characteristics and associated symptoms are in  Table 2 . As anticipated, deep dyspareunia and insertional dyspareunia differed significantly across each of the groups (all  P  < 0.001).\nPhysical exam findings differed significantly across the groups ( Table 3 ). Overall pelvic myofascial tenderness score differed significantly across the four groups ( P  < 0.001) and increased in a linear fashion as degree of restriction increased ( Fig. 2 ). Multiple comparison testing indicated significant differences in total pelvic myofascial pain score between normal activity without pain and severely restricted by pain ( P  = 0.001) and absent due to pain ( P  < 0.001) groups. Normal activity but painful differed significantly from absent due to pain ( P  = 0.009). Each of the individual pelvic floor muscle group scores differed significantly across the four groups as well (pubococcygeus,  P  < 0.001; iliococcygeus,  P  = 0.002; obturator,  P  < 0.001). Overall visceral pelvic tenderness scores differed significantly across the four groups ( P  = 0.023). Bladder tenderness scores did not differ across the groups, whereas uterine tenderness ( P  = 0.003) and adnexal tenderness ( P  = 0.046) scores were significantly different.\nMultinomial logistic regression was used to compare the sexual activity groups, with normal activity without pain as reference group ( Table 4 ). Younger age was associated with higher odds of being in normal activity but painful group compared to normal activity without pain (OR 0.95, 95% CI 0.90–0.99,  P  = 0.032). Total pelvic myofascial score was associated with higher odds of being in severely restricted by pain group (OR 1.05, 95% CI 1.01–1.09,  P  = 0.006) and absent due to pain group (OR 1.09, 95% CI 1.04–1.13,  P  < 0.001) compared to normal activity without pain group. History of endometriosis and PROMIS depression scores were not significant in any of the group comparisons.\n\nIn this cross-sectional study, over half of patients presenting to a chronic pelvic pain and endometriosis referral clinic described severely restricted or absent sexual activity due to pelvic pain. An additional one-third reported pain with sexual activity. It is notable that patients in the ‘normal activity but painful’ group described moderate deep dyspareunia (average 5.29/10), but this did not result in restriction of sexual activity. Despite the fact that over 50% of this patient population had a prior diagnosis of endometriosis, history of endometriosis did not differ significantly across the sexual activity groups and was not significantly associated with restriction of sexual activity in multinomial regression analysis. Pelvic myofascial pain was highly prevalent in this population and was significantly associated with higher odds of restriction of sexual activity. In other words, for every increase of 10 points in pelvic myofascial tenderness on examination, the risk of having sexual activity that is severely restricted by pain increases by 50% and risk of having sexual activity that is absent due to pain increases by 90%.\nPelvic myofascial pain has been implicated as a potential contributor to dyspareunia in previous studies. 14 , 18 , 26 – 28  However, most of the existing literature has analysed pelvic myofascial pain as a binary outcome and has not extensively explored the association between severity of pelvic myofacial pain and degree of dyspareunia or sexual dysfunction. In addition, several prior studies have combined assessment of a single pelvic floor muscle and bladder base tenderness to determine binary outcome of pelvic myofascial pain. 18 , 29  Here, we utilise a comprehensive, standardised pelvic exam that allows for assessment of severity of pelvic myofascial pain independent of pelvic visceral structures. In our analysis, pain on palpation of bladder did not differ significantly according to degree of sexual restriction, whereas pain on palpation of pelvic floor muscles differed significantly according to degree of sexual restriction and was the only factor independently associated with increased odds of having sexual activity that was severely restricted or absent due to pain. These findings have significant clinical implications as pelvic myofascial pain is often overlooked and underdiagnosed despite its high prevalence. The apparent association between pelvic myofascial pain and sexual restriction due to dyspareunia is particularly notable given that pelvic physical therapy has been shown to significantly decrease dyspareunia and improve sexual function. 30 – 33\nThe association between endometriosis and dyspareunia or sexual dysfunction has been extensively documented. 6 , 11  There is a strong association between deep dyspareunia and deep infiltrating endometriosis lesions within the rectovaginal space and posterior culdesac, but otherwise the association between overall stage of endometriosis and dyspareunia is fairly limited. 34  However, much of the existing literature has not considered potential impact of concurrent pelvic myofascial pain in patients with endometriosis, which is a notable omission as multiple studies have documented high prevalence of pelvic myofascial pain in women with endometriosis. 15 , 18 , 35  In studies that have assessed pelvic myofascial pain in patients with endometriosis, findings consistently demonstrate that pelvic myofascial pain is more strongly associated with severity of dyspareunia than severity or presence of endometriosis. 18 , 27 , 28  We did not see a significant relationship between history of endometriosis and restriction of sexual activity due to pain, but it is important to note that we were unable to account for stage, severity, location, or adequately of prior surgical treatment of endometriosis in this cohort.\nIn our patient population, PROMIS depression scores did increase as degree of sexual restriction increased, but was not independently associated with increased odds of having sexual activity that was severely restricted or absent due to pain. There is extensive data regarding the association between depression, sexual dysfunction, and dyspareunia. 36 – 39  However, most of these studies did not account for contributing factors such as pelvic myofascial pain or endometriosis.\nStrengths of this study include utilisation of a detailed questionnaire with a broad range of validated measurement tools and comprehensive, standardised pelvic examination technique to assess for presence and severity of pelvic myofascial pain. A notable limitation is that ~30% of our patients had not previously undergone surgery to assess for endometriosis, and therefore it is possible that we have underestimated prevalance of endometriosis in this sample. However, rate of prior surgery for pain and history of endometriosis did not differ across the groups, indicating that the risk for underestimation of prevalence of endometriosis is likely fairly equivalent across the groups. In addition, the tertiary referral nature of this clinic means that the majority of patients with history of endometriosis had undergone prior surgery at other facilities. We were unable to accurately assess stage of endometriosis given inconsistent availability or limited description of operative findings, so considered endometriosis a binary outcome in our analysis. Pelvic exams were performed by a core group of clinicians trained by a single senior physician on the standardised exam technique described, but we cannot rule out some variability in assessment technique given involvement of multiple providers. However, use of more rigorously standardised physical exam procedure, such as utilisation of a pressure algometer for pelvic examination or a single examiner, is not practical or generalisable. Finally, our findings may have limited generalisability to other settings given the tertiary referral nature of this patient population.\nIn summary, dyspareunia and sexual dysfunction are highly prevalent among patients with chronic pelvic pain and represent a significant negative impact on overall quality of life and relationship satisfaction in patients who present with this condition. Pelvic myofascial pain appears to be strongly associated with restriction of sexual activity due to pain in women with chronic pelvic pain. As part of a comprehensive evaluation for chronic pelvic pain, assessment for pelvic myofascial pain should be a high priority particularly as there is data demonstrating significant improvement in dyspareunia when pelvic myofascial pain is treated with pelvic physical therapy.","source_license":"public-domain-us","license_restricted":false}