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Genitopelvic pain/penetration disorder

• Dyspareunia: pain during intercourse
• Vaginismus: involuntary vaginal muscle contractions interfering with intercourse
• Vulvodynia: vulvar discomfort in absence of physical exam findings
• Provoked vulvodynia: pain triggered by an external stimulus
• Pelvic floor dysfunction seen frequently in setting of vulvodynia
• Clitoral adhesions: hood can develop smegma buildup and lead to pain, may require lysis of adhesions (perform in clinic with topical anesthesia)
• Vaginal atrophy: 40% report dyspareunia
• No proven benefits to "vaginal rejuvenation" techniques
• Conservative therapies: patient education, biofeedback, dilators, massage, electrostimulation
• Vaginal estrogen: applied to vestibule as opposed to vagina may be more beneficial for pain relief
• Ospemifene (SERM): indicated for vulvovaginal atrophy, 60mg daily, can cause hot flashes, vaginal discharge, and muscle spasms do not give if hx estrogen-mediated cancer, VTE, CVA, or MI
• Vestibulectomy: indicated for refractory pain

Female orgasmic disorder

• Definition: delayed, infrequent, absent, or less intense orgasm for 6+ months in 75-100% sexual interactions
• History: important to determine primary vs secondary, situational, inciting/aggravating factors
• Management: sex therapy, patient + partner education, mindfulness, sensate focus, coital alignment, sex devices
• Not recommended: no clear evidence for hormones, PDE5i, oxytocin

Female persistent genital arousal disorder

• Definition: spontaneous, intrusive, unwanted genital arousal in absence of sexual interest/desire
• Differential: differentiate from hypersexuality (increased sexual thoughts/desires) and clitoral priapism (engorged clitoris associated with severe pain)
• Management: CBT, ECT, duloxetine, pregabalin, varenicline

Lower urinary tract symptoms and sexual dysfunction

• OAB, incontinence, prolapse, and pelvic floor dysfunction can have a negative impact on sexual function
• SUI surgical treatment: may prevent coital incontinence but may lead to pain or altered vaginal sensation (concern for dissection in anterior vaginal wall), although studies do not demonstrate this (and some patients see improvement)
• Posterior colporrhaphy: may narrow introitus leading to dyspareunia