Future Directions

Major confusion exists in the literature with respect to the nomenclature and classification of dyspareunia. The DSM-IV-TR classifies idiopathic dyspareunia as a sexual dysfunction (3), whereas the ICD-10 (4) distinguishes between organic and psychogenic dyspareunia, neither of which are explicitly defined. In addition, the current nomenclature with respect to dyspareunia subtypes is confusing and fails to clearly differentiate among the various conditions (16). We suggest that a careful characterization of the pain associated with these conditions will clarify this diagnostic labeling confusion and help to unify the field. Throughout this chapter, we have established the complexity of dyspareunia and how this class of disorders can affect a woman's life on multiple physiological, emotional, cognitive, and interpersonal levels. Given the large prevalence of women suffering from dyspareunia, it is essential for primary health care providers to become familiar with these conditions and to establish collaborations with other health professionals in order to provide their patients with multidisciplinary treatment options.

Given the physiological, cognitive, affective, and interpersonal complexity of dyspareunia, it is likely that no one "cure" for dyspareunia or for other chronic pain conditions will be found. Thus, we propose a multimodal treatment approach for all types of urogenital pain discussed in this chapter, tailored to each patient, and including careful assessment of the different aspects of the pain experience. Clinicians should also educate their patients as to the multidimensional nature of chronic pain so that the treatment of so-called psychological or relationship factors is not experienced as invalidating. Although pain reduction is an important goal, sexual functioning should also be worked on simultaneously through individual or couple therapy, as it has been shown that pain reduction does not necessarily restore sexual functioning (97).

Further research is needed to further examine the pain component of dyspareunia using standardized tools in an effort to more fully understand the mechanisms involved in the development and maintenance of this painful and disruptive condition. Currently, we are investigating the effects of sexual arousal on genital and nongenital sensation, baseline measures of vestibular blood flow through thermal and laser Doppler imaging techniques, and sensitivity to body-wide pressure in women with vulvar vestibulitis syndrome. We hope to extend these research avenues to include the examination of women suffering from vulvodynia and postmenopausal dyspareunia in the near future. In addition, our research group is presently conducting a randomized treatment outcome study of women with vestibulitis, examining the effects of pain relief therapy compared with typical medical treatment. Future treatment outcome studies will include the investigation of the effects of physical therapy, as well as combined treatments, in an effort to develop and implement effective treatment strategies for the numerous women suffering from dyspareunia.

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