Biological Foundations of Sexual Pain · Clinical Exercise

Peripheral, Central, or Both

Sexual pain is not one problem with one mechanism, and which mechanisms are running changes what should happen next. Eight presentations to locate, and a client who has been told there is nothing wrong.

What this exercise practises

Distinguishing tissue and hormonal contributors, peripheral sensitisation, central sensitisation and pelvic floor involvement from history alone, and saying something accurate to a client whose examination was normal.

Calibrated for counselling practice. No examination, no diagnosis, no treatment recommendations. Recognising a mechanism and explaining it plainly, which is what psychoeducation and interdisciplinary referral both require.

Estimated time to complete this exercise: 25 minutes

1Four mechanisms
2Nothing wrong
3The loop
4Formulation
5Close

Before you begin

How this one works

Four mechanisms produce sexual pain, they frequently run together, and which ones are operating changes what the next step should be.
Part 1 gives you eight presentations to locate. Several of them turn on one detail, so read for the detail rather than for the diagnosis.
Two parts are about what you say to a client who has been told that nothing is wrong. That conversation is where most of the clinical damage in this area gets done.
The depth is set for counselling practice. Recognising a mechanism and explaining it is within scope. Diagnosing, examining and recommending treatments is not, and both appear here as wrong answers.
Nothing is graded and nothing is recorded. Reloading starts it again.

One principle sits under the whole exercise and it is worth holding before you start. Pain is always real, even when tissue pathology alone cannot fully explain its severity, and the absence of a discrete structural lesion does not make pain psychological in origin.

References

  1. Bergeron, S., Rosen, N. O., & Pukall, C. F. (2015). Genital pain in women and men: It really hurts and it affects both partners. In L. Lipshultz, A. Pastuszak, A. Goldstein, A. Giraldi, & M. Perelman (Eds.), Management of sexual dysfunction in men and women (pp. 277–287). Springer.
  2. Bornstein, J., Goldstein, A. T., Stockdale, C. K., Bergeron, S., Pukall, C., Zolnoun, D., & Coady, D. (2016). 2015 ISSVD, ISSWSH, and IPPS consensus terminology and classification of persistent vulvar pain and vulvodynia. Journal of Sexual Medicine, 13(4), 607–612. https://doi.org/10.1016/j.jsxm.2016.02.167
  3. Portman, D. J., & Gass, M. L. S. (2014). Genitourinary syndrome of menopause: New terminology for vulvovaginal atrophy. Menopause, 21(10), 1063–1068. https://doi.org/10.1097/GME.0000000000000329
  4. Pukall, C. F., Goldstein, A. T., Bergeron, S., Foster, D., Stein, A., Kellogg-Spadt, S., & Bachmann, G. (2016). Vulvodynia: Definition, prevalence, impact, and pathophysiological factors. Journal of Sexual Medicine, 13(3), 291–304. https://doi.org/10.1016/j.jsxm.2016.01.021
  5. Woolf, C. J. (2011). Central sensitization: Implications for the diagnosis and treatment of pain. Pain, 152(3 Suppl.), S2–S15. https://doi.org/10.1016/j.pain.2010.09.030