Alessandra Graziottin1, 2 and Filippo Murina3
(1)
Center of Gynecology and Medical Sexology, H. San Raffaele Resnati, Milan, Italy
(2)
Graziottin Foundation for the cure and care of pain in women, Italy
(3)
Department of Vulvar Disease V. Buzzi Hospital Obstetrics and Gynecological Clinic, University of Milan, Milan, Italy
Abstract
Vulvodynia is often sadly neglected after delivery, despite its frequent comorbidity with dyspareunia in this vulnerable phase of a woman’s life. Although it is not the only sexual complaint occurring after delivery, dyspareunia is a problem that requires specific medical/gynecological attention to its biological basis, as well as careful evaluation of the delivery outcome and the condition of the pelvic floor.
Vulvodynia is often sadly neglected after delivery, despite its frequent comorbidity with dyspareunia in this vulnerable phase of a woman’s life. Although it is not the only sexual complaint occurring after delivery, dyspareunia is a problem that requires specific medical/gynecological attention to its biological basis, as well as careful evaluation of the delivery outcome and the condition of the pelvic floor.
The prevalence of female sexual dysfunction (FSD) is high after childbirth, in the postpartum and puerperium periods. Data indicate that up to 86% of women report one or more FSD soon after delivery. The most frequently reported complaint is low libido, which is more prevalent in women who are breastfeeding (because, in addition to inducing amenorrhea, high prolactin has a negative impact on the neurobiological basis of sexual drive).
The Prevalence of Postpartum Dyspareunia
Dyspareunia and vaginal dryness frequently occur after childbirth, and may independently contribute to a reduction in sexual drive, because of the negative feedback from the genitals. One study showed that at 6 months post partum about one-quarter of all primiparous women reported reduced sexual sensation, worsened sexual satisfaction, and reduced ability to achieve orgasm, as compared with the period before they gave birth. At 3 and 6 months post partum, 41% and 22% respectively reported dyspareunia.
Relative to women with an intact perineum, those with second-degree perineal trauma were 80% more likely (95% confidence interval [CI] 1.2–2.8) and those with third- or fourth-degree perineal trauma were 270% more likely (95% CI 1.7–7.7) to report dyspareunia at 3 months post partum.
At 6 months post partum, the use of vacuum extraction or forceps was significantly associated with dyspareunia (odds ratio [OR] 2.5; 95% CI 1.3–4.8), and women who breastfed were ≥4 times as likely to report dyspareunia as those who did not breastfeed (OR 4.4; 95% CI 2.7–7.0). Episiotomy conferred the same “negative” profile of sexual outcomes as spontaneous perineal lacerations.
A variable percentage of women who report dyspareunia and consequent vulvodynia undergo a “shift” to spontaneous vulvar pain; if the complaint is not adequately and promptly addressed, this has a dramatic impact on a woman’s life and on her marriage.
Persistent Morbidity and Lack of Professional Recognition
As Glazener pointed out in 1997, persistent morbidity and lack of professional recognition still mean that many women do not receive a prompt diagnosis and therapy for their dyspareunia/vulvodynia. This adds to the disruption of a woman’s sexuality and the quality of sexual intimacy at a time when her relationship is already extremely vulnerable to the challenges and needs of the newborn.
Prevention of Postpartum Dyspareunia/Vulvodynia
It is very important for the clinician to focus on few, practical points and these are discussed next.
Accurate Pelvic Floor Training During Pregnancy
Midwifes are the healthcare providers that are best placed for, and trained in, teaching pregnant women a number of key steps of self-awareness and empowerment:
· knowledge of the pelvic floor, its muscles and their functions;
· increasing competence in responding to the command to contract and completely relax the pelvic floor, with appropriate breathing (yoga can help);
· learning a competent and efficient “pull strategy”;
· in the case of a hyperactive pelvic floor (which is more frequently associated with lifelong dyspareunia and/or vulvodynia), it is essential to use “hands-on” training to teach the woman to relax the pelvic floor, using more specific physiotherapy techniques such as pelvic floor stretching and perineal work.
Key point: The goal is to empower the woman to deliver with an improved body image; a competent dynamic perception of the pelvic floor; and appropriate self-confidence in her ability to properly command her muscles, breathing slowly, deeply and appropriately, and behaving as the true protagonist of a well carried out vaginal delivery.
Antepartum instruction on how to perform pelvic floor exercises is important: in contrast to women who performed pelvic floor exercises, women who were not instructed did not regain antepartum pelvic floor contraction pressures 8 weeks after vaginal delivery and complained of more vulvar pain and dyspareunia.
Adequate Assistance at the Second Stage of Labor
Assistance is invaluable in the second stage of labor, when the baby’s head emerges and distends the pelvic floor. Appropriate and timely pelvic floor massage, performed “hands-on” by the assisting midwife, may ease the baby’s passage, supporting the pelvic floor, and reducing the risk of pudendal nerve damage during delivery and the risk of perineal and clinically visible anal sphincter tears, which are reported in up to 6.4% of vaginal deliveries. Occult sphincter defects occur in up to 33% of primiparous and 4% of multiparous women after vaginal delivery. Direct perineal assistance by the midwife, if started before the second stage of labor begins, may contribute to improving the pelvic floor stretching, thus easing the head passage, while giving the woman a definite and reassuring sense of being individually well cared for.
· Position for birth: a systematic Cochrane database review concluded that the adoption of any upright or lateral position for birth is associated with a shorter second stage of labor, protects the perineum, and is associated with fewer instrumental deliveries and fewer episiotomies.
· Limit episiotomy to selected cases: systematic reviews of episiotomy for vaginal birth concluded that restrictive use of episiotomy is superior to routine episiotomy in relation to perineal trauma, suturing, healing, and dyspareunia. Specifically, perineal pain, disturbed wound healing, and dyspareunia are more common in women who have delivered with a mediolateral episiotomy than with a midline episiotomy or with spontaneous perineal tears. Women in the group with restricted use of episiotomy and those with an intact perineum started postpartum sexual intercourse earlier than women in a group that underwent routine episiotomy. Overall, sphincter laceration is more frequent when midline episiotomy is performed. Vacuum extraction and forceps delivery may specifically contribute to damaging the pelvic floor, causing pudendal nerve damage and vulvodynia - either spontaneous or provoked by intercourse. Epidural anesthesia/analgesia for vaginal delivery is associated with a higher incidence of instrumental deliveries, which may increase the occurrence of episiotomy and subsequent dyspareunia. Pudendal nerve damage during delivery may variably contribute to FSD, and specifically vulvodynia, after childbirth. However, to the authors’ knowledge, there are no accurate figures available on this potential contributor to postpartum vulvodynia.
The primary question is whether or not to use an episiotomy routinely.
Increasing evidence supports the restrictive use of episiotomy compared with its routine use.
· Accurate suturing of the episiotomy: episiorrhaphy is a simple but not insignificant medical procedure. When it is not adequately performed, with no respect for the appropriate reconstruction of different tissues and planes, or when rigorous asepsis is not respected, infection and local abscesses may dramatically increase the risk of a retracting scar, painful introital trigger points, or dyspareunia and vulvodynia.
Key point: Adoption of an upright birth position, perineal massage, warm compresses to the perineum to relax the elevator ani, and flexion of and couterpressure to the baby’s head may reduce both episiotomies and sphincter lacerations. Overall, the restrictive use of episiotomy is superior to routine episiotomy, with respect to perineal trauma, suturing, healing, and dyspareunia.
Postpartum Therapy
The following medical interventions may be used postpartum:
· appropriate care of the episiorrhaphy;
· careful vulvar hygiene. An Italian multicenter study has shown that personal genital hygiene with thymus extracts after childbirth significantly reduces dyspareunia and vaginal dryness, while also increasing sexual desire, genital arousal, and orgasm. Reduction of negative feedbacks from the genitals, because of the reduction of dyspareunia and vulvodynia, may explain the increase in desire, arousal, and orgasm;
· the woman herself may perform vaginal stretching and massage for a few minutes, two to three times a day, to prevent retracting/painful scars and to promote better tissue elasticity;
· local estrogens: estradiol, estriol, or promestriene, twice a week, are minimally absorbed (<1%). They can be used on medical prescription, and contribute to reducing the vaginal pH, improving the vaginal ecosystem, and easing vaginal lubrication, thus reducing vaginal dryness and dyspareunia;
· appropriate treatment of constipation, which usually worsens in pregnancy, and may contribute to vaginitis and cystitis from infection with E. coli, Enterococcus faecalis etc.
Psychosexual intervention may be indicated for:
· women who complain of postpartum depression, traumatic delivery with or without post-traumatic stress disorder, difficulty in regaining a positive body image, or persisting loss of sexual desire, and also after successful treatment of vaginal dryness, dyspareunia, spontaneous or provoked vulvodynia;
· couples: when conflicts, jealousy, or other difficulties make it more difficult to regain a satisfying sexual and emotional intimacy, contributing to low desire, and arousal difficulties with vaginal dryness, dyspareunia, and coital anorgasmia.
Key point: Early recognition of postpartum dyspareunia, and adequate diagnosis and treatment of the different potential contributory factors, may significantly reduce postpartum coital pain and consequent vulvodynia. It may also reduce the number of women whose pain, if persistently unaddressed and untreated, may shift from being nociceptive to becoming neuropathic, contributing to spontaneous vulvodynia.