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Female Genito-Pelvic Pain/Penetration Disorder:
Review of the Related Factors and Overall
Approach
PerturbaçãodedorGênito-pélvicaedapenetração:
revisão dos fatores associados e abordagem geral
Ana Dias-Amaral1André Marques-Pinto2
1Psychiatry and Mental Health Clinic, Centro Hospitalar de São João,
Porto, Portugal
2Department of Urology, Centro Hospitalar do Porto, Porto, Portugal
Rev Bras Ginecol Obstet 2018;40:787–793.
Address for correspondence Ana Dias-Amaral, MD, Clínica de
Psiquiatria e Saúde Mental, Centro Hospitalar de São João, Alameda
Prof. Hernâni Monteiro, 4200-319, Porto, Portugal
(e-mail: ana.s.d.amaral@gmail.com).
Keywords
►dyspareunia
►vaginismus
►vulvodynia
►cognitive therapy
►behavioral therapy
Abstract Genito-pelvic pain/penetration disorder (GPPPD) can be an extremely bothersome
condition for patients, and a tough challenge for professionals regarding its assessment
and treatment. The goal of the present paper is to review the etiology, assessment, and
treatment of GPPPD, especially focusing on the cognitive aspects of the disease and
cognitive-behavioral treatment options, through a non-systematic review of articles
indexed to the Medline, Scopus and Web of Science databases, using the following
MeSH queries: pelvic pain; dyspareunia; vaginismus; vulvodynia; and cognitive therapy.
Altogether, 36 articles discussing the etiology, diagnosis and management of GPPPD
were selected. We provide an overview of GPPPD based on biological, psychological
and relational factors, emphasizing the last two. We also summarize the available
medical treatments and provide strategies to approach the psychological trigger and
persisting factors for the patient and the partner. Professionals should be familiarized
with the factors underlining the problem, and should be able to provide helpful
suggestions to guide the couple out of the GPPPD fear-avoidance circle.
Palavras-chave
►dispareunia
►vaginismo
►vulvodinia
►terapia cognitiva
►terapia
comportamental
Resumo A perturbação de dor gênito-pélvica e da penetração (PDGPP) é uma patologia com
elevado impacto no bem-estar das pacientes, e traduz-se num desafio diagnóstico e de
tratamento para os profissionais que as acompanham. O objetivo deste artigo é rever a
etiologia e o tratamento da PDGPP, tendo em conta, principalmente, os aspetos
cognitivos e as abordagens de inspiração psicoterapêutica cognitivo-comportamental.
Para tal, foi efetuada uma revisão não sistemática dos artigos indexados às bases de
dados Medline, Scopus e Web of Science, usando os termos: dor pélvica;dispareunia;
vaginismo;vulvodinia;eterapia cognitiva. No total, foram incluídos 36 artigos discutindo
a etiologia, diagnóstico e tratamento da PDGPP. Neste artigo, proporcionamos uma
revisãodotratamentodaPDGPPbaseadoemfatoresbiológicos,psicológicose
relacionais, enfatizando os últimos dois. Também resumimos as opções de tratamento
received
April 26, 2018
accepted
September 28, 2018
published online
November 14, 2018
DOI https://doi.org/
10.1055/s-0038-1675805.
ISSN 0100-7203.
Copyright © 2018 by Thieme Revinter
Publicações Ltda, Rio de Janeiro, Brazil
THIEME
Review Article 787
Introduction
Until the publication of the fifth edition of the Diagnost ic and
Statistical Ma nual of Mental Disorders (DSM-5),1women with
pain associated to vaginal penetration were diagnosed either
with dyspareunia or vaginismus, and dyspareunia was fur-
ther categorized as either superficial (generalized or pro-
voked vulvodynia) or deep.
It is important to consider that vaginismus may
be secondary to dyspareunia;2thus, the border between
the two entities may be tenuous. Therefore, in the DSM-5
these entities were integrated in the same diagnostic cate-
gory: genito-pelvic pain/penetration disorder (GPPPD). The
diagnosis of GPPPD requires the presence of at least one of
the following criteria:1persistent or recurrent difficulties
with vaginal penetration during intercourse; marked vulvo-
vaginal or pelvic pain during vaginal intercourse or penetra-
tion attempts; marked fear or anxiety about vulvovaginal or
pelvic pain in anticipation of, during, or as a result of vaginal
penetration; or marked tensing or tightening of the pelvic
floor muscles during attempted vaginal penetration. The
additional criteria are similar to those of other sexual dys-
functions: presence of symptoms for at least six months,
presence of significant distress, and symptoms not better
explained by a diagnosis of non-sexual disturbance, causing
significant relationship problems and not attributed to the
effects of any substance or any other medical condition.
Around 14% to 34% of premenopausal women and 6.5%
to 45% of postmenopausal women are affected by GPPPD.3
Occasional or transient pa in appears to be four to eight times
more frequent than chronic pain. In a Portuguese clinical
population, the prevalence of vaginismus and dyspareunia
was of 25.5% and 6.4% respectively.4The presence of comor-
bidity is fre quent. Almost half of the women with GPPPD also
have another pain disorder, such as fibromyalgia, interstitial
cystitis or irritable bowel syndrome.5It is also associated
with other sexual dysfunctions, such as female sexual inter-
est/arousal disorder and low satisfaction with the sexual
life.3
We hypothesize that this might be an underdiagnosed
condition, possibly due to feelings of shame and hopeless-
ness. Thus, we believe every physician dealing with women,
their reproductive system and their sexual lives should be
aware of the possible GPPPD causes and treatment options.
Besides the biological factors and medical treatments, we
believe every health professional dealing with GPPPD should
be aware of the psychological factors that contribute to the
persistence of the complaints and to hinder the therapeutic
success. In the present paper, we aim to review the etiology,
assessment, and treatment of GPPPD, especially focusing on
the cognitive aspects of the disease and the cognitive-be-
havioral treatment options.
Methods
We have performed a mini-review of systematic reviews and
original articles regarding GPPPD diagnosis and treatment
(and its former classificati on) indexed to the Medline, Scopus
and Web of Science databases, and published between
January 2000 and December 2017, using the following
MeSH queries: pelvic pain;dyspareunia;vaginismus; vulvo-
dynia; and cognitive therapy, which resulted in 53 articles.
The inclusion criteria comprised current evidence regarding
the biological factors that contribute to the etiology and the
medical, surgical, and psychological treatments of GPPPD. A
total of 7 papers were excluded, as they did not address
GPPPD, but other causes of genital pain. Altogether, 36
articles discussing the etiology, diagnosis and treatment of
GPPPD were deemed relevant by 2 separate reviewers, and
were included in the final selection. Additionally, we have
consulted one reference textbook3because, to our knowl-
edge, it is the most recently-updated published textbook on
sex therapy.
Results
The etiological factors can be divided into biological, psy-
chological and relational, and they frequently coexist,
highlighting the multifactorial nature of the conditions
that cause genital pain.
Most of the conditions that cause genital pain are acute
and transient, leading to skin and vulvar mucosa inflamma-
tion, usually due to infections –genital herpes or candidiasis,
for example. Tissue lesions resulting from dermatological
diseases (lichen planus, lichen sclerosus) also cause pain.
Changes in the hormonal environment –and menopause is a
classic example –can lead to vulvovaginal atrophy and
consequent pain.6Premalignant or malignant lesions of
the vulva and their treatment, namely surgery and/or radio-
therapy, can lead to anatomical, vascular and neurological
changes, with consequences to neuronal pain pathways.3
Regarding the genetic factors, polymorphisms that cause
increased vulner ability to inflammatory diseas es were found
in association with provoked vestibulodynia. Repeated uri-
nary tract infections and early and prolonged use of oral
contraceptives have also been associated with this condi-
tion.3Some research suggests a n increased pain sensitivity in
these women, probably due to hyperinnervation, which may
result from genetic, hormonal or inflammatory factors.7
médico disponíveis, e disponibilizamos estratégias para abordar os fatores desenca-
deantes e de manutenção tanto nas doentes quanto nos seus parceiros. Os profissio-
nais devem estar familiarizados com os fatores subjacentes a este problema, e devem
ser capazes de oferecer sugestões úteis para ajudar o casal a quebrar o círculovicioso de
medo e evitamento associado à PDGPP.
Rev Bras Ginecol Obstet Vol. 40 No. 12/2018
Female Genito-Pelvic Pain Penetration Disorder Dias-Amaral, Marques-Pinto788
Several studies have suggested an increase in resting
muscle tone of the pelvic floor muscles in women with
GPPPD, which may contribute to trigger and to the persis-
tence of the complaints. This hypertonicity of the pelvic floor
seems to be associated with decreased vaginal vasoconges-
tion, with a possible contribution to deficient genital arousal ,
with consequent less lubrication and penetration
pain.8►Table 1 summarizes the medical conditions that
have been associated with GPPPD.6
The psychological factors are varied. Women with a
GPPPD diagnosis are more likely to have a positive history
of sexual, physical or emotional abuse.3Pain complaints are
also more frequent in women with history of depressive or
anxious disorders.9It has been hypothesized that there is a
stress-induced central nervous system dysregulation that
increases pain perception.10 It is important to acknowledge
that the pelvic floor works as an emotional organ –anxiety
causes reflex contractions of the pelvic muscles. A previous
study shows that involuntary contractions of the pelvic
diaphragm measured by electromyography in no n-patholog-
ical women are more intense in states of anxiety than in
response to a sexual threat.8Increased pelvic floor tonus in
response to threatening visual stimuli was also reported,
suggesting that in these women vaginismus may be a condi-
tioned protective response to penetration.2
Cognitive schemas, in the context of sexuality, are defined
as nuclear ideas that individuals have about sexuality and
about themselves as sexual beings. Individuals with sexual
dysfunction show beliefs and expectations about sexuality
that are usually unrealistic and inaccurate.11 Cognitive sche-
mas have their origin in past experiences; they are reflected
in current actions, and guide the future sexual behavior.
Therefore, they may be predisposing factors to the develop-
ment of sexual dysfunction. In women with sexual dysfunc-
tion, including vaginismus, there is a significantly greater
activation of negative cognitive schemas, resulting in low
affective involvement, avoidance of intimacy, and higher
levels of anticipatory anxiety about abandonment.12 In these
women, cognitive schemas of incompetence, difference/
loneliness, self-deprecation11,12 and rejection are frequently
observed.12 In another study, women with sexual dysfunc-
tion, including vaginismus, had a significantly higher preva-
lence of early maladaptive schemas, namely in the impaired
autonomy and performance domain: failure, dependence/
incompetence, and vulnerability to danger were notorious.13
Overall, these results indicate that women with sexual
dysfunction tend to interpret negative sexual events as a
sign of personal incompetence and failure.
Negative cognitions about pain also seem to modulate its
intensity. Hypervigilance refers to the permanent attention
and monitoring of genital sensations that may signal the
onset of pain. Catastrophization implies the inference of the
worst possible consequence when pain is experienced. Both
lead to an increase in pain experience and its possible
negative consequences. Moreover, both associate positively
with sexual dysfunction9and predict a poor prognosis.14
Examples of negative beliefs related to pain are ‘pain is
uncontrollable,’‘pain leads to disability,’and ‘all activity
should be avoided.’5Dysfunctional beliefs related to age
(‘in women sexual desire decreases with increasing age’)
were also common a mong women with vaginismus.12 On the
other hand, fewer negative cognitions related to pain and
more positive cognitions related to penetration are associat-
ed with higher couple satisfaction and better sexual
function.14
Automatic thoughts were conceptualized by Aaron Beck
as images or cognitions that result from the activation of
cognitive schemes at particular moments.15 Thus, these
thoughts or images reflect the meaning that the individual
attributes to a given si tuation. In a population of women with
sexual dysfunction, including GPPPD, a significantly higher
prevalence of thoughts of sexual abuse and failure/dis-
engagement and absen ce of erotic thoughts was noti ced.12,15
The emotional response to these thoughts also seems to vary
between women with and without sexual dysfunction:
women with sexual dysfunction, including GPPPD, mention
more often sadness, guilt, disappointment and anger, where-
as women without dysfunction mention sexual pleasure and
satisfaction.16 Examples of automatic thoughts are ‘penetra-
tion is impossible’or ‘it will always cause pain, and this pain
will be unbearable.’17
Although there has been some research in this field in
recent years, it is not yet possible to understand whether the
psychological differences between women with or without
genital pain are a cause or a consequence. They seem to play a
Table 1 Medical causes of Genito-Pelvic Pain/Penetration
Disorder
Superficial pain Deep pain
Allergic reaction (e.g., latex) Chronic pelvic pain
syndrome
Congenital abnormalities
(imperforate hymen, vaginal
agenesis, vaginal septum)
Crohn disease
Dermatologic diseases
(lichen planus, lichen
sclerosus)
Endometriosis
Fistula
Hemorrhoids
Gynecological neoplasm
Irritable bowel syndrome
Interstitial cystitis
Neuropathies
Mechanical or chemical
irritation
Pelvic floor muscle
dysfunction
Pelvic organ prolapse
Inflammatory pelvic disease
Perineal trauma
Vaginitis
Pudendal nerve neuralgia
Infections (herpes, HPV,
vaginosis)
Atrophic vaginitis
Inadequate lubrication
(arousal difficulties,
estrogen deficit)
Source: Adapted from Bornstein et al.6
Note:
Conditions in which pain can be either super ficial or deep.
Rev Bras Ginecol Obstet Vol. 40 No. 12/2018
Female Genito-Pelvic Pain Penetration Disorder Dias-Amaral, Marques-Pinto 789
role as predisposing and persisting factors, as they are
essential in establishing positive coping and pain-reduction
strategies. The development and persistence of GPPPD has
been conceptualized as a vicious circle.10 The fear-avoidance
model of chronic pain has been used to explain the persis-
tence of pain in GPPPD (►Fig. 1). An initia l painful experience
produces fearful and catastrophic thoughts about pain and
its meaning. These lead to somatic hypervigilance that
amplifies all potentially negative sensations, increasing the
negative emotions associated with pain and the avoidance of
sexual activity.10,14 Pelvic floor hypertonicity secondarily
exacerbates this experience. Pain impairs genital excitement ,
leading to less lubrication and painful penetration. Repeated
experiences of sexual pain confirm fear and the need for
vigilance,17 contributing to vaginal penetration avoidance.10
At last, the avoidance of sexual activity prevents automatic
thoughts from being disconfirmed.17
Although pain is experienced by the woman, it is impor-
tant to acknowledge that it also affects the partner. The fear
of pain leads to penetration avoidance and ultimately to
partner avoidance.6Sexual communication between the
couple improves the sexual satisfaction of women, possibly
by enabling an open discussion about pain and by increasing
the couple’s sexual repertoire.9,14
Conversely, partner response to female pain seems to
influenceher perception: men who encourage adaptivecoping
strategies and reinforce attempts to have partnered sex are
associated with lower pain rates in women and improved
overall sexual functioning. On the other hand, both hostile
men, who are easily enraged by any sign of pain, and overly
understanding and solicitous men, who immediately stop all
sexual activity at the first sign of discomfort of the partner, are
associated with increased pain, more depressive symptoms,
and lower marital satisfaction. The explanation seems to be
that an overly sympathetic partner does not stimulate the
search foradaptive responses to pain, but rather the avoidance
of sexual intercourse.18 Differences among partner responses
seem to be associated with their own cognitive distortions.19
The negative pain attributions (internality –personal respon-
sibility; globality –the problem affects all dimensions of life;
and stability –persistence of the problem in the future) made
by the partner increase their distress.20
Genito-Pelvic Pain/Penetration Disorder (GPPPD)
Assessment
Genito-pelvic pain/penetration disorder is difficult to diag-
nose and to treat, so it can become a frustrating condition
for both the patient and the therapist.5When a woman
complains about genital pain, an exhaustive evaluation is
necessary to establish a probable etiology, whenever possi-
ble. A first evaluation implies a general medical evaluation:
characterization of the complaint (acquired or lifelong,
situational or generalized, provoked or spontaneous) and
investigation of the medical, surgical, gynecological, sexual,
psychiatric, and drug histories. Genito-pelvic examination is
mandatory, including “pain mapping,”vaginal pH measure-
ment, and evaluation of the pelvic floor tonus. According to
the history and physical examination findings, complemen-
tary exams such as biopsies or ultrasounds may be
required.21
Fig. 1 Theviciouscircleoffemalegenitalpain.Source: Adapted from Basson.10
Rev Bras Ginecol Obstet Vol. 40 No. 12/2018
Female Genito-Pelvic Pain Penetration Disorder Dias-Amaral, Marques-Pinto790
Genito-Pelvic Pain/Penetration Disorder (GPPPD)
Treatment
After establishing a probable etiology, the therapeutic ap-
proach should be defined by a multidisciplinary team.22 The
best strategy usually results from the combination of several
therapeutic modalities. There is evidence of efficacy for both
the medical therapy and the surgery. Topical applications of
anesthetics and corticosteroids appear to moderately de-
crease pain in dyspareunia. Some studies have reported that
these treatments are more effective in generalized vulvody-
nia, as the pain is constant and unprovoked.3In provoked
vestibulodynia, cognitive-behavioral therapy appears to be
superior to corticosteroids in reducing pain catastrophiza-
tion.23 Actually, the presence of catastrophic thoughts, fear
and avoidance predict a poor response to the medical
therapy.24 On the other hand, feelings of self-efficacy predict
a positive response.24 Low doses of tricyclic antidepressants
and anticonvulsants, such as in other chronic pain disorders,
are also a popular treatment in vulvodynia, but current
evidence seems to contraindicate their use.21 Topical anest-
hetics and corticosteroids and injections of botulinum toxin
have been tested in the treatment of vaginismus, but the
evidence for their benefit is modest, and they are not
recommended as a first-line treatment.21
Surgery (vestibulectomy) in cases of localized vulvody-
nia is effective when other options fail. This procedure
involves the excision of the vestibular area where the
pain originates. Overall, the success rate of the surgery
regarding pain management appears to be twice as high
as cognitive-behavioral psychotherapy and electromyo-
graphic biofeedback,25 with success rates of 60% to 90%.21
The treatment benefits endure at least two and a half years,
and are predicted by pretreatment pain intensity and the
presence of fear/avoidance schemas.25 However, despite
contributing to pain control, surgery may decrease the
vulvar region’s sensitivity to pleasure, which may ultimate-
ly worsen the overall sexual satisfaction.6On the other
hand, a combination approach of physical therapy and
psychosexual therapy in provoked vestibulodynia seems
as effective as surgery.26
Electromyographic biofeedback also appears to have
some therapeutic success. It consists of the insertion in the
vagina of an electromyography sensor that provides the
woman with information about the degree of muscle con-
traction of the pelvic floor.21 Relaxation exercises are then
performed. The association of this modality with the cogni-
tive-behavioral intervention may increase the efficacy of the
treatment in cases of vaginismus.27 Pelvic floor physiother-
apy and electrostimul ation seem to have benefits too, both in
dyspareunia and vaginismus.26 The goals of these interven-
tions are to decrease the degree of muscle tension at rest,
increase the attention directed to this muscle group and its
control, increase the elasticity of the vaginal introitus, and
expose the patients to penetration.28 The latter situation may
be especially beneficial in women with high levels of fear and
anxiety related to penetration, as it provides a calm and
secure environment for a more gradual and comfortable
contact with penetration.6
When a specific etiological diagnosis is made, treatment
should be directed to the primary condition. Cognitive-behav-
ioral psychotherapy has been the most popular and studied
psychotherapeutic intervention in GPPPD, and can be perfor-
med individually, as a couple or as a group.29 The main targets
of the therapy are cognitive distortions, emotional dysregula-
tion, and maladaptive behaviors that perpetuate symptoms
and disturb the couple’s relationship.9This kind of treatmentis
useful in cases in which psychological and/or relational issues
are the predominant components, and several studies have
proven its efficacy.2,17,22,23,28–35 The choice of the most ap-
propriate intervention should be based on the assessment of
the various dimensions of pain (►Table 2).6
Another key point is the establishment of realistic thera-
peutic goals. For many women, therapeutic success is de-
fined as total elimin ation of pain, but som e fail to achieve this
goal. Some examples of positive treatment outcomes31 in
both dyspareunia and vaginismus are reduction of pain from
severe to moderate or mild; reduction of muscular tension in
the perineum/pelvis; reduction of negative cognitions relat-
ed to pain (less frequent catastrophic thoughts and the
ability to assess pain-generat ing situations in a more positive
way); positive coping (the ability to focus on the positive
components of sexual experience); and improvement in
sexual functioning (exploration of expressions of sexuality
that do not include intercourse, and the ability to communi-
cate their own needs to the partner).
The initial therapeutic approach must be psychoeduca-
tion of the couple.36 Neither the patient nor the partner
should face this stage performing a passive role: it is an
opportunity to understand the problem, to learn about
female anatomy, and to challenge myths. The couple should
also be informed about the biopsychosocial nature of GPPPD
and the role of psychological and marital issues as triggers
and persistence factors. 5The couple should be provided with
behavioral strategies that can improve pain (►Table 3).
Table 2 Dimensions of pain
Characteristics
Physiological Etiology and duration of pain
Sensorial Location, intensity and quality of pain
Affective Emotional response to pain (anxiety,
sadness, fear, despair, concern etc.)
Cognitive Underlying thoughts, meaning of pain
and degree of focus on it, coping strategies
used, attitudes and beliefs
Behavioral Pain indicators, behaviors that aim to
control pain, how the patient
communicates the presence of pain and
associated symptoms
Sociocultural Sociodemographic variables, cultural
context (lack of sexual knowledge,
internalized negative messages in relation
to sexuality), social roles played (in the
family, in the workplace), and family history
Source: Adapted from Bornstein et al.6
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Female Genito-Pelvic Pain Penetration Disorder Dias-Amaral, Marques-Pinto 791
Another important goal in the initial approach to GPPPD
should be anxiety reduction. It is not uncommon that, when
presenting to the therapist, the couple is stuck in an avoid-
ance circle: avoidance of intimacy, of problem discussion, of
search for solutions and, ultimately, of sexual activity. When
they finally look for treatment, they are likely to feel anxious
because it will be necessary to discuss the problem and
eventually resume what they have been actively avoiding:
sex. It is important that the therapist is aware of this
situation and positively reinforces the fact that the woman
or the couple has sought help. It is cr ucial to inform them that
the therapy will focus on increasing the couple’s desire,
excitement and intimacy, and not on increasing the frequen-
cy of penetrative sex. Intercourse is not a primary goal, but a
consequence of a successful therapy.3
In a second stage of the treatment, it is important that the
therapist challenges certain cognitions about sex that are
common among couples. Two common cognitive distortions
in these women are hypervigilance and catastrophic pain.
Challenging these distor tions is essential to lessen emotional
reactivity. On the other hand, the use of sexual fantasies
should be encouraged, since positive sexual cognitions in-
crease desire and arousal, which can increase lubricat ion and
pleasure, and reduce pain.
The couple should also be encouraged to actively express
their emotions and to display physical af fection. The goal is to
uncouple physical affection and anticipation of genital pain,
that is, to reduce anticipatory anxiety. This can be achieved
through the sensate focus technique developed by Masters
and Johnson and published in 1970 in their book Human
Sexual Inadequacy.37 The goal is to move from non-genital
touch to genital touch and finally to penetration. At the
beginning, penetration is forbidden, which usually reduces
the patient’s anxiet y, allowing her to focus on pleasant bodily
sensations. This gradual exposure to physical contact usually
results in increased desire and arousal and reduced pain.
Sensate focus is also useful in expanding the couple’s sexual
repertoire. Increased control over pain seems to mediate the
efficacy of these interventions.35
In the particular case of vaginismus, and because muscle
contraction is considered a conditioned response to fear,
exposure methods are usually preferred.2The use of pro-
gressively larger vaginal dilators (systematic desensitiza-
tion) associated with a physiotherapy program should be
strongly encouraged.36 The efficacy of this treatment
appears to be mediated by avoidance behavior2and reduc-
tion of cognitive distortions, and by the increased control
over pain.34 By the end of a cognitive-behavioral program,
women’s anxiety levels decrease, and marital harmony and
global sexual satisfaction improve.38
Final Considerations
Although the origins of GPPPD are not always evident,
cognitions, emotions and behaviors that perpetuate the
complaints are certainly identifiable. We believe most cou-
ples can overcome these issues and engage in a more
satisfying sex life without the need of intensive sex therapy.
In order for this to happen, family physicians and gynecol-
ogists should b e familiarized with the factors underlining the
problem, and should be able to provide helpful suggestions
to guide the couple out of the GPPPD fear-avoidance circle.
Helping the patient and partner identify the triad of factors
that contribute to the persistence of GPPPD (cognitions,
emotions and behaviors associated to pain) can improve
the symptoms, assist in the adaptation to them, and prevent
their resurgence.
Conflict of Interests
The authors have none to declare.
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Situation Behavioral strategies
Intercourse Use water-based lubricants
Explore different coital positions
Sitz bath or ice packs after intercourse
Urinate immediately after intercourse
Physical activity Avoid exercises that put pressure on the
vulvar region or that produce friction
(e.g., cycling)
Avoid swimming pools or saunas/steam
baths
Personal
hygiene
Avoid scented products
Do not wash the genital region more
than once a day
Do not shave the vulvar region
Clothing Avoid tight underwear or trousers
Remove wet clothing immediately after
an activity
Use cotton underwear (avoid synthetic
fabrics)
Wash your clothes with hypoallergenic
products
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