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=Genito-Pelvic Pain/Penetration Disorder=

Genito-Pelvic Pain/Penetration Disorder is a new diagnosis proposed for the upcoming fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V). Genito-Pelvic Pain/Penetration Disorder would replace the DSM-IV’s diagnoses of vaginismus and dyspareunia. There is a great deal of over lap between diagnoses of vaginismus and dyspareunia, making differential diagnosis unreliable, and calling into question their definitions as separate disorders (Binik, 2009a; Binik, 2009b; Lahaie, Boyer, Khalifé, & Binik, 2010).

Proposed diagnostic criteria
A diagnosis of Genito-Pelvic Pain/Penetration Disorder would require the following:


 * A. Persistent or recurrent difficulties for at least 6 months with one or more of the following:


 * 1) Inability to have vaginal intercourse/penetration


 * 2) Marked vulvovaginal or pelvic pain during vaginal intercourse/penetration attempts


 * 3) Marked fear or anxiety either about vulvovaginal or pelvic pain or vaginal penetration


 * 4) Marked tensing or tightening of the pelvic floor muscles during attempted vaginal penetration


 * B.   The problem causes clinically significant distress or impairment


 * C.    The sexual dysfunction is not better accounted for by another Axis I disorder (except another Sexual Dysfunction) and is not due to the effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition

Primary vaginismus
A woman is said to have primary vaginismus when she has never been able to have penetrative sex or experience vaginal penetration without pain. It is commonly discovered in teenagers and women in their early twenties, as this is when many young women in the Western world first attempt to use tampons, have penetrative sex, or undergo a Pap smear. Women with vaginismus may be unaware of the condition until they attempt vaginal penetration. A woman may be unaware of the reasons for her condition.

Vaginismus has been classified by Lamont according to the severity of the condition. He describes four degrees of vaginismus: In first degree vaginismus, the patient has spasm of the pelvic floor that can be relieved with reassurance. In second degree, the spasm is present but maintained throughout the pelvis even with reassurance. In third degree, the patient elevates the buttocks to avoid being examined. In fourth degree vaginismus (also known as grade 4 vaginismus), the most severe form of vaginismus, the patient elevates the buttocks, retreats and tightly closes the thighs to avoid examination. Pacik expanded the Lamont classification to include a fifth degree in which the patient experiences a visceral reaction such as sweating, hyperventilation, palpitations, trembling, shaking, nausea, vomiting, losing consciousness, wanting to jump off the table, or attacking the doctor. The Lamont classification continues to be used to the present and allows for a common language among researchers and therapists. However, it does not provide for a language with which a woman might best be able to verbalise her concerns, pain or problems and might not be an accurate way of classifying the severity of vaginismus. For instance, a woman with a lot of trust in the doctor might be classified as 1 but experience severe pain. A woman with less trust, or a woman who is or has been subjected to harsh examination, might be classified as 4 or 5 even if the physical discomfort she experiences with attempts at penetration in non-clinical settings is comparatively mild.

Though spasm of the pubococcygeus muscle is commonly thought to be the primary muscle involved in vaginismus, Pacik identified two additionally-involved spastic muscles in treated patients under sedation. These include the entry muscle (bulbocavernosum) and the mid-vaginal muscle (puborectalis). This accounts for the common complaint that patients often report when trying to have intercourse: "It's like hitting a brick wall".