Painful Sexual poSiTions in endometriosis patients (the PSST! Study): a prospective cohort study

BACKGROUND: Dyspareunia is a common symptom in women with endometriosis, yet its positional dependency is not routinely assessed in clinical practice.

AIM: To investigate the relationship between endometriosis and positional dyspareunia, identifying the most painful sexual positions and correlating them with lesion location.

METHODS: In this prospective monocentric study, women with dyspareunia aged 18 or older undergoing laparoscopic surgery for endometriosis were recruited. Participants completed a preoperative questionnaire assessing dyspareunia and positional dependency. Intraoperative findings were coded according to the Enzian classification. Data were analyzed using descriptive statistics and Fisher's exact test.

OUTCOMES: The primary outcomes were the prevalence of positional dyspareunia, identification of the most painful sexual positions, and their correlation with lesion location.

RESULTS: Among 531 patients screened, 111 met inclusion criteria and 71 completed the study. Endometriosis was histologically confirmed in all participants. 83.1% complained of deep dyspareunia, 7% of superficial dyspareunia, and 9.9% of both. Positional dyspareunia was reported by 68.3% (95%CI, 55.8 to 78.7) of participants, with the doggy style position being the most frequently reported as most painful. Positional dyspareunia was significantly associated with endometriosis cysts on the left ovary (n = 17/18; P = 0.005) and showed a tendency toward association with deep endometriosis of the rectum. No clear link was found between lesion location and avoidance of sexual intercourse.

CLINICAL IMPLICATIONS: The findings highlight the need for clinicians to address positional dyspareunia during evaluations and suggest exploring alternative sexual positions as a coping strategy. Standardized questionnaires should be updated to include positional aspects of dyspareunia.

STRENGTH & LIMITATIONS: Strengths include prospectively collected data and the study's conduction in a certified endometriosis center. Limitations include a small sample size, and the exclusion of psychological factors like anxiety and depression.

CONCLUSION: Positional dependency in dyspareunia is highly prevalent among women with endometriosis, highlighting the need for awareness in clinical evaluations, as standardized questionnaires like Female Sexual Function Index and Endometriosis Health Profile-30 do not address this aspect. Further research is needed to explore alternative sexual positions and their effectiveness in mitigating dyspareunia. Avoidance of sexual intercourse may not be solely linked to the extent or location of endometriosis.

CLINICAL TRIAL REGISTRATION: DRKS - German Clinical Trials Register, ID: DRKS00023833, https://www.drks.de/search/de/trial/DRKS00023833.