This is a cross-sectional study which included 450 married sexually active females evaluating their sexual pain. Four hundred and fifty females aged 18–66 years old were selected from three districts of Fayoum governorate (Fayoum district, Sennores, and Itsa). They were selected randomly (simple random method) from primary health care centers, dermatology and family planning clinics of Fayoum University, and general hospitals of the governorate. Subjects who had no sexual activity within the past month, unmarried, divorced, or widow were excluded from the study.
This study was approved by the Ethical committee of Faculty of Medicine, Fayoum University, and was done in accordance to the Declaration of Helsinki. Before obtaining informed consent from the participants, full explanation was given about the nature and aim of the study. They volunteered to participate and had the right to end their participation at any stage of the interview. All participants’ information was kept confidential and was used only for research purposes.
Subjects were assessed for the following:
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Demographic characteristics including age, educational level, age of marriage, occupation, etc.
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Assessment of gynecological and past medical history to search for risk factors including chronic disease (e.g., hypertension, cardiovascular disease, neurological disease, or diabetes), previous pelvic surgery (gynecologic, urologic, or colorectal surgeries), menstrual cycle regularities, contraception methods, and genital causes of pain as skin rash, ulcers, inflammation, and others.
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Sexual functions using a self-administered detailed 19-item questionnaire (female sexual function index (FSFI)) [8] which assess the sexual functioning during the past 4 weeks. The Arabic validated version of FSFI [9] was used to assess the sexual function of the subjects.
According to the FSFI, sexual function domains included sexual desire, arousal, lubrication, orgasm, satisfaction, and pain during sexual intercourse. Here, we calculated domain score for pain only as it was our concern in this study.
Pain was assessed as frequency during vaginal penetration, frequency following vaginal penetration, and level during or following vaginal penetration with 3 questions 17, 18, and 19 respectively (score range 0–5 for each question). Pain score was obtained by adding the pain domain score and was calculated by multiplying the sum by the pain domain factor (0.4).
Pain score was analyzed as zero for no pain (no sexual activity) and from 1–6 for pain. According to FSFI, one is minimum score (maximum degree of pain) while 6 is maximum score (very low or no pain).
The pain score was categorized into marked and trivial pain based on a cutoff ≤ 3.6 for marked pain and > 3.6 for trivial pain. This cutoff represents pain of high frequency, high degree, or both. This cutoff was calculated as the sum of the choices made by the patients for questions 17, 18, and 19 as follows:
Answers for questions 17 and 18 include sometimes, most times, almost always, or always (3–1), and answer for question 19 include moderate, high, or very high (3–1). The sum of these three questions was then multiplied by the pain domain factor (0.4).
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Psychiatric assessment
Structured Clinical Interview based on DSM-IV (SCID-I) [10] Arabic version [11]: It is used to diagnose an axis I diagnosis. It is applied to the case group for diagnosis of anxiety and depressive disorders. It is a semi-structured diagnostic interview based on DSM-IV that had been modified to DSM-5 clinical criteria. It is considered the standard interview to verify diagnosis in clinical trials and is extensively used in other forms of psychiatric research.
Beck Depression scale by Beck et al. [12] and Arabic version by Abdel-Khalek [13]: This is a self-report scale designed to assess DSM-IV-defined symptoms of depression such as sadness, guilt, loss of interest, social withdrawal, increase and decrease in appetite or sleep, suicidal ideation, and other behavioral manifestations of depression over time to monitor symptoms and to assess response to therapeutic interventions. It has an acceptable degree of validity, as it evaluates a wide variety of symptoms and attitudes associated with depression.
The inventory is composed of 21 statements on a four-point scale, with the patient selecting the one that best matches his or her current state. Each statement corresponds to a specific behavioral manifestation. Responses to each question are scored on a scale from 0–3, equivalent to no, mild, moderate, or severe disturbances. The score range of the inventory varies from 0 to 63, where a higher score indicates higher depressive symptom severity. According to Beck et al. [14], the scoring range is as follows: 0–13 indicate no or minimal depression, 14–19 indicate mild depression, 20–28 indicate moderate depression, and 29–63 indicate severe depression.
Beck Anxiety scale by Beck et al. [15] and Arabic version by Al-Issa et al. [16]: Beck Anxiety Inventory (BAI) is a 21-item multiple-choice self-report inventory that measures the severity of an anxiety. Each of the items on the Beck Anxiety Inventory is a simple description of a symptom of anxiety in one of its four expressed aspects: (A) subjective (e.g., “unable to relax”), (B) neurophysiologic (e.g., “numbness or tingling”), (C) autonomic (e.g., “feeling hot”), or (D panic-related (e.g., “fear of losing control”). It has acceptable reliability and validity.
Respondents are asked to report the extent to which they have been anxious by each of the 21 symptoms in the week preceding (including the day of) their completion of the BAI. Each symptom item has four possible answer choices: not at all, mildly (it did not bother me much), moderately (it was very unpleasant, but I could stand it), and severely (I could barely stand it). The clinician assigns the following values to each response: not at all = 0, mildly = 1, moderately = 2, and severely = 3. The values for each item are summed yielding an overall or total score for the 21 symptoms that can range between 0 and 63 points. Scores from 0 to 7 indicate a minimal level of anxiety. Scores from 8 to 15 indicate mild level of anxiety. Scores from 16 to 25 indicate moderate level of anxiety. Scores from 26 to 63 indicate severe level of anxiety.
Statistical methods of data analysis
Results were analyzed by the statistical package for social science (SPSS) version 23 [17]. Quantitative data were subjected to Shapiro-Wilk test to determine the distribution and method of analysis. Qualitative (categorical) data were presented by frequency and percentage. Quantitative data were presented by mean ± SD, median, and range. Mann-Whitney (Z test) and Kruskal-Wallis Test were used for non-parametric data. Spearman linear correlation coefficient (r) was estimated to show the relationship between quantitative parameters. Linear regression was used to ascertain the effect of possible risk factors on the pain score [18].