Introduction: According to the World Health Organization (WHO), sexual health is fundamental to an individual’s overall health. Sexual intercourse should not be painful; however, for many women, pain significantly impacts their well-being and intimate relationships. Pain during sexual intercourse is described with various terms in the literature. The terms “dyspareunia” and “vaginismus” were once considered distinct, but the Diagnostic and Statistical Manual of Mental Disorders, in its Fifth Edition (DSM-5) has combined them under the term “Genito-Pelvic Pain/Penetration Disorder” (GPPPD). GPPPD is a common sexual dysfunction in women, diagnosed when pain is persistent or recurrent and at least one of the following criteria are present: 1) persistent or recurrent difficulty with vaginal penetration, 2) vaginal or pelvic pain during or at the attempt of penetration, 3) fear or anxiety about vaginal or pelvic pain before, during, or after penetration, and 4) hypertonicity of the pelvic floor muscles before or during penetration. These conditions must be present for at least six months and not have a medical cause that explains the pain. Although the exact cause is unknown, evidence suggests a multifactorial etiology, involving psychological and personal factors. These factors can be biological, psychological, cultural, or interpersonal. Additionally, GPPPD can be classified as a persistent pain condition, sharing characteristics with other conditions such as fibromyalgia or complex regional pain syndrome. The initial cause of the pain may be biological, but it can persist even in the absence of a medical or pathological cause. Similar to other persistent pain conditions, women with GPPPD exhibit changes at the central nervous system level, known as nociplastic changes. After an acute pain episode, nociplastic changes occur in the central nervous system, resulting in an amplification of the pain signal, also known as central sensitization. Given its multifactorial etiology, the appropriate treatment according to evidence is a multidisciplinary approach, incorporating medical, psychological, and physiotherapy treatments. Physiotherapy treatments include electrostimulation, biofeedback, myofascial release techniques, pelvic floor muscle relaxation, education, and gradual exposure with dilators, among others. It has been shown that various combined physiotherapy treatments yield the best results in terms of pain. In other persistent pain disorders, Pain Neuroscience Education (PNE) has been shown to reduce pain levels. Through education, women change their attitudes towards pain and reduce catastrophic thoughts. Although not extensively studied in GPPPD, education has the potential to reduce pain, given the hypervigilance and catastrophizing these women exhibit. Additionally, another well-utilized therapy in persistent pain is Graded Motor Imagery (GMI). Currently there are no studies implementing GMI in women with GPPPD, but there is evidence for implementing one of its phases in chronic pelvic pain, as well as gradual exposure in women with vaginismus and chronic pelvic pain. Objectives: The objective of the first study is to analyze the quality of YouTube videos on the term "dyspareunia". The objective of the second study is to establish the levels of correlation between the outcomes of a Pain Neuroscience Education program and the participants’ socioeconomic status. The third study examines the outcomes of the same Pain Neuroscience Education program across all domains of the Female Sexual Function Index questionnaire. The fourth study aims to translate and validate the Vaginal Penetration Cognition Questionnaire into Spanish. Finally, the fifth study analyzes the effectiveness of a Graded Motor Imagery program in women with GPPPD in terms of pain and sexual function. Materials and Method: Study I: An observational study was conducted in February 2021 by searching YouTube with the term "dyspareunia." The first 150 videos were retrieved and qualitatively analyzed by two independent researchers. The quality of the videos was assessed using the DISCERN, Global Quality Scale (GQS), and Quality Evaluation Scoring Tool (QUEST), and their popularity was measured with the Video Popularity Index (VPI). Study II: The correlation levels between the outcomes of a Pain Neuroscience Education program and the socioeconomic status of the participants were established, considering their age, educational level, household monthly income, and occupation. The correlation analysis was conducted using Pearson's correlation coefficient for quantitative variables and Spearman's rho for qualitative variables. Study III: In a randomized controlled trial, participants diagnosed with GPPPD received a Pain Neuroscience Education program. The Female Sexual Function Index (FSFI) was analyzed across all of its domains, and changes in each questionnaire item were assessed using multiple t-tests. Study IV: The Spanish version of the Vaginal Penetration Cognition Questionnaire (VPCQ-Sp) was developed, and its psychometric properties were analyzed. Women diagnosed with GPPPD completed the questionnaire, and its validity, reliability, and internal consistency were assessed. Study V: In a randomized controlled trial, women with GPPPD were assigned to either a group undergoing a Graded Motor Imagery program adapted for localized pelvic floor pain or a control group. The Graded Motor Imagery program was conducted over six weeks and included laterality discrimination exercises, mental movement stimulation, and gradual exposure. Pain intensity and sexual function were assessed, and the potential roles of the ability to imagine and negative beliefs about vaginal penetration in these participants were analyzed. Results: Study I: A total of 150 videos were analyzed, with an average of 35,513 views, an average duration of 5:39 minutes, and an average time since publication of 1,396.3 days. The average view ratio was 29.8, with 333 "likes'' and 13 "dislikes". The VPI was 92.1%. The average DISCERN score was 40.9 points (Researcher 1) and 39.3 points (Researcher 2). The average GQS was 3.1 points (Researcher 1) and 3.0 points (Researcher 2). The average QUEST scores were 13.3 points (Researcher 1) and 13.1 points (Researcher 2). Study II: No significant correlation levels were found between the outcomes of the Pain Neuroscience Education program and the participants' age, educational level, household monthly income, and occupation. Study III: Significant improvements were found in the "pain" domain of the FSFI in the group that received in-person Pain Neuroscience Education sessions (-1.1 points, SD 1.8, p<0.05), and in the "satisfaction" (-0.8 points, SD 1.8, p<0.05) and "pain" (-0.8 points, SD 1.7, p<0.05) domains of the FSFI in the group that received online sessions. Study IV: The Spanish version of the Vaginal Penetration Cognition Questionnaire was found to be valid, reliable, and consistent in women with GPPPD. Exploratory factor analysis revealed a total of four domains with 62.5% variance. Convergent and discriminant validity were confirmed. Test-retest reliability was high, with an intraclass correlation coefficient of 0.9. Each domain showed good levels of internal consistency, with Cronbach's α between 0.84 and 0.89. Study V: The group that received Graded Motor Imagery sessions showed a significant reduction in pain intensity (from 6.9 points, SD 1.3 to 4.7 points, SD 1.3, p<0.05). Participants with good imaginative abilities had greater improvements, while those with higher negative beliefs about vaginal penetration showed fewer improvements in sexual function. Conclusions: Study I: The overall quality of YouTube videos on dyspareunia is acceptable according to the DISCERN, GQS, and QUEST tools. Videos published by academic institutions are of the highest quality, although they are not the most popular, unlike those produced by media outlets. Study II: The Pain Neuroscience Education program is effective in reducing pain intensity and improving sexual function in women diagnosed with GPPPD, regardless of their age, educational level, household monthly income, or occupation. Study III: The Pain Neuroscience Education program does not produce a significant improvement in the FSFI overall, but does significantly improve some of its domains, such as "pain" and "satisfaction." Study IV: The Spanish version of the Vaginal Penetration Cognition Questionnaire is a valid, reliable, and consistent tool for analyzing cognitions about vaginal penetration in women with Genito-Pelvic Pain/Penetration Disorder. Study V: A Graded Motor Imagery program is effective in improving significantly pain intensity and non-significantly sexual function in women diagnosed with Genito-Pelvic Pain/Penetration Disorder.
