Dyspareunia
Jill C. Cash and Rhonda Arthur
Definition
A.Dyspareunia is genital or pelvic discomfort associated with sexual intercourse (entry or deep penetration) and interferes with sexual satisfaction. Dyspareunia may be superficial relating to vulvar and vaginal pain, or it may be deep relating to deep pelvic pain.
Incidence
A.60% of women have dyspareunia at some time in their life. Up to 30% of women experience chronic dyspareunia.
Pathogenesis
Physical and psychosocial etiologies have been identified:
A.Physical causes:
1.Vulvovaginal anomalies:
a.Thick imperforate hymen.
b.Short vagina.
c.Vaginal agenesis.
d.Vaginal septum.
2.Organic dyspareunia:
a.Episiotomy scars (trauma from childbirth).
b.Bartholin’s gland cyst.
c.Vulvar dystrophy.
d.Inflammation or infection, sexually transmitted infection (STI).
e.Vulvovaginal cancer.
f.Pelvic pathology:
i.Pelvic inflammatory disease (PID).
ii.Uterine or ovarian tumors.
iii.Adenomyosis.
iv.Endometriosis.
3.Musculoskeletal anomalies:
a.Disk disease.
b.Myofascial pain.
c.Coccygodynia.
4.Extensive prolapse or organ displacement.
5.Urethral syndrome or other urinary tract disorders.
6.Vulvodynia.
7.Gastrointestinal (GI) anomalies:
a.Constipation.
b.Irritable bowel syndrome (IBS).
c.Inflammatory bowel disease.
d.Anorexia.
8.Hypoestrogenism/atrophic vulvovaginitis.
B.Psychosocial causes:
1.Childhood molestation.
2.Fear of pain, infection, or pregnancy.
3.Pelvic congestion syndrome.
4.Poor partner communication.
5.History of sexual assault.
6.Previous trauma during intercourse.
7.Domestic violence.
Common Complaints
A.Irritation or burning with intercourse.
B.Lack of vaginal lubrication.
C.Pain with vulvar or vaginal contact.
D.Pain with deep penetration.
E.Postcoital bleeding.
Other Signs and Symptoms
A.Vulvar pain.
B.Vaginal pain or burning.
C.Vaginal dryness.
Subjective Data
A.Review the onset, duration, and course of presenting symptoms.
B.Review the patient’s medical or surgical history for physical causes (see Pathogenesis).
C.Ask: How often does pain occur: with every intercourse, near periods, in certain sexual positions? What relief measures have been tried? Is there improvement with using extra lubrication? How much relief was obtained with each measure?
D.Obtain a complete sexual history, including the following:
1.Sexual practices.
2.Sexual satisfaction.
3.Orgasm.
4.Perception of partner satisfaction.
5.Age at first coitus.
6.History of sexual abuse, molestation, rape.
7.Perceptions regarding sexuality.
8.Number of sexual partners and preferences.
9.Time spent on foreplay.
10.History of recent delivery and breastfeeding.
11.Age at onset of puberty, date of last menses, and cycle history.
12.Current method of birth control and satisfaction with method; previous methods and why they were discontinued.
13.Presence of vaginal discharge, odor, dysuria, or other physical symptoms before or after intercourse.
14.Medications, including prescription and over-the-counter (OTC) drugs.
15.Can the woman insert a tampon without pain?
Physical Examination
A.Check temperature, pulse, respirations, and blood pressure (BP).
B.Inspection: Observe generally for discomfort before, during, and after examination. Look for signs of physical or sexual abuse, abrasions, bruises, and lacerations. For pain greatest upon deep penile penetration, suspect PID, ovarian cyst, endometriosis, pelvic adhesions, relaxation of pelvic support, or uterine fibroids.
C.Auscultate: Auscultate the abdomen for bowel sounds in all quadrants. Auscultation of the abdomen should precede any palpation or percussion due to the changes in intensity and frequency of sounds after manipulation.
D.Palpate:
1.Palpate the abdomen for masses; check for suprapubic tenderness.
2.Examine the back for range of motion.
E.Pelvic examination:
1.Inspect: Perform perineal exam for atrophic vaginitis. Atrophic vaginitis presents as red, shiny, smooth vaginal sidewalls (loss of rugae); vaginal thinning; decreased elasticity of vaginal tissues. Vulvar inflammation may be present. Assess discharge and rugae for hormonal
support.
2.Evaluate the patient for vulvovaginitis. Perform vulvar exam for Bartholin’s/Skene’s gland enlargement, fissures, lesions. Inspect for anatomic variants: narrowed introitus, congenital malformations (septum), and pelvic relaxation (cystocele and rectocele).
F.Speculum examination: Inspect for cervicitis, friability, and discharge. If the woman can insert a tampon without pain, a mechanical obstruction is unlikely.
G.Bimanual examination: Check cervical motion tenderness (CMT); adnexal masses; and uterine size, consistency, and position.
H.Rectovaginal examination: Palpate uterosacral ligaments for pain and nodularity and other signs of PID and endometriosis. In cases of rectal trauma/intercourse, cultures may be needed to rule out STIs.
Diagnostic Tests
A.Complete blood count (CBC).
B.Sedimentation rate, if indicated by physical.
C.Hormonal assays: Follicle-stimulating hormone (FSH), estradiol.
D.Wet prep to rule out candidiasis, trichomoniasis, and bacterial vaginosis (BV).
E.Vaginal/urine cultures for Chlamydia trachomatis (CT), gonorrhea (GC).
F.Viral cultures of lesions, if any.
G.Urine culture, if applicable.
H.Stool culture, if applicable.
I.Pelvic ultrasonography, if indicated.
J.Fecal occult blood test.
Differential Diagnoses
A.Dyspareunia.
B.See Pathogenesis.
Plan
A.General interventions:
1.Detailed physical examination after a thorough history.
2.Patients should be encouraged to involve their partner(s) in assessment, diagnosis, and treatment of dyspareunia.
3.A secure, trusting relationship must be established with the care provider before many patients feel comfortable discussing sexuality issues. Continuity with one provider is essential.
4.Patients with dyspareunia should be evaluated for multiple etiologies. Treat underlying pathologies such as musculoskeletal anomalies, pelvic infection, urinary tract infection (UTI), STIs, hormonal deficiencies, and GI etiologies (see specific chapters for treatment plans and drug therapy).
B. 
See Section III: Patient Teaching Guide Dyspareunia (Pain With Intercourse).
C.Pharmacologic therapy:
1.Refer to specific chapter for therapies related to etiology.
2.Vulvodynia: Consider the use of topical agents applied to the vulva or vestibule, antihistamine therapy, and/or tricyclic antidepressants.
3.Lidocaine (Xylocaine) 2% gel applied to vulva, vestibule, and fourchette.
4.Diphenhydramine (Benadryl) 25 to 50 mg orally at bedtime, or 0.1% triamcinolone acetonide cream twice daily for pruritus.
5.Amitriptyline 10 mg orally at bedtime.
Follow-Up
A.Perform test of cure for all diagnosed infections, if indicated (see specific infection and therapy).
B.Refer to follow-up plans for specific etiology.
Consultation/Referral
A.Treat/refer the patient for removal of cysts, endometriomas.
B.Refer the patient to a gynecologist for vulvovaginal anomalies, including thickened imperforate hymen, shortened vagina, and vaginal agenesis. Vaginal dilator therapy may be instituted.
C.Refer the patient for sexual therapy consultation for continued complaints without an identifiable physical cause.
Individual Considerations
A.Pregnancy or postpartum: Sexual intercourse may continue throughout pregnancy unless there is pain, bleeding, preterm labor, or premature rupture of the membranes. Alternate positions should be suggested by the provider. Sexual intercourse may resume in the postpartum period when the bleeding has decreased or stopped, incision or episiotomy is healed, and the woman is comfortable upon finger insertion and test of vaginal discomfort. Breastfeeding causes hormonal changes that may produce a menopause-like state, and extra lubrication is usually required.
B.Partners: Encourage the patient to have partner(s) participate in sexual health counseling.