Dyspareunia (Painful Intercourse)

Key Features

General Considerations

• Dyspareunia and vaginismus are two subcategories of sexual pain disorders

• Dyspareunia is defined as recurrent or persistent genital pain associated with sexual intercourse that is not caused exclusively by lack of lubrication or by vaginismus and that causes marked distress or interpersonal difficulty

• Vaginismus is defined as recurrent or persistent involuntary spasm of the musculature of the outer third of the vagina that interferes with sexual intercourse, causing marked distress or interpersonal difficulty

Etiology

• May be caused by vulvovaginitis, vulvar disease (including lichen planus, lichen sclerosus, and lichen simplex chronicus), pelvic disease (eg, endometriosis or chronic pelvic inflammatory disease), vulvodynia, or vaginal atrophy

• Vulvovaginitis: inflammation or infection of the vagina

• Vaginismus

  • Voluntary or involuntary contraction of muscles around the introitus

  • Results from fear, pain, sexual trauma, or having learned negative attitudes toward sex during childhood

• Infection, endometriosis, tumors, or other pathologic conditions: pain occurring with deep thrusting during coitus is usually due to acute or chronic infection of the cervix, uterus, or adnexa; endometriosis; adnexal tumors; or adhesions resulting from prior pelvic disease or operation

• Vulvodynia is the most frequent cause of dyspareunia in premenopausal women

Clinical Findings

Symptoms and Signs

• Questions related to sexual functioning should be asked as part of the reproductive history. Three helpful questions are

  • "Are you currently involved in a sexual relationship?"

  • "With men, women, or both?"

  • "Do you have any sexual concerns or pain with sex?"

• Vulvovaginitis

  • During the pelvic examination, the patient should be placed in a half-sitting position and given a hand-held mirror and then asked to point out the site of pain and describe the type of pain

• Vulvodynia

  • A sensation of burning along with other symptoms including pain, itching, stinging, irritation, and rawness

  • Discomfort may be constant or intermittent, focal or diffuse, and experienced as either deep or superficial

  • Generally no physical findings except minimal erythema that may be associated with a subset of vulvodynia called vulvar vestibulitis

• Vulvar vestibulitis

  • Normally asymptomatic

  • However, pain is associated with touching or pressure on the vestibule, such as with vaginal entry or insertion of a tampon

  • Pain occurring with deep thrusting during coitus is usually due to

    • Acute or chronic infection of the cervix, uterus, or adnexa

    • Endometriosis

    • Adnexal tumors

    • Adhesions resulting from prior pelvic disease or operation

Differential Diagnosis

• Vulvodynia or vulvar vestibulitis

• Vaginismus

• Insufficient vaginal lubrication

• Vulvovaginitis

• Vulvar disease, including lichen planus, lichen sclerosus, and lichen simplex chronicus

• Pelvic disease, such as endometriosis or chronic pelvic inflammatory disease

• Vaginal atrophy

• Ovarian tumor

• Pelvic adhesions

Diagnosis

Diagnostic Procedures

• Colposcopy to evaluate vulvovaginitis: areas of marked tenderness in the vulvar vestibule ...