Dyspareunia (Painful Intercourse)

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

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

Diagnostic Procedures

• Colposcopy to evaluate vulvovaginitis: areas of marked tenderness in the vulvar vestibule without visible inflammation occasionally show lesions resembling small condylomas

Vulvovaginitis

• Warty lesions on colposcopy or biopsy should be treated appropriately (see Vaginitis)

Vulvar disease

• Lichen sclerosus is treated with clobetasol propionate 0.05% ointment, applied twice daily for 2–3 months

• See Lichen Planus and Lichen Simplex Chronicus for treatment options

Vaginismus

• Sexual counseling and education may be useful

• Self-dilation, using a lubricated finger or dilators of graduated sizes, may help. Before coitus (with adequate lubrication) is attempted, the patient and her partner should be able to painlessly introduce two fingers into the vagina

Insufficient lubrication of the vagina

• See Menopausal Syndrome

• For inadequate sexual arousal, sexual counseling is helpful

• Lubricants during sexual foreplay may be of use

• If lubrication remains inadequate, use estradiol vaginal ring worn continuously and replaced every 3 months. Concomitant progestin therapy is not needed with the ring

• Estrogen vaginal cream

Infection, endometriosis, tumors, or other pathologic conditions

• Temporarily abstain from coitus during treatment

• Consider hormonal or surgical treatment of endometriosis

• Dyspareunia from chronic pelvic inflammatory disease or extensive adhesions is difficult to treat without extirpative surgery. Couples can be advised to try coital positions that limit deep thrusting and to use manual and oral sexual techniques

Vulvodynia

• Difficult management since etiology unclear

• Surgical vestibulectomy has had success

• Antiviral, antifungal, corticosteroid, or anesthetic agents have varied success

• Pain control through behavioral therapy, biofeedback, or acupuncture has varied success

• Continuous genital burning or pain may be relieved with

  • Amitriptyline in gradually increasing doses from 10 mg once daily orally to 75–100 mg once daily orally

  • Gabapentin, starting at 100–300 mg three times daily orally and increasing to 1200 mg three times daily orally, as tolerated

When to Refer

• When symptoms persist despite first-line therapy

• For expertise in procedures