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For further information, see CMDT Part 20-11: Female Sexual Dysfunction

KEY FEATURES

General Considerations

  • ”Dyspareunia” refers to women who experience persistent or recurrent pain with sexual intercourse, including pain with vaginal penetration

  • Vulvovaginal or pelvic pain during genital contact (vulvodynia)

  • Marked fear or anxiety about vulvovaginal or pelvic pain in anticipation of, during, or as a result of genital contact

  • Marked hypertonicity or overactivity of pelvic floor muscles with or without genital contact (ie, vaginismus)

  • It has a host of potential causes, including

    • Vulvovaginitis

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

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

    • Vaginal atrophy

    • Vaginismus

    • Insufficient vaginal lubrication

    • Vulvodynia or vulvar vestibulitis

    • Postmenopausal vaginal atrophy

    • Pelvic adhesions

    • Ovarian tumor

CLINICAL FINDINGS

Symptoms and Signs

  • There are generally no physical findings except a subset of patients may have vulvar erythema

DIAGNOSIS

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

TREATMENT

  • May be treated initially with

    • Sexual counseling

    • Education about anatomy and sexual function

    • Pelvic floor physical therapy by a specialized provider

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

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

  • Vaginismus is treated with sexual counseling, education on anatomy and sexual functioning, and pelvic floor physical therapy by a specialized provider

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

    • Injection of botulinum toxin has been successfully used in women with refractory vaginismus

  • Insufficient lubrication of the vagina

    • 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

    • Topical anesthetics (eg, estrogen cream and a compounded mixture of topical amitriptyline 2% and baclofen 2% in a water washable base) are useful

    • Useful oral medications include

      • Amitriptyline in gradually increasing doses from 10 mg/d to 75–100 mg/day

      • Gabapentin, starting at 300 mg three times daily and increasing to 1200 mg three times daily

      • Various selective serotonin reuptake inhibitors

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