Diagnosing and managing dyspareunia.

Introduction

Women often keep silent about experiencing pain during vaginal intercourse because they feel they have a duty to meet their partner's sexual needs. Eventually symptoms including loss of sexual interest, mood changes and other psychological or somatic symptoms may develop.

Dyspareunia is defined as persistent or recurrent pain occurring with either attempted or complete vaginal penetration. Dyspareunia is also classified according to the anatomical site; entry or superficial, vaginal and deep.

Pain with intercourse affects about 8-22% of women and is more likely to occur in younger women, mainly in the 16-39 year old age group. However, an increasing number of postmenopausal women also complain of dyspareunia mainly due to the atrophic skin changes.

Causes of dyspareunia

Superficial

• Size disparity- if penis too big it hurts, if vagina too small it tears
• Introital scarring after surgery, eg. episiotomy, posterior vaginal repair
• Postmenopausal atrophic changes with introital narrowing
• Vulvovaginitis eg. Chronic Candidiasis
• Vulval skin disorders such as eczema, lichen sclerosus, psoriasis
• Vulvitis due to allergens e.g. soaps, sanitary napkins, perfumed toilet paper
• Vulvodynia including vestibulodynia
• Condylomata

Vaginal Dyspareunia

• Vaginal atrophy
• Interstitial cystitis
• Scar tissue form surgery, radiation therapy
• Levator ani muscle spasm or myalgia, including vaginismus
• History of sexual abuse

Deep Dyspareunia

• Endometriosis
• Adenomyosis
• Fibroids
• Pelvic venous congestion
• Uterine retroversion
• Pelvic inflammatory disease
• Ovarian adhesions
• Irritable bowel syndrome
• History of sexual abuse
• Residual ovary syndrome. 

History and Examination.

Many women are reluctant to volunteer information about their sexual lives so it is important that initial sexual history taking include open-ended or standard questions about sexual function in particular pain, dryness, discomfort and desire.

Once dyspareunia has been identified as a problem, more specific questions should be asked in an empathic manner. It is necessary to establish the location of the pain, (superficial, vaginal or deep), when it occurs, whether it is persistent or intermittent, lifelong or recent onset and whether there are factors which increase or provoke as well as alleviate the pain.

In premenopausal women it is important to establish whether there is a relationship between the dyspareunia and the menstrual cycle. For example in women with endometriosis or adenomyosis the pain may be maximal immediately premenstrual or in the initial days of the menses.

A thorough history of pain, including changes, quality and site may assist in diagnosis. Changes such as this may indicate involvement of other tissues or organs which will increase the complexity of the condition and therefore its management.

An understanding of the partner and their relationship will also aid in developing a diagnosis and management plan.

Examination should include the abdomen to determine intra-abdominal tenderness or musculoskeletal pain.

The vulva should be visualised for skin changes or if vestibulodynia is suspected a cotton bud may be applied to the vestibule to determine where the pain map exists. Stretching the introitus in women with size disparity or introital narrowing may reproduce the pain experienced with intercourse. Inserting one finger through the introitus and palpating the levator muscles at 4-5 o'clock and 7-8 o'clock may elicit the pain in women with levator spasm or myalgia. At the same time assess the urethra or bladder neck for tenderness or pain. Then palpation of the cervix, uterus and fornices with bimanual palpation is performed to assess for pelvic masses, Pouch of Douglas tenderness, thickening of the uterosacral ligaments or uterine tenderness.

Diagnosis and Management

Investigations such as a transvaginal ultrasound may be performed if deep dyspareunia is the major presentation. Screening for STIs especially Chlamydia and vaginal swabs should be performed depending on the symptoms and examination.

Superficial Dyspareunia with its varied causes may be simply treated with appropriate therapy either in the short term or long term depending on the chronicity. Surgical intervention with referral to a gynaecologist may be necessary for satisfactory vaginal penetration where there is introital scarring or narrowing. Chronic vulval conditions may require referral to a specialist dermatologist or gynaecologist in vulva disorders or a Vulval Clinic. Vulval hygiene instruction is important to avoid any possible allergens which may cause a vulvitis.

Vaginal Dyspareunia may respond to the use of vaginal oestrogen preparations but may require long term maintenance therapy to avoid recurrence. If interstitial cystitis is the cause, referral to a urogynaecologist or urologist may be necessary. Levator ani conditions or vaginismus may respond satisfactorily to treatment under the care of a specialist pelvic floor physiotherapist alone or in combination with psychological counseling.

Deep Dyspareunia may have many causes. If pelvic pathology is suspected referral to a gynaecologist is necessary. Diagnostic or operative laparoscopy is appropriate for diagnosis and treatment however further treatment may be necessary to alleviate the pain. Treatment may be ongoing and along side psychological therapy.

  

 Diagnosing and managing with dyspareunia 126.39 Kb   

References

Boardman L and Stockdale CK. Sexual Pain. Clinical Obstetrics and Gynecology 2009; 52:682–690

van Lankveld J, Granot M, Willibrord CM, Schultz W, Binik YM Wesselmann U, Pukall CF, Bohm-Starke N, and Achtrari C, J Women's Sexual Pain Disordersj_Sex Med 2010;7:615–631

Steege JF and Zolnoun DA Evaluation and treament of dyspareunia Obstetrics & Gynaecology 2009; 113:1124-1136

See Medical Observer http://www.medicalobserver.com.au/

Content updated January 28, 2011