Catherine M. Leclair

Fact#1: Dyspareunia is persistent or recurrent pain with attempted or complete vaginal entry and/or penile vaginal intercourse.

Fact#2: The female postmenopausal population is particularly susceptible to dyspareunia because of vaginal hypoestrogenism.

Fact#3: In the National Health and Social Life Survey of 1,749 women, 43% of women surveyed experienced sexual dysfunction, which included the diagnosis of dyspareunia.

Fact#4: A study evaluating the chief complaint of women presenting to a specialty vulvovaginal clinic revealed that 70% (228/330) reported dyspareunia.

Fact#5: Approximately 1% to 2% of women will have painful intercourse on more than one occasion.

Fact#6: The true prevalence of dyspareunia is unknown and is seen much more commonly in women than in men.

Fact#7: Dyspareunia Risk Factors:

• Sexual abuse
• Vaginal hypoestrogenism (menopause, lactation, breast cancer)
• Chronic inflammatory vulvovaginal conditions
• Chronic pelvic pain

Diagnosis

Fact#8: Medical History of Dyspareunia:

• Onset, duration, location, frequency, severity, and character of pain (vulva, introitus or vagina)
• Hormonal status, associated vaginal discharge or bleeding
• New sexual partner
• Sexually transmitted diseases (STDs)
• Method of contraception
• Menstrual history
• Presence of urinary or gastrointestinal symptoms
• Past gynecologic, obstetric, and surgical history
• History of sexual abuse
• Techniques tried (lubricant, position change), therapies prescribed and attempted

Fact#9: Physical Exam at Dyspareunia includes:

• Inspection of vulva for erythema, skin changes, fissuring, loss labia contours, HSV lesions, condyloma
• Q-tip test of vulvar vestibule
• Evaluation of vaginal discharge for pH, infection, inflammation
• Evaluation of vaginal mucosa for estrogen status
• Palpation of levator muscle for tenderness and tone
• Bimanual exam to evaluate uterus and adnexa

Fact#10: Interventional Diagnosis of Dyspareunia:

• Vulvar biopsy if skin changes noted
• Herpes simplex virus (HSV) culture for vesicular lesions
• Vaginal culture if recurrent or difficult vaginitis
• Evaluation by pelvic floor physical therapist if suspect pelvic floor muscle involvement
  
• Ultrasound when clinically indicated

Fact#11: Lab-Tests include:

• Wet mount
• Vaginal culture
• Gonorrhea and Chlamydia culture
• HSV culture
• Urinalysis and vulvar biopsy when indicated
  

Fact#12: If clinically indicated, imaging usually begin with ultrasound of the pelvis.

Fact#13: Diagnostic Procedures/Surgery of Dyspareunia:

• Evaluation by pelvic floor physical therapist for levator myalgia
• Diagnostic laparoscopy for pelvic pain
• Psychological evaluation

Fact#14: Dyspareunia Differential Diagnosis:

✓ Vulva:

• Lichen sclerosus
• Lichen planus
• Lichen simplex chronicus
• Herpes simplex
• Trauma
• Vulvodynia
• Vulvar phimosis
• Vulvar atrophy secondary to hypoestrogenism

✓ Introitus:

• Vulvar vestibulitis syndrome (vestibulodynia)
• Imperforate hymen
• Lichen planus
• Desquamative inflammatory vaginitis
• Chronic vaginitis
• Vaginismus
• Posterior commissure band
• Anatomic changes secondary to surgery/episiotomy
• Trauma
  

✓ Vagina:

• Lichen planus
• Desquamative inflammatory vaginitis
• Chronic vaginitis
• Vaginismus
• Endometriosis
• Trauma
• Vaginal atrophy secondary to hypoestrogenism
• Vaginal prolapse

✓ Pelvis:

• Endometriosis
• Chronic pelvic pain
• Disorders of the uterus (leiomyoma or adenomyosis)
• Ovarian cyst
• Pelvic inflammatory disease (PID)
• Pelvic mass
• Pelvic prolapse

✓ Gastrointestinal tract:

• Inflammatory bowel disease (IBS)
  
• Chronic constipation

✓ Urinary tract:

• Urinary tract infection
• Interstitial cystitis
  

✓ Neuropsychiatric:

• Neuropathic pain syndrome
• Posttraumatic stress syndrome
• Depression
• Sexual aversion disorder
• Hypoactive sexual desire disorder
• Female sexual arousal disorder

Medication (Drugs)

Fact#15: First Line Drugs may include:

• Topical or vaginal steroids
• Oral or vaginal antibiotics
• Oral or vaginal antifungals
• Antivirals for HSV
• Hormonal supplement or suppression
• Oral neuropathic modulators
• Fiber-bulking agents for some GI disorders

Fact#16: If a focal peripheral neuropathy is identified gabapentin and antidepressants with antihyperalgesic potential, including tricyclic antidepressants and duloxetine should be considered:

Fact#17: Pelvic floor physical therapy is effective treatment for vaginismus. It may be appropriate to consider opioid analgesia, specifically to facilitate rehabilitation/physical therapy efforts

Fact#18: Many women find dyspareunia damaging to their sexual confidence and interpersonal relationships.

Fact#19: Appropriate referral to a mental health care worker for sexual counseling often is needed.

Fact#20: Screen each woman for depression and anxiety is necessary.

Fact#21: Surgical treatment may be appropriate in some etiologies, such as:

• Vulvar vestibulitis syndrome (vestibulodynia)
• Imperforate hymen
• Surgical revision for phimosis and trauma
• Uterine abnormalities
• Ovarian pathology
• Endometriosis
• Pelvic organ prolapse
• PID

Follow-Up

Fact#22: Prognosis depends on the etiology. Most patients generally respond to treatment and show improvement.

Fact#23: Most women appreciate close follow-up for this sensitive and difficult problem.

Fact#24: Interval follow-up of every 6 to 12 months is reasonable unless otherwise dictated by the cause.

Fact#25: By avoiding foods high in acid, some women with interstitial cystitis will show improvement of their symptoms. A high-fiber diet may help some women with IBS (Irritable Bowel Syndrome) and chronic constipation.

References

1. American College of Obstetricians and Gynecologists. Sexual dysfunction. Technical bulletin no. 211. Washington, DC: ACOG, 1995.
2. Glazer HI, et al. Treatment of vulvar vestibulitis syndrome with electromyographic biofeedback of pelvic floor musculature. J Reprod Med. 1995;40(4):283-290.
3. Haefner HK. Critique of new gynecologic surgical procedures: surgery for vulvar vestibulitis. Clin Obstetr Gynecol. 2000;43(3):689-700.
4. Hansen A, Carr K, Jensen J. Characteristics and initial diagnoses of women presenting to a referral center for vulvovaginal disorders in 1996-2000. J Reprod Med. 2002;47(10):854-860.
5. Jamieson DJ, Steege JF. The prevalence of dysmenorrhea, dyspareunia, pelvic pain, and irritable bowel syndrome in primary care practices. Obstet Gynecol. 1996;87:55.
6. Laumann A, et al. Sexual dysfunction in the United States: prevalence and predictors. JAMA. 1999;281:537-544.
7. Meana M, et al. Biopsychosocial profile of women with dyspareunia. Obstet Gynecol. 1997;90:583.