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Dyspareunia
Scott T. Henderson, MD
image BASICS
DESCRIPTION
  • Recurrent and persistent genital pain associated with sexual activity, which is not exclusively due to lack of lubrication or vaginismus.
  • May be the result of organic, emotional, or psychogenic causes
    • Primary: present throughout one's sexual history
    • Secondary: arising from some specific event or condition (e.g., menopause, drugs)
    • Superficial: pain at, or near, the introitus or vaginal barrel associated with penetration
    • Deep: pain after penetration located at the cervix or lower abdominal area
    • Complete: present under all circumstances
    • Situational: occurring selectively with specific situations
  • System(s) affected: reproductive
EPIDEMIOLOGY
  • Predominant age: all ages
  • Predominant sex: female > male
Incidence
>50% of all sexually active women will report dyspareunia at some time.
Geriatric Considerations
Incidence increases dramatically in postmenopausal women primarily because of vaginal atrophy.
Prevalence
  • Most sexually active women will experience dyspareunia at some time in their lives.
    • ˜15% (4-40%) of adult women will have dyspareunia on a few occasions during a year.
    • ˜1-2% of women will have painful intercourse on a more-than-occasional basis.
    • Male prevalence is ˜1%.
ETIOLOGY AND PATHOPHYSIOLOGY
  • Disorders of vaginal outlet
    • Adhesions
    • Condyloma
    • Clitoral irritation
    • Episiotomy scars
    • Fissures
    • Hymeneal ring abnormalities
    • Inadequate lubrication
    • Infections
    • Lichen planus
    • Lichen sclerosus
    • Postmenopausal atrophy
    • Psoriasis
    • Trauma
    • Vulvar papillomatosis
    • Vulvar vestibulitis/vulvodynia
  • Disorders of vagina
    • Abnormality of vault owing to surgery or radiation
    • Congenital malformations
    • Inadequate lubrication
    • Infections
    • Inflammatory or allergic response to foreign substance
    • Masses or tumors
    • Pelvic relaxation resulting in rectocele, uterine prolapse, or cystocele
  • Disorders of pelvic structures
    • Endometriosis
    • Levator ani myalgia/spasm
    • Malignant or benign tumors of the uterus
    • Ovarian pathology
    • Pelvic adhesions
    • Pelvic inflammatory disease (PID)
    • Pelvic venous congestion
    • Prior pelvic fracture
    • Uterine fibroids
  • Disorders of the GI tract
    • Constipation
    • Crohn disease
    • Diverticular disease
    • Fistulas
    • Hemorrhoids
    • Inflammatory bowel disease
  • Disorders of the urinary tract
    • Interstitial cystitis
    • Ureteral or vesical lesions
    • Urethritis
  • Chronic disease
    • Behçet syndrome
    • Diabetes
    • Sjögren syndrome
  • Male
    • Cancer of penis
    • Genital muscle spasm
    • Infection or irritation of penile skin
    • Infection of seminal vesicles
    • Lichen sclerosus
    • Musculoskeletal disorders of pelvis and lower back
    • Penile anatomy disorders
    • Phimosis
    • Prostate infections and enlargement
    • Testicular disease
    • Torsion of spermatic cord
    • Urethritis
  • Psychological disorders
    • Anxiety
    • Conversion reactions
    • Depression
    • Fear
    • Hostility toward partner
    • Phobic reactions
    • Psychological trauma
RISK FACTORS
  • Fatigue
  • Stress
  • Depression
  • Diabetes
  • Estrogen deficiency
    • Menopause
    • Lactation
  • Previous PID
  • Vaginal surgery
  • Alcohol/marijuana consumption
  • Medication side effects (antihistamines, tamoxifen, bromocriptine, low-estrogen oral contraceptives, SSRIs, depo-medroxyprogesterone, desipramine)
Pregnancy Considerations
Pregnancy is a potent influence on sexuality; dyspareunia is common. Women who experience delivery interventions including episiotomy are at greater risk than women who deliver over an intact perineum or have an unsutured tear.
COMMONLY ASSOCIATED CONDITIONS
Vaginismus
Pregnancy Considerations
Episiotomies do not have a protective effect (1)[A].
image DIAGNOSIS
PHYSICAL EXAM
  • A complete exam, including a focused pelvic exam, to identify pathology and provide patient education.
  • Because examination often reproduces the pain, examiner should be cautious and sensitive to patient's anxiety. Exam must include inspection and palpation of vulva and vaginal areas, palpation of the uterine and adnexal structures, and a rectovaginal exam. Sensory mapping with a cotton-tipped applicator to identify sensitive and painful areas.
  • Inspect and palpate urethra and base of the bladder.
DIFFERENTIAL DIAGNOSIS
Vaginismus
DIAGNOSTIC TESTS & INTERPRETATION
Initial Tests (lab, imaging)
Based on history and exam findings
  • Wet mount
  • Gonorrhea and chlamydia cultures
  • Herpes culture
  • Urinalysis and urine culture
  • Pap smear
Follow-Up Tests & Special Considerations
  • Serum estradiol if vulvodynia or atrophic vaginitis
  • Voiding cystourethrogram if urinary tract involvement
  • GI contrast studies if GI symptoms
  • Ultrasound and CT scan are of limited value; perform if clinically indicated.
P.323

Diagnostic Procedures/Other
Based on history and exam findings
  • Colposcopy and biopsy if vaginal/vulvar lesions
  • Laparoscopy if complex deep-penetration pain
  • Cystoscopy if urinary tract involvement
  • Endoscopy if GI involvement
Test Interpretation
Depends on etiology
image TREATMENT
  • Potential relationships exists between primary dyspareunia and vaginismus, low libido, and arousal disorders.
  • Endocrine factors, such as primary amenorrhea, might reduce the biologic basis of sexual response.
  • If pain prevents penetration, severe vaginismus may be present.
GENERAL MEASURES
  • Educate the patient and partner regarding the nature of the problem. Reassure both that there are solutions to the problem.
  • Initiate specific treatment when initial evaluation identifies an organic cause.
  • Once organic causes are ruled out, treatment is a multidimensional and multidisciplinary approach (2)[C].
    • Individual behavioral therapy
      • Indicated to help the patient deal with intrapersonal issues and assess the role of the partner
    • Couple behavioral therapy
      • Indicated to help resolve interpersonal problems
      • May involve short-term structured intervention or sexual counseling
      • Designed to desensitize systemically uncomfortable sexual responses and intercourse through a series of interventions over a period of weeks
      • Interventions range from muscle relaxation and mutual body massage to sexual fantasies and erotic massage.
MEDICATION
First Line
Depends on the etiology
  • Antibiotics, antifungals, or antivirals, as indicated, for infection
  • Vaginal moisturizers and lubricants for dryness
  • Analgesics and topical anesthetics for pain
  • Topical estrogen for vaginal and vulvar atrophy
  • Neuropathic pain associated with vulvar vestibulitis/vulvodynia may respond to tricyclic antidepressants (amitriptyline or nortriptyline) or gabapentin.
Second Line
Ospemifene for moderate to severe symptoms due to menopause-related vulvar and vaginal atrophy (3)[B]
ISSUES FOR REFERRAL
Referral for long-term therapy may be necessary.
ADDITIONAL THERAPIES
Physical therapy for pelvic floor muscle pain
SURGERY/OTHER PROCEDURES
  • Laparoscopic excision of endometriotic lesions has shown benefit (4)[C].
  • Surgical vestibulectomy can be considered if medical measures fail with vulvar vestibulitis (5)[B].
COMPLEMENTARY & ALTERNATIVE MEDICINE
  • Sitz baths may relieve painful inflammation.
  • Perineal massage
  • Antioxidants may improve symptoms associated with endometriosis.
image ONGOING CARE
FOLLOW-UP RECOMMENDATIONS
Patient Monitoring
  • Outpatient follow-up depends on therapy.
  • Every 6 to 12 months once resolved
DIET
A high-fiber diet may help if constipation is a contributing cause.
PATIENT EDUCATION
  • Boston Women's Health Book Collective. Our Bodies, Ourselves: A New Edition for a New Era. New York, NY: Simon & Schuster; 2005.
  • Kegel exercise information
  • Provide couples with information about sexual arousal techniques.
PROGNOSIS
Depends on underlying cause but most patients will respond to treatment.
REFERENCES
1. Carroli G, Mignini L. Episiotomy for vaginal birth. Cochrane Database Syst Rev. 2009;(1):CD000081.
2. Crowley T, Richardson D, Goldmeier D. Recommendations for the management of vaginismus: BASHH Special Interest Group for Sexual Dysfunction. Int J STD AIDS. 2006;17(1):14-18.
3. Portman DJ, Bachmann GA, Simon JA, et al. Ospemifene, a novel selective estrogen receptor modulator for treating dyspareunia associated with postmenopausal vular and vaginal atrophy. Menopause. 2013; 20(6):623-630.
4. Ferrero S, Abbamonte LH, Giordano M, et al. Deep dyspareunia and sex life after laparoscopic excision of endometriosis. Hum Reprod. 2007;22(4): 1142-1148.
5. Steege JF, Zolnoun DA. Evaluation and treatment of dyspareunia. Obstet Gynecol. 2009;113(5): 1124-1136.
Additional Reading
&NA;
  • Boardman LA, Stockdale CK. Sexual pain. Clin Obstet Gynecol. 2009;52(4):682-690.
  • Frank JE, Mistretta P, Will J. Diagnosis and treatment of female sexual dysfunction. Am Fam Physician. 2008;77(5):635-642.
  • Sung SC, Jeng CJ, Lin YC. Sexual health care for women with dyspareunia. Taiwan J Obstet Gynecol. 2011;50(3):268-274.
See Also
&NA;
  • Balanitis; Endometriosis; Pelvic Inflammatory Disease (PID); Sexual Dysfunction in Women; Genito-Pelvic Pain/Penetration Disorder (Vaginismus); Vulvovaginitis, Estrogen Deficient; Vulvovaginitis, Prepubescent
  • Algorithms: Dyspareunia; Discharge, Vaginal
Codes
&NA;
ICD10
  • N94.1 Dyspareunia
  • F52.6 Dyspareunia not due to a substance or known physiol cond
Clinical Pearls
&NA;
  • Careful history to determine if patient feels pain before, during, or after intercourse will help identify cause.
    • Pain before intercourse suggests a phobic attitude toward penetration and/or the presence of vestibulitis.
    • Pain during intercourse combined with the location of the pain is most predictive of the causes of pain.
    • Introital pain after intercourse suggests vestibulitis in women of childbearing age, hypertonic pelvic floor, or vulvovaginal dystrophia.
  • Potential relationship exists between primary dyspareunia and vaginismus, low libido, and arousal disorders.
  • Episiotomy does not offer any benefit in the prevention of dyspareunia; an episiotomy in fact may cause more future discomfort.