Dyspareunia

Dyspareunia is defined as painful and/or difficult sexual intercourse. There is a large differential requiring detailed history and physical exam. Distinguish primary dyspareunia (dyspareunia occurs from the outset of sexual experience) from secondary dyspareunia (dyspareunia was preceded by painless intercourse).

Differential Diagnosis

• Definitions
  –Sexual pain disorder: Persistent or recurrent genital pain of nonorganic cause associated with sexual stimulation, thus causing personal stress; subcategories include dyspareunia and vaginismus
  –Superficial dyspareunia: Pain or dysfunction felt upon initial penetration
  –Deep dyspareunia: Pain or dysfunction felt deep within the pelvis during intercourse
  –Vaginismus: Painful involuntary spasm of the vagina, preventing intercourse
  –Vulvar vestibulitis: A chronic and persistent clinical syndrome characterized by severe pain with vestibular touch or attempted vaginal entry, tenderness in response to pressure within the vulvar vestibule, and physical findings confined to various degrees of vestibular erythema
  –Vulvodynia: Chronic vulvar discomfort (e.g. burning, stinging, irritation, rawness)

• Neurologic etiologies: Nerve damage or infection, dysesthetic (essential) vulvodynia
• Gynecologic etiologies: Gynecologic tumors (e.g., vulvar, cervical, uterine, ovarian, or rectal cancer; fibroids), Bartholin's gland inflammation
• GI: Constipation, irritable bowel syndrome, colitis, diverticulitis, GI tumors (in pelvis)
• Urinary: Interstitial cystitis, urethritis, urethral diverticulum
• Infectious: Endometritis, vaginitis, PID, salpingitis, vulvovaginitis, herpes genitalis, post-herpetic neuralgia, Bartholin's abscess
• Dermatologic etiologies: Vaginal atrophy, lichen sclerosis, Behçet syndrome, contact dermatitis
• Musculoskeletal: Pelvic floor myopathy, fibromyalgia, levator ani myalgia, dysfunctional vaginismus
• Endocrine: Estrogen deficiency, endometriosis
• Psychiatric: Female sexual dysfunction(s)
• Iatrogenic: Surgical (e.g., pelvic adhesions, episiotomy, strictures), pharmacologic (drying soaps or agents, topical medications, OCPs)
• Trauma: Vaginal lacerations or ecchymoses
• Primary pain disorder
• Severely retroverted uterus
• Imperforate hymen

Workup and Diagnosis

• History and physical examination with pelvic and rectal exams
  –Timing: Onset (e.g., upon entry, after intercourse), duration, persistence after intercourse, prior occurrence(s)
  –Associations: Symptoms may occur with all vaginal or vulvar contact, with intercourse only, with exams only, with masturbation, or with memories or recollections of prior occurrences or traumatic experiences
  –Alleviating and aggregating factors during intercourse
  –Qualifiers: Burning, sharp, dull, aching, throbbing, stabbing
  –Old medical records may be of crucial importance
  –Include complete psychiatric history and exam
• Cervical and/or vulvar cultures and microscopic evaluation of normal saline and potassium hydroxide wet mounts should be done
• Imaging studies may be indicated, including pelvic and/or abdominal ultrasound and/or CT scan
• Management of psychiatric causes is particularly challenging and requires specific and specialized therapy
• Consider gynecology and/or psychiatry consult

Treatment

• Treatment varies depending on etiology
• Infections require appropriate antimicrobials
• Steroids or topical treatment may be indicated for dermatologic causes
• Topical treatments or oral hormone replacement may be indicated for endocrine-related causes
• Psychological causes may require counseling with behavioral feedback and/or pharmacological treatment
• Symptoms refractory to initial treatment of proper duration require prompt reconsideration and further workup
• Referral may be necessary for specialized cases or cases with psychiatric components

Book Source Details

• Book Title: In a Page: Signs and Symptoms
• Author(s): Scott Kahan, Ellen G. Smith
• Year of Publication: 2004
• Copyright Details: In a Page: Signs and Symptoms, Copyright © 2004 Lippincott Williams & Wilkins.

Other Book Chapters Related to Female sexual symptoms

Read excerpts from these other book chapters related to Female sexual symptoms:

Copyright Details: In a Page: Signs and Symptoms, Copyright © 2008 Williams & Wilkins.

More About Causes of Female sexual symptoms

• Back to symptom: Female sexual symptoms: Introduction (review 468 causes)
• Next Book Extract About Female sexual symptoms: Vaginal Discharge (In a Page: Signs and Symptoms)
• All Book Extracts: All Online Book Extracts for Female sexual symptoms

More About This Book: Title: In a Page: Signs and Symptoms Authors: Scott Kahan, Ellen G. Smith Publisher: Lippincott Williams & Wilkins Copyright: 2004 ISBN: 1-4051-0368-X

 » Next page: Vaginal Discharge (In a Page: Signs and Symptoms)

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