Dyspareunia

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Chapter 11 DYSPAREUNIA

Dyspareunia is recurrent genital pain during or after sexual intercourse. The pain may occur in the more superficial structures, such as the vulva, or deeper in the pelvic structures. Although dyspareunia occurs in both men and women, it is more prevalent in women. Dyspareunia may occur in as many as 60% of women, although far fewer seek medical care for this problem. Dyspareunia often has multiple causes, including both physical and psychologic causes.

Patients with dyspareunia may complain of a well-defined and localized pain, or they may express a general disinterest in and dissatisfaction with intercourse that results from the associated discomfort. The most common pain with dyspareunia occurs during coitus, but some women experience pain afterward, and others report pain at both times. Dyspareunia is differentiated from vaginismus and from problems resulting from inadequate lubrication.

The Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV), defines dyspareunia as a sexual pain disorder, a subcategory of sexual dysfunction. However, the biopsychosocial approach emphasizes that physical and psychologic factors may be instigating causes and reasons for perpetuation of the symptoms. The causes of women’s sexual pain differ for each subtype of pain, with substantial overlap between types of pain. What remains the most unclear is the cause of the original sensitization.

Medications Linked to Dyspareunia

Bromocriptine mesylate (which can cause painful clitoral tumescence)

Desipramine hydrochloride (which can cause painful orgasm)

Letrozole (which can cause vaginal dryness)

Risperidone (which can cause vaginal dryness)

Key Historical Features

✓ Gynecologic

• Location and timing of pain with relation to sexual intercourse

— Pain with arousal may indicate Bartholin gland cyst swelling.

— Pain of the external genitalia may indicate vulvitis or vestibulitis.

— Pain with initial penile penetration may indicate vaginismus, vaginitis, vaginal/vulvar atrophy, vaginal/vulvar scarring, inadequate vaginal lubrication, or vaginal septation.

— Midvaginal pain may indicate interstitial cystitis or urethritis.

— Deep pain may indicate pelvic inflammatory disease, endometriosis, uterine fibroids, inflammatory bowel disease, or a pelvic mass.

• Quality and severity of pain

• Associated pruritus or vaginal discharge, which may indicate vaginitis or sexually transmitted diseases

• Timing of onset of pain (patients with pain since their first sexual experience may have a psychological cause, whereas patients with more recently acquired dyspareunia are more likely to have a physical cause)

• History of sexually transmitted diseases

• History of trauma, including that occurring during childbirth

• History of gynecologic surgery or irradiation

• Contraceptive method, especially intrauterine device

• Difficulty with lubrication or arousal

✓ Gastrointestinal

• Associated diarrhea, bleeding, or abdominal pain, which may indicate inflammatory bowel disease or diverticular disease

• Chronic constipation

✓ Genitourinary

• Dysuria, urinary urgency, or frequency, which may indicate interstitial cystitis or infection

• Hematuria, which may indicate bladder neoplasm or infection

• A history of recurrent urinary tract infections associated with negative culture results, which may indicate interstitial cystitis

• Use of new lotions or creams

• History of skin diseases such as atopic dermatitis or psoriasis

✓ Psychologic

• History of sexual or physical abuse

• Symptoms of depression and anxiety

Key Physical Findings

✓ Gynecologic examination

• Inspection of the external genitalia for tenderness, erythema, or any lesions

• Examination of the external genitalia with a cotton swab for superficial tenderness; tenderness of the vulvar vestibule indicates vestibulitis

• Vaginal examination with one finger to palpate the walls of the vagina, as well as the bladder and urethra, and evaluation of the tone of the pelvic floor muscles and voluntary muscle control

• Speculum examination with a narrow speculum that is lubricated, to examine the vaginal mucosa and cervix

• Bimanual examination to evaluate for cervical motion tenderness, adnexal or uterine tenderness, or any masses or nodules

✓ Gastrointestinal examination

• Palpation of the abdomen for any tenderness, masses, or organomegaly

• Rectal examination to evaluate for any masses

Suggested Work-Up

Pap smear	To evaluate for cervical dysplasia
Wet mount	To evaluate for vaginitis
Cervical culture/swab for gonorrhea and chlamydia	To evaluate for infection with Neisseria gonorrhoeae or Chlamydia organisms
Urinalysis and urine culture	To evaluate for urinary tract infection

Additional Work-Up

Herpesvirus culture	If lesions indicative of herpes are visualized
Pelvic ultrasonography	If a pelvic mass is palpated
Computed tomography of the pelvis or abdomen	If a pelvic or abdominal mass is palpated
Colposcopy	If a cervical lesion is visualized
Biopsy	If a vulvar, vaginal, or cervical lesion is visualized
Cystoscopy	If interstitial cystitis is suspected
Laparoscopy	If endometriosis is suspected
Flexible sigmoidoscopy or colonoscopy	If a colonic source of pain is suspected

FURTHER READING

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th, Washington, DC: American Psychiatric Association; 1994:511-518.

Canavan TP, Heckman CD. Dyspareunia in women: breaking the silence is the first step toward treatment. Postgrad Med. 2000;108(2):149-166.

Carey JC. Pharmacological effects on sexual function. Obstet Gynecol Clin North Am. 2006;33:599-620.

Heim LJ. Evaluation and differential diagnosis of dyspareunia. Am Fam Physician. 2001;63:1535-1544. 1551-1552

MacNeill C. Dyspareunia. Obstet Gynecol Clin North Am. 2006;33:565-577.

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