Dyspareunia resident survival guide

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Roghayeh Marandi

Overview

Dyspareunia is recurrent or persistent pain with sexual activity that causes marked distress or interpersonal conflict. It can affect men, but more common in women. It can due to psychological factors, physical factors, or combined factors. It may be classified into two types in women: superficial, which occurs in or around the vaginal entrance, and is characterized by initial discomfort in initial or attempted penetration of the vaginal introitus. Deep dyspareunia is a pain that occurs with deep vaginal penetration. which resulting from pelvic thrusting during intercourse. Causes are divided into three groups according to Onset, Frequency, or Location. According to dyspareunia's location, there are two types of dyspareunia in women: superficial, which occurs in or around the vaginal entrance, and is characterized by early discomfort in initial or attempted penetration of the vaginal introitus, and deep dyspareunia is pain that occurs with deep vaginal penetration, Which resulting from pelvic thrusting during intercourse. Determining whether dyspareunia is the entry or deep can point to specific causes. Based on the onset, dyspareunia can be divided into two groups: Primary (onset with first sexual experience) Often has psychological causes, such as sexual abuse in childhood, feeling of guilt or shame toward sex or fear of intercourse or painful first intercourse, and secondary dyspareunia that its beginning is after a previous sexual activity that was not painful. Dyspareunia can be Persistent, which occurs in all situations, possibly due to physical or psychological factors, or conditional dyspareunia that occurs in certain situations. Abdomino-pelvic disorders such as endometriosis, imperforate hymen, vaginal septum, or organic vulvodynia due to infection, lichen sclerosis, or vestibulitis, vaginal infections, prolapse, trauma, or vaginal dryness can cause Dyspareunia. It can also be due to gastrointestinal disorders such as chronic constipation, diverticular diseases, inflammatory bowel disease/proctitis. Scarring due to previous pelvic surgery, episiotomy, and perineorraphy, or urological causes such as cystitis, interstitial cystitis, or urethritis can cause dyspareunia as well.

Causes

Common Causes

• Vaginitis
• Hormonal changes perimenopause and menopause
• Vaginismus
• Pelvic inflammatory disease
• Vulvodynia
• Endometriosis

Diagnosis

Shown below is an algorithm summarizing the diagnosis of dyspareunia.

Assessment of dyspareunia in female

History and physical exam ❑Ask about Pain Characteristics: ❑Timing, duration, quality, location Ask about associated vulvovaginal symptoms: ❑Itching ❑Burning ❑Irritation ❑Abnormal discharge Take musculoskeletal history: ❑Pelvic floor surgery, trauma, obstetrics Take bowel and bladder history: ❑Constipation, diarrhea, urgency, frequency Obtain sexual hsitory: ❑Frequency, desire, arousal, satisfaction, relationship Obtain psychological history: ❑Mood disorder, anxiety, depression Inquire about any history of abuse: ❑Sexual, physical, neglect Physical exam: ❑Look for any abnormal areas of erythema or edema, white patches,vulvular scarring,ulcers on external genitalia Vagina and cervix examination:❑Look for any erythema, erosions,atrophy,discharge Evaluation of external musculoskeletal: ❑complete lower back, abdomen, and pelvic examination external visual and sensory examination internal single digit palpation of the pelvic floor bimanual examination for evaluation of: ❑ uterus, cul-de-sac, and adnexal regions ❑ the internal vaginal tissue, cervix Work up: vaginal secretions: ❑vaginal pH and saline wet mount and 10% KOH microscopy If history is suggestive, perform: ❑NAAT test for gonorrhea, chlamidia,trichomonas ❑herpes simplex virus (HSV) culture, HSV-1 and HSV-2 type specific IgG antibodies ❑rapid plasma reagent (RPR) ❑vulvar or vaginal biopsy for dermatological problems, malignancy ❑Urine analysis,culture for urological problems ❑blood count ❑Glucose ❑Hormones: ❑prolactin, TSH, FSH,LH, Testosterone ❑Ultrasound of plevis ❑Laprascopy More detail evaluations for systemic disorders

Genital alterations Atrophic vaginitis Atrophic vulvitis Atrophic vulvovaginitis Premenopause Menopause Autoimmune interstitial cystitis Bartholin gland cyst Bartholinitis Chronic pain syndromes Congenital absence of lower part of vagina Endometrial conditions: Endometriosis Episiotomy Estrogen deficiency Estrogen-based contraceptives Prolactin secreting tumor Female genital mutilation Genital system cancer Genital tract tumor Genital ulcers Gonorrhea Gynaecological conditions: Gynecologic surgery Healed perineal lacerations Hemorrhoids Imperforate hymen Inflamed hymeneal orifice Lactation Prolactinoma Prolactin secreting tumors Myofascial pelvic pain syndrome Narrow vagina Obstetric perineal injury Obstetric surgery Ovarian tumour Pelvic adhesions Pelvic disorders: Pelvic infection Pelvic inflammatory disease Pelvic malignancy Pelvic organ prolapse Interstitial cystitis Renal nutcracker syndrome Pelvic tumor Poor vaginal lubrication Post-childbirth Prolapsed tender ovaries with retroverted uterus Uterus Sarcoma Provoked vulvar pain Remnants of the hymen Salpingo-oophoritis Unruptured hymen Vagina cancer Vaginal abnormality Vaginal dryness Vaginal surgery Postradiation therapy Vaginismus Virilising ovarian tumour Vulva infection Vulval dystrophy Vulval neoplasia Vulvar vestibulitis syndrome Vulvitis Vulvodynia Vulvovaginitis Dermatological problems: Contact dermatitis Allergic dermatitis Lichen sclerosis Lichen planus

Systemic disorders/Comorbid conditions/Medications Sjögren's syndrome Systemic sclerosis Vulvar Crohn's disease Inflammatory bowel disease Irritable bowel syndrome Parkinson's disease Peripheral neurpathies Fibromyalgia Behçet's syndrome Diabetes Some antidepressants, antihistamines, antihypertensives, birth control, or sedatives can decrease lubrication, potentially making intercourse painful

Psychological problems Anxiety Depression Psychological disorders Reduced libido Relationship dysfunction

Treatment

Shown below is an algorithm summarizing the treatment of dyspareunia.

Treatment of dyspareunia: It depend on underlying cause and subsequent therapy(see table below for details) educating patients about pelvic anatomy, physiology, and lifestyle modification

Medical Treatment Specific treatment for the identified cause Topical anesthetics Oral anti-inflammatory agents Botox and trigger point injections Topical hormonal treatments Pelvic floor physical therapy

Psychosexual Therapy: Oral tricyclic antidepressants Refferal for couple sexual counseling or therapy to explore non-penetrating pleasuring techniques(as appropriate) Cognitive behavioral therapy

Surgical treatment is performed as a last resort when all conservative and medical management options have failed or when surgery is indicated in situations such as: Endometriosis Adhesion pelvic organ prolapse tumors

Cardiovascular	Hemorrhoids, Renal nutcracker syndrome , Thrombosed piles
Dermatologic	Allergic contact dermatitis, Healed perineal lacerations, Irritant contact dermatitis, Kraurosis vulvae, Lichen planus, Lichen sclerosus, Obstetric perineal injury
Ear Nose Throat	Sjögren's syndrome
Endocrine	Menopause, Perimenopause, Prolactin secreting pituitary tumour, Prolactinoma, Reduced estrogen, Reduced libido
Gastroenterologic	Inflammatory bowel disease , Irritable bowel syndrome
Genetic	Congenital absence of lower part of vagina, Müllerian anomalies
Iatrogenic	Episiotomy, Gynecologic surgery, Obstetric surgery, Vaginal surgery
Infectious Disease	Atrophic vaginitis, Atrophic vulvitis, Atrophic vulvovaginitis, Autoimmune interstitial cystitis , Bartholin gland cyst, Bartholinitis, Candida albicans, Candidiasis, Chlamydia, Cystitis, Herpes simplex virus, Herpes virus 2, Pelvic infection, Trichomonas vaginalis, Trichomonas, Trichomoniasis , Urethritis, Urinary tract infection, Vaginitis, Vulva infection, Vulvovaginitis
Musculoskeletal/Orthopedic	Parkinson’s disease, Vaginismus, Vulval dystrophy
Neurologic	Parkinson’s disease, Peripheral neuropathies
Obstetric/Gynecologic	Atrophic vaginitis, Atrophic vulvitis, Atrophic vulvovaginitis, Autoimmune endometriosis , Autoimmune interstitial cystitis , Bartholin gland cyst, Bartholinitis, Chronic pain syndromes, Congenital absence of lower part of vagina, Endometrial conditions, Endometriosis, Episiotomy, Estrogen deficiency, Estrogen-based contraceptives, Female genital mutilation, Genital system cancer , Genital tract tumor, Genital ulcers, Gonorrhea, Gynaecological conditions , Gynecologic surgery, Healed perineal lacerations, Hemorrhoids, Imperforate hymen, Inflamed hymeneal orifice, Lactation, Myofascial pelvic pain syndrome, Narrow vagina, Obstetric perineal injury, Obstetric surgery, Ovarian tumour, Pelvic adhesions, Pelvic disorders, Pelvic infection, Pelvic inflammatory disease, Pelvic malignancy, Pelvic organ prolapse, Pelvic tumor, Perimenopause, Poor vaginal lubrication, Post-childbirth, Prolapsed tender ovaries with retroverted uterus, Provoked vulvar pain, Remnants of the hymen, Salpingo-oophoritis, Unruptured hymen, Vagina cancer, Vaginal abnormality, Vaginal dryness, Vaginal surgery, Vaginismus, Virilising ovarian tumour , Vulva infection, Vulval dystrophy, Vulval neoplasia, Vulvar vestibulitis syndrome , Vulvitis, Vulvodynia, Vulvovaginitis
Oncologic	Genital system cancer , Genital tract tumor, Ovarian tumour, Pelvic malignancy, Pelvic organ prolapse, Pelvic tumor, Prolactin secreting pituitary tumour, Prolactinoma, Uterine sarcoma , Uterine tumour, Vagina cancer, Virilising ovarian tumour , Vulval neoplasia, Yolk sack tumour
Psychiatric	Anxiety, Depression, Psychological disorders, Reduced libido, Relationship dysfunction
Renal/Electrolyte	Interstitial cystitis, Renal nutcracker syndrome
Rheumatology/Immunology/Allergy	Arthritis of the hips, Fibromyalgia, Kraurosis vulvae, Lichen planus, Menopause, Scleroderma, Sicca syndrome, Sjögren's syndrome
Sexual	Chlamydia, Estrogen-based contraceptives, Female genital mutilation, Genital ulcers, Gonorrhea, Herpes simplex virus, Herpes virus 2, Trichomonas vaginalis, Trichomonas, Trichomoniasis
Trauma	Allen-masters syndrome , Anal fissure, Cystitis, Trauma
Urologic	Interstitial cystitis, Peyronie's disease, Urethral caruncle, Urethritis, Urinary tract infection, Uterine sarcoma , Uterine tumour
Miscellaneous	Relationship dysfunction

Do's

• use of a water-based lubricant with intercourse
• Women with chronic dyspareunia who feel that the pain is having a significant impact on libido or psychosexual self-image should be referred for counseling
• Multimodal sex therapy, consisting of individual and couples therapy and other interventions such as cognitive–behavior techniques, is an important part of the multidisciplinary approach to these disorders.

Don'ts

• Avoiding soaps and chemical irritants to decrease vulvar or vestibular inflammation

References

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