Approach to Dyspareunia

Key points:

- Painful intercourse is a source of considerable distress both physically and psychologically for the sufferer and also for her partner.

- Some authors claim that most cases (80%) of dyspareunia have a physical cause and careful physical examination is mandatory


- History is the key

- Causes of dyspareunia

• Pain worse on insertion 
• physiological inadequate lubrication
• Vaginitis in chronic candidiasis
• Vulvar dermatoses 
• Postnatal perineal scarring 
• Incompletely ruptured hymen 
• Vulvar vestibular sydrome (vestibulitis): well defined entry pain, painful inflammation of vulvar vestibular area, dull ache, burning or pruritus. Tenderness on touch of cotton tipped applicator
• Vulvovaginal atrophy 
• Vaginismus: well defined entry, involuntary spasm of muscles, difficulty of insertion of penis, tampons or digit. Palpable spasm and difficult inserting speculum. 
• Pain worse on deep penetration 
• Endometriosis: Deep pain; cyclic pain with menses, complained of something being bumped into. Enlarged adnexa and tender to touch. 
• PID
• Pelvic adhesions
• Ovarian and uterine tumours
• Postnatal

- Questions to ask

• Where is the located?
• When is the onset of the pain ? (before, entry, vaginal, deep or after)
• Is it pruritic, burning or aching in quality?
• What is the chronologic history? If multiple pain sites, which came first?
• Is it situational or positional ?
• Has it been lifelong or acquired?
• Are there other sexual dysfunctions such as arousal, lubrication or orgasmic difficulties ?
• What treatments have been attempted?
• Explore potential gynecologic causes
• Are there vaginal symptoms including discharge, burning or itching?
• Does patient have a history of STDs, especially HSV or HPV?
• Is there an obstetric delivery history of lacerations, episiotomies or other trauma?
• Is there an obstetric delivery history of lacerations, episiotomies or other trauma?
• Is there an abdominal of genitourinary surgical or radiation history?
• Has the patient had prior pgynecologic diagnoses, including endometriosis, fibroids or chronic pelvic pain?
• What is the patient's current contraception method and its here any history of intrauterine device use?

References:

aafp : http://www.aafp.org/afp/2001/0415/p1535.html

John murtagh 8th edition