Dyspareunia is the feeling of pain on, or shortly after sexual intercourse. It can be superficial (around the introitus) or felt deep inside. It affects approximately 10% of women to varying degrees and can have a medical cause, although often the cause is psychological. It is important that this is a diagnosis of exclusion though, and a psychological component is almost invariably present even if the cause if organic.

 

Men can also experience dyspareunia (due to infection, skin disorders, Peyronie's disease, post-ejaculatory pain syndrome), although this is less common.

History

  • Nature of pain - deep or superficial?
  • Timing of pain
  • Gynaecological history
  • Obstetric history, including whether breastfeeding
  • Sexual history, including any history of sexual abuse
  • Other symptoms e.g. fever, bowel symptoms, urinary symptoms
  • Psychological - important to explore possible psychogenic causes, in addition to the patient's reaction to the pain

 

Examination

Abdominal examination - looking for areas of tenderness or any masses

 

PV examination- carefully inspect vulva and vagina for any skin changes, signs of trauma, prolapse, masses etc and pinpoint any tenderness. Take note of any vaginal discharge, including its characteristics.

Assess for cervical excitation, uterine mobility and adnexal tenderness. 

Tenderness on posterior palpation of the rectum may indicate IBS/IBD.

Causes

Investigations

  • Swabs, to rule out infection
  • MSU, if history indicative of UTI
  • Laparoscopy may be indicated to rule out certain causes of deep dyspareunia

 

Management

  • Infection: treat appropriately with antibiotics (trichomonas, gardenella, chlamydia), antifungals (candida) or acyclovir (HSV)
  • Vulval skin changes: biopsy and treat accordingly 
  • Bartholin's abscess: antibiotics +/- incision and drainage
  • Atrophic vaginitis: topical oestrogen cream, HRT, vaginal lubricants
  • Vaginismus: digital exploration and gradual dilatation, vaginal lubricants, referral for psychosexual counselling as necessary
  • Deep: organic causes should be treated accordingly; if no pelvic pathology found, treat as chronic pain and consider psychotherapy

 

Further Information

Women approaching menopause, and those who are sexually inexperienced are most at risk of experiencing dyspareunia. Bromocriptine (a dopamine agonist) may cause painful clitoral tumescence and so enquiries should be made as to it's use.

 

For best outcome, and especially important where there is a strong psychological component to the dyspareunia (either cause or reaction), the problem should be approached as a couple in much the same way as erectile dysfunction

 

See Institute of Psychosexual Medicine for more information.

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