Bradley C. Gill, MD, MS
Sandip P. Vasavada, MD, FACS
BASICS
DESCRIPTION
• Dyspareunia is defined as pain associated with sexual intercourse.
– Most often used in associated with female sexual dysfunction and is the focus of this section.
• Present since 1st (primary) intercourse or acquired (secondary) thereafter.
• Etiologies can be physiologic and/or psychological.
EPIDEMIOLOGY
Incidence
Lacking disclosure to clinicians and treatment pursuit suggests underestimation
Prevalence
Up to a 60% prevalence in women, but varies widely by sample and definition
RISK FACTORS
• Menopause (physiologic or iatrogenic)
• Physical trauma (physiologic or iatrogenic)
• Psychological trauma (supporting evidence is mixed)
• Tissue irritation (infection, inflammation, malignancy, etc.)
• Urogenital anatomy (congenital)
Genetics
Early menopause should be considered
PATHOPHYSIOLOGY
• Pain results from irritation or trauma to the female reproductive tissues.
• Can be entrance, vaginal, or deep-thrust dyspareunia per the etiology.
ASSOCIATED CONDITIONS
• Vaginal atrophy
• Urogenital malformations
• Posttraumatic stress disorder (prior physical or psychological trauma)
• Pelvic inflammatory disease
• Endometriosis
GENERAL PREVENTION
• Maintenance of vaginal mucosal integrity
• Good hygiene and health maintenance
DIAGNOSIS
HISTORY
• Description of pain
– Specific localization: Superficial, deep, anterior, posterior
– Timing and duration: When starting, throughout, after finishing
– Consistency with intercourse: Occasional; sometimes, always
– Character: Burning, sharp, aching, throbbing
– Associations: Discharge, bleeding, urinary symptoms, bowel symptoms
• Factors altering the pain
– Positioning, specific maneuvers, location
– Use of lubricants, condoms, sex toys, hygiene products
– Specific partners or partner-related factors
– Timing of menstrual cycle
– Bowel or bladder habits
• Urogenital conditions
– Sexually transmitted or urinary tract infections
– Complicated pregnancies
– Endometriosis
– Uterine fibroids
– Inflammatory bowel disease
• Urogenital interventions
– Surgery or radiation
– Injections or topical therapy
• Urogenital trauma
– Vaginal childbirth injuries
– Difficult or forced intercourse
• Systemic conditions
– Menopause (physiologic or iatrogenic)
– Pain disorders or fibromyalgia
– Cancer
– Other chronic diseases
• Current or prior abuse
– Sexual abuse
– Verbal or physical abuse
PHYSICAL EXAM
• Visual inspection of external genitalia
– Distribution of pubic hair
– Diffuse vulvo-vestibulitis
– Ulcerations, pustules, discharge, or bleeding
– Inflamed Bartholin or Skene glands
– Prolapsed urethra, vagina, or cervix
– Skin or mucosal lesions suspicious for cancer
• Speculum exam
– Diffuse vaginitis or cervicitis
– Mucosal rugae, moisture, thinning, or excoriation
– Ulcerations, pustules, discharge, or bleeding
– Cystocele, rectocele, or enterocele
– Vaginal wall masses
– Mucosal lesions suspicious for cancer
• Diagnostic sampling with cervical surface scrapings, brushings, and culture swabs
– Ulcerations, pustules, or discharge
– Masses, skin changes, mucosal changes, bleeding
• Palpation of external genitalia, vaginal sidewalls, pelvic floor muscles, cervix, and ovaries
– Bartholin or Skene gland tenderness
– Urethral or vaginal sidewall mass
– Surgically placed foreign bodies
– Pelvic floor muscle tension, spasm, or tenderness
– Cervical motion, ovarian, or adnexal tenderness
– Vaginal cul-de-sac mass or tenderness
DIAGNOSTIC TESTS & INTERPRETATION
Lab
• Urinalysis and urine culture to screen for infection or cystitis
• Endocervical swabs for gonorrhea, chlamydia, or bacterial vaginosis
• Cervical scrapings or brushings for malignancy and human papilloma virus
• Vaginal pH, wet mount, or whiff test for bacterial or fungal infection
Imaging
• Transvaginal ultrasound for reproductive organ or pelvic masses
• Transabdominal ultrasound for abdominal masses
• Pelvic magnetic resonance imaging for urethral diverticula or pelvic masses
Diagnostic Procedures/Surgery
• Cystourethroscopy for cystitis, urethritis, urethral diverticula
• Double balloon urethrography for urethral diverticula
• Colposcopy for human papilloma virus or uterocervical malignancies
• Colonoscopy for inflammatory bowel disease or colorectal malignancy
• Diagnostic laparoscopy for endometriosis or pelvic masses
DIFFERENTIAL DIAGNOSIS
• Congenital
– Vaginal agenesis, vaginal malformation, imperforate hymen, rigid hymen, retroverted uterus
• Gynecologic
– Structural: Hymenal remnant, introital or vaginal stenosis, prolapse, childbirth, adhesions
– Cellular: Vaginal atrophy, lichen sclerosis, vulvar hyperplasia, cancer
– Infectious: Sexually transmitted, viral, bacterial vaginosis, fungal, pelvic inflammatory disease
– Allergic: Contraceptive device, condom, latex, semen, hygiene product, sex toy
– Reproductive: Endometriosis, fibroids, ectopic pregnancy, adnexal cyst, ovarian cyst
– Iatrogenic: Implanted mesh erosion, exposed suture, postoperative fistula
• Urologic
– Urethral prolapse, urethral caruncle, urethral diverticulum, urethral cancer, urethritis, cystitis
• Colorectal
– Inflammatory bowel disease, abscess, hemorrhoids, constipation, rectal cancer
• Musculoskelet al
– Vaginismus, pelvic floor muscle spasm, trauma, chronic pain disorder, fibromyalgia
• Psychological
– Posttraumatic stress disorder, sexual aversion disorder, genital sexual arousal disorder
TREATMENT
GENERAL MEASURES
• Behavioral (1,2)
– Identify and eliminate any allergy-related hygienic or sexual practices
– Encourage using water-based lubrication or hypoallergenic products
– Utilize infection prophylaxis like postcoital voiding when appropriate for UTI issues
– Psychological counseling, couples therapy, or relaxation exercises as indicated
• Careful consideration of replacing condoms or other barrier devices with another contraceptive
MEDICATION
First Line
• Ospemifene is an estrogen agonist/antagonist indicated for the treatment of moderate to severe dyspareunia, a symptom of vulvar and vaginal atrophy, due to menopause
– 1 tablet (60 mg) taken orally once daily with food
– Do not use estrogens or estrogen agonist/antagonist or fluconazole concomitantly
• Appropriate dose and duration of antibiotics or antifungals for infection
• Topical estrogen for atrophy considering benefits over systemic forms
• Topical corticosteroids for vulvar hyperplasia or testosterone for lichen sclerosis
Second Line
N/A
SURGERY/OTHER PROCEDURES
• Laparoscopic endometriosis excision or ablation
• Laparoscopic lysis of adhesions if indicated
• Laparoscopic sacral colpopexy for problematic retroverted uterus
• Urethral diverticulectomy if indicated
• Excision of implanted mesh, eroded sutures, or other foreign body
• Trigger point injections for muscle spasm
ADDITIONAL TREATMENT
Radiation Therapy
N/A
Additional Therapies
• Daily passive dilation with progressive vaginal dilators for stenosis
• Use of pessary for problematic retroverted uterus
• Pelvic floor physiotherapy or biofeedback for muscle spasms
• Ultrasound or electrical stimulation for persistent muscle spasm
• Tibolone (synthetic steroid) is commonly used in Europe in postmenopausal women with desire and arousal disorders
Complementary & Alternative Therapies
• Education, sex therapy, psychotherapy, and cognitive behavioral therapy are also important in the multidisciplinary management of sexual dysfunction including those with a history of sexual abuse.
• Currently there are limited studies on the effectiveness of herbal remedies to aid female sexual dysfunction in general.
ONGOING CARE
PROGNOSIS
• Results vary with etiology and treatment of many is long term
• Multimodal approach to any etiology should be most beneficial
FOLLOW-UP
Patient Monitoring
• Frequent follow-up with initiation of new behavioral or medical therapies is best
• Upon resolution and improved patient satisfaction follow-up may be spaced out
REFERENCES
1. Dhingra C, Kellogg-Spadt S, McKinney TB. Urogynecological causes of pain and the effect of pain on sexual function in women. Female Pelvic Med Reconst Surg. 2012;18(5):259–267.
2. Fugl-Meyer KS, Bohm-Starke N, Damsted Petersen C. Standard operating procedures for female genital sexual pain. J Sex Med. 2013;10(1):83–93.
ADDITIONAL READING
• Frenkl TL, Potts JM. Sexually transmitted infections. In: Wein A, Kavoussi LR, Novick AC, Partin AW, Peters CA, eds, Campbell-Walsh Urology. 10th ed. Philadelphia, PA: Elsevier/Saunders; 2012. Chapter 13. pp. 402–416.
• Moore CK. Female sexual function and dysfunction. In: Wein A, Kavoussi LR, Novick AC, Partin AW, Peters CA, eds, Campbell-Walsh Urology. 10th ed. Philadelphia, PA: Elsevier/Saunders; 2012. Chapter 30. pp. 823–833.
• Rovner ES. Bladder and female urethral diverticula. In: Wein A, Kavoussi LR, Novick AC, Partin AW, Peters CA, eds, Campbell-Walsh Urology. 10th ed. Philadelphia, PA: Elsevier/Saunders; 2012. Chapter 78. pp. 2262–2289.
See Also (Topic, Algorithm, Media)
• Dysorgasmia
• Dyspareunia Algorithm 
• Dyspareunia, Male
• Sexual Dysfunction, Female
• Urinary Tract Infections
• Urogenital Prolapse
• Urethra, Diverticulum, Female (Urethral Diverticulum)
• Vaginal Atrophy, Urologic Considerations
CODES
ICD9
• 302.76 Dyspareunia, psychogenic
• 625.0 Dyspareunia
• 627.3 Postmenopausal atrophic vaginitis
ICD10
• F52.6 Dyspareunia not due to a substance or known physiol cond
• N94.1 Dyspareunia
• N95.2 Postmenopausal atrophic vaginitis
CLINICAL/SURGICAL PEARLS
• Do not discount behavioral interventions.
• Topical estrogen can work wonders.
• Changing the hygiene routine can help.