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Sexual Health & Intimacy

Dyspareunia: A Systematic Approach to Diagnosis

Andrew E. Good, MD, MSc

A patient who complains of painful intercourse often requires extra time and effort from the physician. However, many causes of dyspareunia can be easily and quickly diagnosed using a slight variation in the normal pelvic examination that gives additional attention to certain anatomic areas. Thus, although the patient may be reluctant to discuss the problem, many of the causes "make sense" anatomically, so that a careful examination often reveals the diagnosis.

DIAGNOSIS

A "fractional pelvic examination" can quickly locate the source of the patient’s discomfort in many cases. It’s important to be disciplined when performing this variation of the gynecologic examination, because omitting steps or changing the order can lead to missed diagnoses or obscured clues. Another important reason for performing a fractional pelvic examination is that it increases potential patient discomfort in a step-wise manner, saving the least comfortable parts of the evaluation for last.

Step One. A good history is paramount, with emphasis on where the pain occurs, under what circumstances, and whether there were initiating factors (see Case History). As always, if physicians listen carefully, patients can often tell them what is wrong.

Step Two. The abdominal wall is palpated, first asking the patient to point out any areas of tenderness. These areas should be outlined, and even marked with a pen if desired. If there are tender spots, these could be from myofascial injury, or may be trigger points for pain referred from intra-abdominal disease.¹ The patient should then be asked to flex her abdominal wall muscles, either by having her raise her shoulders off the table or by lifting her legs, and the area of tenderness is palpated again when the muscles are flexed. If the spot is still painful, the injury is most probably in the muscle itself, and not intraperitoneal.

Step Three. The vulva must be inspected for rashes, lichen sclerosus, and other obvious lesions. The introitus should be examined gently, especially the area between Hart’s line and the hymen, looking for areas of erythema. This may be the first clue that the patient has vulvar vestibulitis.²

Then, using a small cotton swab, the surface of the vulva is touched lightly, concentrating on the vestibular area. If there is exquisite tenderness over the area of erythema, the diagnosis of vestibulitis is confirmed. Also, it is important to look specifically at the area of the Skene’s glands and the site where the Bartholin duct empties into the vestibule. A urethral caruncle will be obvious here, but this is an unusual cause of dyspareunia. The physician should be alert to point tenderness in episiotomy scars, which is a sign of neuroma.

Step Four. The vaginal opening is then palpated, paying particular attention to the bulbocavernosus (ischiocavernosus) muscle. Spasm or pain in this muscular bandæthe "guard" of the vaginaæis vaginismus, which is easily treated. The usual finding is tightness and pain localized to this muscle. When palpating this area, the physician should try to avoid touching the vestibule, especially if vestibulitis is present. Vaginismus can occur secondary to primary vestibulitis, so both should be investigated. Crooking the forefinger as it is introduced into the vagina can help to avoid touching the vestibule.

Step Five. A one-finger pelvic examination is performed, without the second hand on the abdomen. First, the pelvic floor lateral to the sacrum is palpated bilaterally. Spasm in the muscles of the pelvis is a common and often overlooked cause of dyspareunia. Tenderness and tightness in the pelvic floor muscles signal this condition, known as pelvic floor tension myalgia or coccygodynia. Sometimes, massaging these muscles will produce a spasm (like a charley horse), and will elicit the typical symptoms of pelvic floor tension myalgia (ie, a deep aching, often exacerbated by sitting for long periods).
After palpating the pelvic floor, the finger should be rotated and used to examine and "milk" the urethra. Point tenderness along the urethra could signal the presence of a urethral diverticulum, an infrequent but classic cause of dyspareunia.

At this point, the abdominal hand can be used to push the pelvic organs to the examining finger (or fingers, as a second finger can be inserted at this point). It is helpful to use light abdominal pressure initially, so that pain from abdominal wall structures does not confuse the findings. The pelvic structures should be palpated, remembering to feel the bladder separately from the underlying uterus.
Step Six. A rectovaginal examination should be performed with particular attention to the uterosacral ligaments, feeling for the scarring or nodularity that can signal endometriosis. If the patient has had prior incontinence surgery, the physician should feel for the sling or tape, either of which can be the source of dyspareunia.

Step Seven. Now the speculum examination can be performed, with cultures and wet smears obtained if appropriate. The vaginal mucosa should be examined for atrophic changes or monilial infection, two common causes of dyspareunia. By waiting until the last step to introduce the speculum, the largest of the examining tools, the effects of pressure on painful areas are increased in a step-wise fashion, reserving the potentially most uncomfortable parts until last.

It is important to remember that adhering to this order and not eliminating any steps maximizes the opportunity to find some of the most common causes of dyspareunia. Because the emphasis of the examination is on anatomic (ie, treatable) factors, the possibility of providing relief is increased.

DIFFERENTIAL DIAGNOSIS

Following is a list of various causes of dyspareunia. It is helpful to think of these based on the frequency of appearance. This ordering is not precise, but is based on the author’s impression of how frequently a condition is encountered. Common causes include endometriosis/adenomyosis, myofascial pain of the abdominal wall, pelvic floor tension myalgia, pelvic inflammatory disease (PID), psychosocial factors, vaginismus, and vaginitis. Less common conditions include episiotomy pain, pelvic adhesions, and vulvar vestibulitis. Rare possibilities are lichen planus, lichen sclerosus (a common finding but uncommon cause of dyspareunia), neuroma, ovarian remnant syndrome, pudendal nerve neuralgia, and urethral diverticulum. Other causes may be bladder disease (interstitial cystitis) or bowel disease.

TREATMENT

Common Causes

Endometriosis should always be considered in patients with dyspareunia. A recent study of the incidence of endometriosis in Olmsted County, Minnesota found that 33% of women diagnosed with endometriosis had dyspareunia.³ This is in contrast to the 50% incidence of pelvic pain in the same population. There is some debate as to whether endometriosis should be visualized to confirm diagnosis or medical therapy should be initiated empirically.⁴ This author’s bias is toward visualization/pathologic confirmation. In either case, treatment with oral contraceptives, medroxyprogesterone acetate, leuprolide, or surgical removal will depend on age, parity, and degree of disability.

Adenomyosis is suggested by the presence of a painful, symmetrically enlarged uterus, usually in a multiparous woman. Ultrasonography or magnetic resonance imaging (MRI) visualization of the uterus can confirm the clinical suspicion. Hysterectomy is curative for appropriate patients.

Myofascial abdominal wall pain is diagnosed by careful palpation of the abdominal wall to look for maneuvers that exacerbate the pain. Treatment consists of injections into the trigger points and appropriate physical therapy. Consultation with a physiatrist or physical therapist may be helpful in these cases.

Pelvic floor tension myalgia (coccygodynia) is caused by involuntary spasm of the pelvic floor musculature. Inciting factors can be any previous pelvic surgery, trauma to the perineum, or childbirth. Diagnosis is made by a history typical of the condition and physical examination. The usual symptoms are dyspareunia and aching pain with fullness and pressure in the pelvis. This pain is made worse by coitus, sitting for extended periods, and (occasionally) bowel movements. The discomfort is improved by heat to the pelvis (hot baths or heating pads) and lying down with the hips flexed. In the author’s institution, treatment consists of a series of physical therapy sessionsætypically twice a day for 5 days. The patient is taught to relax the muscles (essentially with reverse Kegel exercises) using biofeedback, stretching, and deep heat with ultrasound. Often, a horseshoe-shaped pillow can be employed while seated to take pressure off the perineal muscles. Partial or complete improvement is achieved in about 70% of patients.⁵

Pelvic inflammatory disease can be present without an obvious acute episode. Diagnosis can be elusive, but a history of acute PID, infertility, or pain that increases at the time of menses are diagnostic clues. Treatment with antibiotics can be attempted, and if unsuccessful, hysterectomy may be appropriate.
Psychosocial causes, although listed last, are important factors in dyspareunia. These can be subdivided into arousal disorders, sexual abuse, vaginismus, and vaginitis.

In the context of arousal disorders, lubrication in the woman is analogous to erection in men. However, women sometimes engage in sexual intercourse without adequate arousal and lubrication. This can be secondary to fatigue (the working mother with young children and a domestically impaired mate), inadequate foreplay (a sexually naïve, ignorant, or insensitive partner), or relationship problems (the husband who now looks similar to the armchair he constantly inhabits).

Treatment consists of giving the patient "permission" to become more selfish, allowing her to take time for herself to exercise, read, or simply be in a room by herself. Also, the couple should strive to "eroticize" their life with more snuggling, time by themselves, and perhaps reading or viewing erotic materials. It is often helpful to suggest one of the books on sexuality that is available at most bookstores. It may be necessary to remind the male partner of his obligation to be clean, companionable, and attentive. Additionally, the use of a water-based lubricant such as Astroglide or K-Y Personal Lubricant Liquid may be helpful.

Sexual abuse, either past or current, can also lead to dyspareunia. Some studies indicate that up to 10% of women have suffered some form of abuse. Questions in this area should be posed tactfully, perhaps in a hypothetical or third-person context. An example would be, "Some women have pain with intercourse because of unpleasant experiences in the past. Do you know of anyone this has happened to? Has that kind of thing ever happened to you?" Abuse should always be considered in patients with dyspareunia, but should be approached only after physical causes have been ruled out. Counseling with a psychiatrist or psychologist may be necessary to overcome the potentially devastating effects of abuse.

Vaginismus is easily diagnosed by the presence of pain and tightness in the bulbocavernosus muscle. Palpation of the muscle will reproduce the spasm. Typically, dyspareunia will be on initial penetration and will improve somewhat as intercourse proceeds. In mild cases, simply waiting for the muscle to relax after penetration, before thrusting begins, may alleviate the problem. More commonly, treatment with graduated dilators is necessary. The patient is given a set of dilators of increasing diameters. These can be made from Lucite or, if those are unavailable, syringe covers of increasing sizes can be used. Using adequate lubrication, such as Astroglide or lubricating jelly, the dilator is inserted into the vagina deeply enough to pass over the bulbocavernosus, and is left in place for 15 minutes. This should be done three times a week for 2 weeks. Dilators of increasing diameter should be used sequentially until the largest size (approximately equal to the cover of a 50-mL syringe) can be accommodated without much discomfort. Use of a dilator or manual massage during foreplay may be necessary to make penetration more comfortable. Masters and Johnson reported success in 100% of their patients using a similar method.⁶

Vaginitis, either monilial or atrophic, is a surprisingly common cause of dyspareunia. The typical symptom is that of burning, especially after coitus. The patient with a yeast infection will describe the sensation as having "sandpaper" in the vagina. Diagnosis is usually made with wet-mount microscopic examination of secretions/discharge. Yeast infection is characterized by the presence of pseudohyphae. Atrophic vaginitis is diagnosed when the pH of the discharge is higher than 6 and there are numerous parabasal and white cells present.

Uncommon Causes

Pelvic adhesions are an uncommon cause of dyspareunia. Suspicion should be raised when the pain is only with movement (not palpation) of the uterus or the adnexa. This may be present in a woman with a history suggesting adhesion formation, such as PID or prior surgery. Diagnosis and treatment with laparoscopy is appropriate. It must be remembered that adhesions usually do not cause dyspareunia, and their presence and lysis may not treat the condition.

Episiotomy scars can be a source of pain during intercourse, especially with initial penetration. Close inspection of the scar to look for one small area of tenderness is important. That localized area could be a small neuroma, characterized by intense point tenderness. If the tenderness is relieved with injection of a small amount of local anesthetic, then the area can be removed with minor surgery. Occasionally, a horizontal band of scar tissue is created from an overzealous repair of the episiotomy. This "dashboard" effect can be a distressing source of dyspareunia. Revision of the band is necessary to repair this. Proactive attention during the initial episiotomy repair is obviously preferable.

Lichen sclerosus is a common finding, but is usually not a cause of dyspareunia. Treatment with clobetasol, 0.05%, should improve the discomfort by thinning the epithelium and making it more pliable.⁷

Ovarian remnant syndrome occurs when a small piece of ovarian tissue remains after oophorectomy. These remnants can form cysts and cause pain from pressure effects. Diagnosis can be elusive, but dyspareunia is a common symptom. The patient may have measurable levels of estradiol, especially after clomiphene citrate stimulation. Poststimulation MRI can sometimes locate the tissue. Treatment consists of careful removal of all of the parametrial tissues on the effected side.⁸

Pudendal nerve entrapment is a controversial cause of dyspareunia. The patient has symptoms of pain in the distribution of the pudendal nerve. Neurologic testing involves pin prick, light touch, and looking for the anal "wink."⁹ The diagnosis is more probable if a pudendal block relieves the pain. Some authors suggest surgery to free the pudendal nerve from Alcock’s canal, while others recommend such agents as amitriptyline or gabapentin.

Vulvar vestibulitis is characterized by erythema and pain on light touch in the vestibular area of
the vulva between Hart’s line and the hymen. The pain is present only with touch, which can include attempted intercourse, tampon insertion, or tight clothing. It is not present otherwise. Treatments include surgical removal of the surface layers of vestibular skin (vestibulectomy), antidepressants, or a hypoallergenic regimen.¹⁰ Recent analysis of the surgical treatment for vestibulitis at the author’s institution found a 90% cure rate, with the majority (84%) having no residual pain or recurrence.¹¹ Intercourse can be resumed 6 weeks postsurgery, a significant advantage over either the hypo-allergenic or antidepressant routines, which take 6 months or longer to have any effect.

Rare Conditions

Lichen planus is characterized by a "beefy" redness of the vaginal mucosa accompanied by a purulent, irritating discharge. It may also be found with skin and oral manifestations. There is progressive scarring of the vaginal tissues, in some cases causing the caliber of the vagina to become so small only a cotton swab can be admitted. The etiology is unknown, and treatment is seldom helpful. Intercourse is impossible in most cases. The use of high-potency steroids like clobetasol or fluocinonide gel intravaginally along with dilator therapy has been advocated. The use of metronidazole¹² and hydroxychloroquine has also been tried with varying success.¹³

Neuromas can form in any scar tissue, including episiotomies and in the vaginal cuff. In the latter case, the patient will complain of discomfort with intercourse and there will be localized tenderness to touch. Diagnosis and treatment can be achieved by local injection with a long-acting local anesthetic. If this persists, then surgical revision of the vaginal cuff can be performed.

Urethral diverticula are characterized by localized tenderness when the urethral length is palpated. Sometimes pus can be milked from the urethral orifice, helping to confirm the diagnosis. Definitive diagnosis is achieved with cystoscopy and, less frequently, dye studies of the urethra. Surgical correction with a layered closure will relieve the dyspareunia.¹⁴

Other Causes

Chronic trigonitis, frequent urinary tract infections, or interstitial cystitis can cause bladder pain. Even more rarely, malignancy in the bladder can cause dyspareunia. Diagnosis is made through urine cultures and cystoscopy. The treatment of interstitial cystitis is sometimes difficult, with much frustration on the part of both patient and physician. Pentosan polysulfate sodium seems to provide as much relief as bladder instillations.

Bowel disease, especially the inflammatory diseases, can be associated with dyspareunia. Diagnosis is usually obvious, suggested by the bowel symptoms.

CONCLUSION

Dyspareunia is a common complaint, and often has a defined anatomic cause. Diagnosis should be approached with a detailed history of onset and location. Physical evaluation should be performed using the fractional pelvic examination, which allows for a systematic approach to the anatomy and starts with the least painful inspections first to prevent masking of symptoms. Treatment is directed toward the specific cause of dyspareunia with psychological referral, if necessary.

Andrew E. Good, MD, MSc, is chief, Division of Medical Gynecology, Department of Obstetrics and Gynecology, Mayo Clinic College of Medicine, Rochester, Minn.

References

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2. Friedrich E. Vulvar vestibulitis syndrome. J Reprod Med. 1987;32(2): 110-114.
3. Leibson C, Good A, Hass S, et al. Is endometriosis overdiagnosed? Incidence rates from a geographically-defined population. Fertil Steril. (In press.)
4. Jacobs S. Using GnRH agonists to diagnose endometriosis in chronic pelvic pain patients. Contemp OB/GYN. 1996;41:78-84.
5. Sinaki M, Merritt JL, Stillwell GK. Tension myalgia of the pelvic floor. Mayo Clinic Proc. 1977;52(11):717-722.
6. Masters, W, Johnson V. Human Sexual Inadequacy. Boston, Mass: Little, Brown & Co; 1970:262-263.
7. Dalziel K, Wojnarowska F. Long-term control of vulval lichen sclerosus after treatment with a potent topical steroid cream. J Reprod Med. 1993;38(1):25-27.
8. Pettit P, Lee R, Ovarian remnant syndrome: diagnostic dilemma and surgical challenge. Obstet Gynecol. 1988; 71(4):580-583.
9. Turner ML, Marinoff SC. Pudendal neuralgia. Am J Obstet Gynecol. 1991;165(4 Pt 2):1233-1235.
10. Fowler S. Vulvar vestibulitis: response to hypocontactant vulvar therapy. J Lower Gen Tract Dis. 2000;4(4):200-203.
11. Gaunt G, Good A, Stanhope CR. Vestibulectomy for vulvar vestibulitis. J Reprod Med. 2003;48(8):591-595.
12. Buyuk AY, Kavala M. Oral metronidazole treatment of lichen planus. J Am Acad Dermatol. 2000:43(2 Pt 1);260-262.
13. Eisen D. The vulvovaginal-gingival syndrome of lichen planus. Arch Dermatol. 1994;130(11):1379-1382.
14. Wheeless CR. Suburethral diverticulectomy. In: Atlas of Pelvic Surgery. Malvern, Pa: Lea & Febiger; 1988: 120-121.

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