Doctor123.org

Dyspareunia

- Disorders of vagina - Abnormality of vault owing to surgery or radiation - Congenital malformations - Inadequate lubrication - Infections - Inflammatory or allergic response to foreign substance - Masses or tumors - Pelvic relaxation resulting in rectocele, uterine prolapse, or cystocele

- Disorders of pelvic structures - Endometriosis - Levator ani myalgia/spasm - Malignant or benign tumors of the uterus - Ovarian pathology - Pelvic adhesions - Pelvic inflammatory disease (PID) - Pelvic venous congestion - Prior pelvic fracture - Uterine fibroids

- Disorders of the urinary tract - Interstitial cystitis - Ureteral or vesical lesions - Urethritis

- Male - Cancer of penis - Genital muscle spasm - Infection or irritation of penile skin - Infection of seminal vesicles - Lichen sclerosus - Musculoskeletal disorders of pelvis and lower back - Penile anatomy disorders - Phimosis - Prostate infections and enlargement - Testicular disease - Torsion of spermatic cord - Urethritis

- Identify pain characteristics - Onset - Duration - Location: entry versus deep, single versus multiple sites; positional - Intensity/quality: varying degrees of pelvic/genital pressure, aching, tearing, and/or burning - Pattern (precipitating or aggravating factors): when pain occurs (at entry, during, or after intercourse) - Relief measures: Avoid intercourse, change positions, and have intercourse only at certain times of the month.

- Couple behavioral therapy - Indicated to help resolve interpersonal problems - May involve short-term structured intervention or sexual counseling - Designed to desensitize systemically uncomfortable sexual responses and intercourse through a series of interventions over a period of weeks - Interventions range from muscle relaxation and mutual body massage to sexual fantasies and erotic massage.

para>Incidence increases dramatically in postmenopausal women primarily because of vaginal atrophy.

Prevalence

  • Most sexually active women will experience dyspareunia at some time in their lives.~15% (4-40%) of adult women will have dyspareunia on a few occasions during a year.~1-2% of women will have painful intercourse on a more-than-occasional basis.Male prevalence is ~1%.

ETIOLOGY AND PATHOPHYSIOLOGY

  • Disorders of vaginal outletAdhesionsCondylomaClitoral irritationEpisiotomy scarsFissuresHymeneal ring abnormalitiesInadequate lubricationInfectionsLichen planusLichen sclerosusPostmenopausal atrophyPsoriasisTraumaVulvar papillomatosisVulvar vestibulitis/vulvodynia
  • Disorders of vaginaAbnormality of vault owing to surgery or radiationCongenital malformationsInadequate lubricationInfectionsInflammatory or allergic response to foreign substanceMasses or tumorsPelvic relaxation resulting in rectocele, uterine prolapse, or cystocele
  • Disorders of pelvic structuresEndometriosisLevator ani myalgia/spasmMalignant or benign tumors of the uterusOvarian pathologyPelvic adhesionsPelvic inflammatory disease (PID)Pelvic venous congestionPrior pelvic fractureUterine fibroids
  • Disorders of the GI tractConstipationCrohn diseaseDiverticular diseaseFistulasHemorrhoidsInflammatory bowel disease
  • Disorders of the urinary tractInterstitial cystitisUreteral or vesical lesionsUrethritis
  • Chronic diseaseBeh §et syndromeDiabetesSj ¶gren syndrome
  • MaleCancer of penisGenital muscle spasmInfection or irritation of penile skinInfection of seminal vesiclesLichen sclerosusMusculoskeletal disorders of pelvis and lower backPenile anatomy disordersPhimosisProstate infections and enlargementTesticular diseaseTorsion of spermatic cordUrethritis
  • Psychological disordersAnxietyConversion reactionsDepressionFearHostility toward partnerPhobic reactionsPsychological trauma

RISK FACTORS

  • Fatigue
  • Stress
  • Depression
  • Diabetes
  • Estrogen deficiency
  • Previous PID
  • Vaginal surgery
  • Alcohol/marijuana consumption
  • Medication side effects (antihistamines, tamoxifen, bromocriptine, low-estrogen oral contraceptives, SSRIs, depo-medroxyprogesterone, desipramine)

Pregnancy Considerations

Pregnancy is a potent influence on sexuality; dyspareunia is common. Women who experience delivery interventions including episiotomy are at greater risk than women who deliver over an intact perineum or have an unsutured tear.

COMMONLY ASSOCIATED CONDITIONS

Vaginismus

Pregnancy Considerations

Episiotomies do not have a protective effect (1)[A].

DIAGNOSIS

HISTORY

  • Identify pain characteristicsOnsetDurationLocation: entry versus deep, single versus multiple sites; positionalIntensity/quality: varying degrees of pelvic/genital pressure, aching, tearing, and/or burningPattern (precipitating or aggravating factors): when pain occurs (at entry, during, or after intercourse)Relief measures: Avoid intercourse, change positions, and have intercourse only at certain times of the month.
  • Include menstrual, obstetric, reproductive, sexual, domestic violence, and rape histories with medical, surgical, and psychosocial history

PHYSICAL EXAM

  • A complete exam, including a focused pelvic exam, to identify pathology and provide patient education.
  • Because examination often reproduces the pain, examiner should be cautious and sensitive to patient's anxiety. Exam must include inspection and palpation of vulva and vaginal areas, palpation of the uterine and adnexal structures, and a rectovaginal exam. Sensory mapping with a cotton-tipped applicator to identify sensitive and painful areas.
  • Inspect and palpate urethra and base of the bladder.

DIFFERENTIAL DIAGNOSIS

Vaginismus

DIAGNOSTIC TESTS & INTERPRETATION

Initial Tests (lab, imaging)

Based on history and exam findings

  • Wet mount
  • Gonorrhea and chlamydia cultures
  • Herpes culture
  • Urinalysis and urine culture
  • Pap smear

Follow-Up Tests & Special Considerations

  • Serum estradiol if vulvodynia or atrophic vaginitis
  • Voiding cystourethrogram if urinary tract involvement
  • GI contrast studies if GI symptoms
  • Ultrasound and CT scan are of limited value; perform if clinically indicated.

Diagnostic Procedures/Other

Based on history and exam findings

  • Colposcopy and biopsy if vaginal/vulvar lesions
  • Laparoscopy if complex deep-penetration pain
  • Cystoscopy if urinary tract involvement
  • Endoscopy if GI involvement

Test Interpretation

Depends on etiology

TREATMENT

  • Potential relationships exists between primary dyspareunia and vaginismus, low libido, and arousal disorders.
  • Endocrine factors, such as primary amenorrhea, might reduce the biologic basis of sexual response.
  • If pain prevents penetration, severe vaginismus may be present.

GENERAL MEASURES

  • Educate the patient and partner regarding the nature of the problem. Reassure both that there are solutions to the problem.
  • Initiate specific treatment when initial evaluation identifies an organic cause.
  • Once organic causes are ruled out, treatment is a multidimensional and multidisciplinary approach (2)[C].Individual behavioral therapyIndicated to help the patient deal with intrapersonal issues and assess the role of the partnerCouple behavioral therapyIndicated to help resolve interpersonal problemsMay involve short-term structured intervention or sexual counselingDesigned to desensitize systemically uncomfortable sexual responses and intercourse through a series of interventions over a period of weeksInterventions range from muscle relaxation and mutual body massage to sexual fantasies and erotic massage.

MEDICATION

First Line

Depends on the etiology

  • Antibiotics, antifungals, or antivirals, as indicated, for infection
  • Vaginal moisturizers and lubricants for dryness
  • Analgesics and topical anesthetics for pain
  • Topical estrogen for vaginal and vulvar atrophy
  • Neuropathic pain associated with vulvar vestibulitis/vulvodynia may respond to tricyclic antidepressants (amitriptyline or nortriptyline) or gabapentin.

Second Line

Ospemifene for moderate to severe symptoms due to menopause-related vulvar and vaginal atrophy (3)[B]

ISSUES FOR REFERRAL

Referral for long-term therapy may be necessary.

ADDITIONAL THERAPIES

Physical therapy for pelvic floor muscle pain

SURGERY/OTHER PROCEDURES

  • Laparoscopic excision of endometriotic lesions has shown benefit (4)[C].
  • Surgical vestibulectomy can be considered if medical measures fail with vulvar vestibulitis (5)[B].

COMPLEMENTARY & ALTERNATIVE MEDICINE

  • Sitz baths may relieve painful inflammation.
  • Perineal massage
  • Antioxidants may improve symptoms associated with endometriosis.

ONGOING CARE

FOLLOW-UP RECOMMENDATIONS

Patient Monitoring

  • Outpatient follow-up depends on therapy.
  • Every 6 to 12 months once resolved

DIET

A high-fiber diet may help if constipation is a contributing cause.

PATIENT EDUCATION

  • Boston Women's Health Book Collective. Our Bodies, Ourselves: A New Edition for a New Era. New York, NY: Simon & Schuster; 2005.
  • Kegel exercise information
  • Provide couples with information about sexual arousal techniques.

PROGNOSIS

Depends on underlying cause but most patients will respond to treatment.

REFERENCES

11 Carroli G, Mignini L. Episiotomy for vaginal birth. Cochrane Database Syst Rev. 2009;(1):CD000081.22 Crowley T, Richardson D, Goldmeier D. Bashh Special Interest Group for Sexual Dysfunction. Recommendations for the management of vaginismus: BASHH Special Interest Group for Sexual Dysfunction. Int J STD AIDS. 2006;17(1):14-18.33 Portman DJ, Bachmann GA, Simon JA, et al. Ospemifene, a novel selective estrogen receptor modulator for treating dyspareunia associated with postmenopausal vular and vaginal atrophy. Menopause. 2013; 20(6):623-630.44 Ferrero S, Abbamonte LH, Giordano M, et al. Deep dyspareunia and sex life after laparoscopic excision of endometriosis. Hum Reprod. 2007;22(4):1142-1148.55 Steege JF, Zolnoun DA. Evaluation and treatment of dyspareunia. Obstet Gynecol. 2009;113(5):1124-1136.

ADDITIONAL READING

  • Boardman LA, Stockdale CK. Sexual pain. Clin Obstet Gynecol. 2009;52(4):682-690.
  • Frank JE, Mistretta P, Will J. Diagnosis and treatment of female sexual dysfunction. Am Fam Physicia. 2008;77(5):635-642.
  • Sung SC, Jeng CJ, Lin YC. Sexual health care for women with dyspareunia. Taiwan J Obstet Gynecol. 2011;50(3):268-274.

SEE ALSO

  • Balanitis; Endometriosis; Pelvic Inflammatory Disease (PID); Sexual Dysfunction in Women; Genito-Pelvic Pain/Penetration Disorder (Vaginismus); Vulvovaginitis, Estrogen Deficient; Vulvovaginitis, Prepubescent
  • Algorithms: Dyspareunia; Discharge, Vaginal

CODES

ICD10

  • N94.1 Dyspareunia
  • F52.6 Dyspareunia not due to a substance or known physiol cond

ICD9

  • 625.0 Dyspareunia
  • 302.76 Dyspareunia, psychogenic

SNOMED

  • 71315007 Dyspareunia (finding)
  • 41021005 Psychologic dyspareunia
  • 286992006 Dyspareunia - non-psychogenic
  • 81712001 pain in female genitalia on intercourse (finding)

CLINICAL PEARLS

  • Careful history to determine if patient feels pain before, during, or after intercourse will help identify cause.Pain before intercourse suggests a phobic attitude toward penetration and/or the presence of vestibulitis.Pain during intercourse combined with the location of the pain is most predictive of the causes of pain.Introital pain after intercourse suggests vestibulitis in women of childbearing age, hypertonic pelvic floor, or vulvovaginal dystrophia.
  • Potential relationship exists between primary dyspareunia and vaginismus, low libido, and arousal disorders.
  • Episiotomy does not offer any benefit in the prevention of dyspareunia; an episiotomy in fact may cause more future discomfort.