Dyspareunia

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 outlet
- Adhesions
- Condyloma
- Clitoral irritation
- Episiotomy scars
- Fissures
- Hymeneal ring abnormalities
- Inadequate lubrication
- Infections
- Lichen planus
- Lichen sclerosus
- Postmenopausal atrophy
- Psoriasis
- Trauma
- Vulvar papillomatosis
- Vulvar vestibulitis/vulvodynia
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 GI tract
- Constipation
- Crohn disease
- Diverticular disease
- Fistulas
- Hemorrhoids
- Inflammatory bowel disease
Disorders of the urinary tract
- Interstitial cystitis
- Ureteral or vesical lesions
- Urethritis
Chronic disease
- Beh §et syndrome
- Diabetes
- Sj ¶gren syndrome
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
Psychological disorders
- Anxiety
- Conversion reactions
- Depression
- Fear
- Hostility toward partner
- Phobic reactions
- Psychological trauma

RISK FACTORS

Fatigue
Stress
Depression
Diabetes
Estrogen deficiency
- Menopause
- Lactation
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 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.
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 therapy
  - Indicated to help the patient deal with intrapersonal issues and assess the role of the partner
- 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.

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.

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.

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