Dyspareunia

Dyspareunia is recurrent or persistent genital pain with attempted or completed vaginal penetration. It is a symptom with many causes. The key step is to separate pain at entry (vulval, vestibular, pelvic floor) from deep pain (pelvic organs), because the examination and investigations differ. Once organic causes are treated or excluded, pain lasting 6 months or more that causes distress fits genito pelvic pain or penetration disorder.

Anatomy. Superficial: vestibule, hymenal remnants, Bartholin and Skene gland openings, posterior fourchette, perineal scars. Mid vaginal: levator ani and obturator internus. Deep: cervix, uterosacral ligaments, pouch of Douglas, ovaries, bladder base, rectosigmoid.

Mechanisms. Mucosal inflammation or atrophy, nociceptor proliferation and central sensitisation, protective pelvic floor spasm, nerve injury, deep pelvic inflammation or endometriosis, traction on fixed structures, and a fear and avoidance cycle. Inadequate arousal alone reduces lubrication and causes pain.

Classification. By site: superficial, mid vaginal or deep. By onset: primary (from first attempts) or secondary (after pain free intercourse). By pattern: always present or situational.

Key distinctions. Pain only at entry suggests vestibulodynia, atrophy, infection, dermatosis or vaginismus. Pain with deep thrusting, position dependent or cyclical, suggests endometriosis, adenomyosis, adhesions or ovarian disease. New pain after childbirth or pelvic surgery suggests scar, mesh or pelvic floor injury. Fever, discharge and lower abdominal pain suggest pelvic inflammatory disease.

History

• Pain: site (entry, mid, deep), quality, timing (start, during, after), duration, positions, cyclical variation, effect on intercourse, severity score from 0 to 10.
• Onset: primary or secondary, relation to childbirth, surgery, radiotherapy, menopause, new relationship or new contraception.
• Associated: discharge, itch, burning, postcoital bleeding, dysmenorrhoea, heavy periods, dyschezia, dysuria, bladder pain, constipation, back or hip pain.
• Infection risk: new partners, previous sexually transmitted infection, previous pelvic inflammatory disease.
• Obstetric and surgical: perineal tears, episiotomy, prolapse or incontinence surgery with mesh, hysterectomy, female genital cutting.
• Menopausal symptoms, breastfeeding, cancer treatment (tamoxifen, aromatase inhibitors, pelvic radiotherapy).
• Drugs: antidepressants, antihistamines, anticholinergics, depot medroxyprogesterone acetate, gonadotropin releasing hormone agonists.
• Sexual function: desire, arousal, lubricant use, fear of pain, relationship, past abuse or coercion (ask with permission and privately), mood and anxiety.

Examination

• Chaperone and consent. Inspect the vulva: erythema, fissures, scarring, white atrophic skin, Bartholin swelling, hymenal tags, narrowed introitus, perineal scar.
• Cotton swab test of the vestibule at the 2, 4, 6, 8 and 10 o'clock positions; pain over 4 of 10 at a specific point supports vestibulodynia.
• Single finger examination: introital tone, levator ani and obturator internus tenderness and spasm (vaginismus or hypertonicity), scar tenderness, anterior wall (urethra, bladder base), posterior fornix nodularity.
• Bimanual: uterine size, fixation or retroversion, uterosacral nodularity and tenderness, cervical motion tenderness, adnexal mass or tenderness.
• Speculum if tolerated: discharge, atrophy, polyps, mesh exposure, cervical lesion, vaginal septum or stenosis.
• Abdomen and spine: masses, hernia, hip range, sacroiliac and lumbar spine.

Red flags

• Postcoital or intermenstrual bleeding with a visible cervical or vaginal lesion.
• Pelvic mass, ascites, weight loss or bloating (ovarian cancer).
• Fever, offensive discharge or cervical motion tenderness (pelvic inflammatory disease, tubo ovarian abscess).
• Pregnancy with pain or bleeding (ectopic pregnancy).
• Mesh erosion or exposure.
• Sexual assault, coercion or suspected abuse, and any girl under 18 with unexplained pain.
• Saddle anaesthesia or bladder and bowel dysfunction.

Special groups. Postpartum: scar pain and hypo-oestrogenism with breastfeeding usually settle within 6 months, and persistent pain needs examination. Postmenopausal: atrophy is the commonest cause. Cancer survivors: radiotherapy fibrosis and stenosis, and aromatase inhibitors.

Organised by site.

Superficial (entry) pain

• Infection and inflammation: vulvovaginal candidiasis, bacterial vaginosis, trichomoniasis, genital herpes, vaginitis, urethritis, Bartholin or Skene gland abscess.
• Dermatoses: lichen sclerosus, erosive lichen planus, contact dermatitis, plasma cell vulvitis.
• Hormonal: genitourinary syndrome of menopause, lactational atrophy, premature ovarian insufficiency, antioestrogen treatment, depot medroxyprogesterone acetate.
• Neuropathic: provoked vestibulodynia (the commonest cause in premenopausal women), generalised vulvodynia, pudendal neuralgia.
• Muscular: vaginismus, pelvic floor hypertonicity.
• Structural and scar: perineal scar or episiotomy, fourchette fissure, female genital cutting, hymenal remnants or rigid hymen, vaginal septum, vaginal stenosis, radiotherapy fibrosis.
• Allergy and irritants: latex, spermicide, lubricant, soap.
• Insufficient arousal or lubrication.

Mid vaginal and bladder related

• Levator ani myalgia.
• Interstitial cystitis (bladder pain syndrome), recurrent cystitis.
• Urethral diverticulum.
• Pelvic organ prolapse and pessary or mesh complications.

Deep pain

• Endometriosis and adenomyosis (deep pain, dysmenorrhoea, dyschezia, infertility).
• Chronic pelvic inflammatory disease and hydrosalpinx.
• Ovarian cyst, ovarian torsion, ruptured corpus luteum.
• Uterine fibroids.
• Pelvic adhesions after surgery or infection.
• Pelvic congestion syndrome.
• Retroverted fixed uterus.
• Ovarian remnant syndrome.
• Irritable bowel syndrome, constipation, diverticular disease, inflammatory bowel disease.
• Serious: ectopic pregnancy, tubo ovarian abscess.
• Serious: ovarian cancer, cervical cancer, vaginal cancer, endometrial cancer, pelvic radiation injury.
• Psychological: sexual abuse sequelae, anxiety, depression, post traumatic stress disorder, relationship problems.

Stepwise reasoning

1. Exclude pregnancy and pelvic infection, then identify the site of pain.
2. For entry pain: examine the vulva, test for infection, map vestibular tenderness and assess pelvic floor tone.
3. For deep pain: bimanual examination, transvaginal ultrasound, and MRI or laparoscopy when imaging is negative and symptoms persist.
4. Biopsy any visible lesion.
5. Assess psychosexual factors in every patient.

Tests

• Urine pregnancy test.
• Vaginal pH, saline and potassium hydroxide microscopy, Candida culture, and nucleic acid amplification tests for chlamydia, gonorrhoea, trichomoniasis and Mycoplasma genitalium.
• Herpes simplex virus PCR from any ulcer or fissure.
• Urine dipstick and culture.
• Full blood count and C reactive protein when infection is suspected.
• Transvaginal ultrasound: endometrioma, adenomyosis (heterogeneous myometrium, globular uterus), fibroids, hydrosalpinx, ovarian mass, and the sliding sign for pouch of Douglas obliteration.
• MRI pelvis for suspected deep endometriosis, adenomyosis or urethral diverticulum.
• CA 125 only when an ovarian mass is present, interpreted with menopausal status and ultrasound features.
• Colposcopy or biopsy for any lesion. Vulval punch biopsy (4 mm) for ulcer, hyperkeratosis or pigmentation.
• Cystoscopy for suspected bladder pain syndrome. Colonoscopy for bowel symptoms with alarm features.
• Diagnostic laparoscopy when imaging is normal, treatment has failed, and endometriosis or adhesions remain likely.

Limitations. Normal ultrasound does not exclude endometriosis. Candida carriage is common. Examination findings in vestibulodynia are subtle. Multiple causes often coexist.

Immediate steps. Treat pelvic inflammatory disease or sepsis if present. Refer ectopic pregnancy, ovarian torsion and tubo ovarian abscess the same day. Arrange urgent referral for suspected cancer. Provide a safe, non judgemental explanation and agree a plan; advise stopping penetration until pain is treated.

General measures. Water based or silicone lubricant, longer foreplay, position changes, avoidance of irritants, and cotton underwear. Treat the cause found.

Cause specific treatment

• Candidiasis: fluconazole 150 mg orally as a single dose, or clotrimazole 500 mg vaginal pessary once. Avoid fluconazole in pregnancy.
• Bacterial vaginosis: metronidazole 400 mg orally twice daily for 7 days; maximum 4 g daily; avoid alcohol during treatment and for 48 hours after.
• Trichomoniasis: metronidazole 400 mg orally twice daily for 7 days, with partner treatment.
• Chlamydia: doxycycline 100 mg orally twice daily for 7 days (azithromycin 1 g single dose in pregnancy). Gonorrhoea: ceftriaxone 1 g intramuscularly once.
• Pelvic inflammatory disease: ceftriaxone 1 g intramuscularly once, doxycycline 100 mg orally twice daily for 14 days and metronidazole 400 mg orally twice daily for 14 days; review at 72 hours. Admit if severe.
• Atrophy: oestradiol 10 microgram vaginal tablet nightly for 2 weeks, then twice weekly; maximum one tablet daily; review at 3 months; report any bleeding; contraindicated with undiagnosed vaginal bleeding, active venous thromboembolism or active liver disease. Ospemifene 60 mg orally once daily with food is an alternative for women who cannot use local oestrogen.
• Lichen sclerosus: clobetasol propionate 0.05% ointment, 0.5 g to affected skin nightly for 4 weeks, then on alternate nights for 4 weeks, then twice weekly for 4 weeks.
• Vestibulodynia and neuropathic pain: lidocaine 5% ointment to the vestibule 15 to 20 minutes before intercourse (within the labelled daily maximum; warn about partner numbness). Amitriptyline 10 mg orally at night, increased by 10 mg every 1 to 2 weeks to 50 to 75 mg; maximum 100 mg; ECG over age 50 or with heart disease; avoid with MAO inhibitors; caution with SSRIs, tramadol, glaucoma and urinary retention. Gabapentin 300 mg orally at night, increased by 300 mg every 3 to 7 days to 900 to 1800 mg daily in 3 doses; maximum 3.6 g daily; reduce for creatinine clearance under 60 mL/min; avoid in pregnancy.
• Vaginismus and pelvic floor hypertonicity: pelvic floor physiotherapy with biofeedback, graduated vaginal dilators, cognitive behavioural therapy and sex therapy. Botulinum toxin has limited evidence.
• Bartholin abscess: incision and drainage with a catheter left for 4 to 6 weeks; antibiotics only for cellulitis.
• Perineal scar: topical lidocaine, physiotherapy and scar massage; surgical revision if refractory.
• Endometriosis and adenomyosis: ibuprofen 400 mg orally every 6 to 8 hours with food, maximum 2.4 g daily (avoid in peptic ulcer, renal impairment, heart failure and NSAID sensitive asthma), or naproxen 500 mg orally twice daily with food, maximum 1 g daily. Hormonal suppression: dienogest 2 mg orally once daily continuously (maximum 2 mg daily); or a monophasic combined pill with 30 to 35 microgram ethinylestradiol taken continuously or in 3 pack cycles; or norethisterone acetate 5 mg orally once daily, increased by 2.5 mg every 2 weeks as needed to a maximum of 15 mg daily; or medroxyprogesterone acetate depot 150 mg intramuscularly every 12 weeks (bone density loss). Second line: leuprorelin 3.75 mg intramuscularly every 4 weeks for up to 6 months with add back norethisterone acetate 5 mg daily, with bone density monitoring. Laparoscopic excision for deep disease or medical failure.
• Irritable bowel syndrome and constipation: treat directly. Interstitial cystitis: urology referral.

Psychosexual care. Offer counselling and sex therapy to every patient with chronic pain. Screen for depression, anxiety and abuse.

Monitoring. Review at 4 to 6 weeks and 3 months. Use a pain score from 0 to 10 and intercourse frequency to track response. Monitor bone density with prolonged depot medroxyprogesterone acetate or gonadotropin releasing hormone agonist use.

Referral and escalation. Refer urgently within 2 weeks for suspected cancer. Refer to gynaecology for suspected endometriosis, adenomyosis, adhesions, mesh problems or failure of 3 months of treatment. Refer to a vulval or pain clinic for refractory vestibulodynia, and to psychosexual services when psychological factors dominate. Involve safeguarding services when abuse is suspected.

Admission criteria. Pelvic inflammatory disease with systemic illness, tubo ovarian abscess, ectopic pregnancy, torsion, and severe uncontrolled pain.

Discharge and follow up. Most patients are outpatients. Provide a written plan and review.

Safety netting. Return for fever, heavy bleeding, severe pain, new lesion, or no improvement within 3 months.