Differential Diagnosis of Dyspareunia
Complaints of sexual pain - that is, dyspareunia or vulvodynia - typically fall into one of three categories - vulvar pain (pain at the opening or at the external genitalia), vaginal pain, or deep pain - or some combination of all three. There is some evidence for the existence of several subtypes of dyspareunia (Binik et al. 2000): vulvar vestibulitis (the most common type of premenopausal dyspareunia), vulvar or vaginal atrophy (which typically occurs postmenopausally), and deep dyspareunia or pelvic pain (associated with such gynecological conditions as endometriosis, ovarian cysts and pelvic adhesions, inflammatory disease, or congestion).
Vulvar Vestibulitis Syndrome Vulvar vestibulitis syndrome (VVS) is the most common subtype of vulvodynia affecting premenopausal women. It tends to be associated with a highly localized “burning” or “cutting” type of pain. The feelings of irritation and burning can persist for hours or days following sexual activity, engendering a sense of hopelessness and depression (Bergeron et al. 1997; Marinoff and Turner 1991; Peckham et al. 1986).
The prevalence of VVS is quite high: the syndrome has been cited as affecting about 10%-15% of women seeking gynecological care (Bergeron et al. 1997). It is characterized by severe pain with attempted penetration of the vaginal introitus and complaints of tenderness with pressure within the vulvar vestibule. Usually there are no reports of pain with pressure to other surrounding areas of the vulva. Diagnosis is readily made by the cotton-swab test, in which pressure is applied in a circular fashion around the vulvar vestibule to assess complaints of pain. Laboratory tests are used to exclude bacterial or viral infection, and a careful examination of the vulvo/vaginal area is conducted to assess whether any atrophy is present.
VVS involves multiple tiny erythematous sores in the vulvar vestibule (Friedrich 1987; Marinoff and Turner 1991). A number of etiological factors may be involved, including subclinical human papillomavirus infection, chronic recurrent candidiasis, or chronic recurrent bacterial vaginosis (Marinoff and Turner 1991; Peckham et al. 1986). Muscular causes have been implicated as well, since chronic vulvar pain may be the result of chronic hypertonic perivaginal muscles, leading to vaginal tightening and subsequent pain. Some investigators have postulated the existence of neurological causes such as vestibular neural hyperplasia. Finally, psychological factors may contribute to or exacerbate the problem, since the anticipation of pain often results in a conditioned spasmodic reflex along with sexual desire and arousal problems. Relationship problems are generally the result of chronic frustration, disappointment, and depression associated with the condition.
A number of treatment options are available, including cognitive-behavioral interventions for pain, couples therapy, hypnosis, relaxation, and sex therapy. Biofeedback to relax the tight pelvic muscles has been used successfully in some cases. Medications - including amitriptyline at low dosages and intralesional a-interferon injections for some cases of human papillomavirus - are sometimes prescribed to ameliorate the pain complaint.
A recent study by Bergeron and colleagues (S. Bergeron, Y. Binik, S. Khalife, K. Pagidas, and K. Glazer: “A Randomized Comparison of Group Cognitive-Behavioral Therapy, Surface Electromyographic Biofeedback, and Vestibulectomy in the Treatment of Dyspareunia Resulting From Vulvar Vestibulities,” submitted for publication, 1998) comparing the efficacy of biofeedback, cognitive-behavioral therapy, and surgery found that vestibulectomy - surgical excision of the affected area - was the most successful intervention in a group of 76 women with VVS. Laser surgery has been reported to be successful in selected cases (Schover et al. 1993). Antidepressants (e.g., amitriptyline) or topical anesthetic gels may provide temporary relief.
For many women, dyspareunic pain cannot be totally eliminated. It is therefore important that coping strategies be reviewed and enhanced as part of the total treatment. Active rather than passive coping is encouraged. There is some suggestion that catastrophizing cognitions such as “I’m going to have unbearable pain that will never get better and will lead to my partner leaving me” enhance the woman’s experience of pain during standardized gynecological examination (Y. Binik and N. Koerner, “Catastrophizing as a Predictor of Pain Ratings in the Cotton Swab Test,” unpublished raw data, April 1998). Challenging these negative cognitions is an important component of all treatment protocols.
Vaginal Atrophy Vaginal atrophy as a source of dyspareunia is most frequently seen in postmenopausal women and is generally associated with estrogen deficiency. Estrogen deficiency is associated with lubrication inadequacy, which can lead to painful friction during intercourse.
In women with VVS and vulvar/vaginal atrophy, the pain is associated with penetration or with discomfort in the anterior portion of the vagina. There are some women, however, who report deeper vaginal or pelvic pain. Little is known about these types of pain syndromes, except that they are thought to be associated with gynecological conditions such as endometriosis, ovarian cysts, pelvic adhesions, or inflammatory disease.
Revision date: July 7, 2011
Last revised: by Dave R. Roger, M.D.