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.