Painful Intercourse (Dyspareunia)

Introduction

Questions related to sexual functioning should be asked as part of the reproductive history. Two helpful questions are, "Are you sexually active?" and "Are you having any sexual difficulties at this time?"

During the pelvic examination, the patient should be placed in a half-sitting position and given a hand-held mirror and then asked to point out the site of pain and describe the type of pain.

Etiology

A. Vulvovaginitis

Vulvovaginitis is inflammation or infection of the vagina. Areas of marked tenderness in the vulvar vestibule without visible inflammation occasionally show lesions resembling small condylomas on colposcopy.

B. Vaginismus

Vaginismus is voluntary or involuntary contraction of muscles around the introitus. It results from fear, pain, sexual trauma, or having learned negative attitudes toward sex during childhood.

C. Remnants of the Hymen

The hymen is usually adequately stretched during initial intercourse, so that pain does not occur subsequently. In some women, the pain of initial intercourse may produce vaginismus. In others, a thin or thickened rim or partial rim of hymen remains after several episodes of intercourse, causing pain.

D. Insufficient Lubrication of the Vagina

See vaginal atrophy in the section on Menopausal Syndrome.

E. Infection, Endometriosis, Tumors, or Other Pathologic Conditions

Pain occurring with deep thrusting during coitus is usually due to acute or chronic infection of the cervix, uterus, or adnexa; endometriosis; adnexal tumors; or adhesions resulting from prior pelvic disease or operation. Careful history taking and a pelvic examination will generally help in the differential diagnosis.

F. Vulvodynia

This is the most frequent cause of dyspareunia in premenopausal women. It is characterized by a sensation of burning along with other symptoms including pain, itching, stinging, irritation, and rawness. The discomfort may be constant or intermittent, focal or diffuse, and experienced as either deep or superficial. There are generally no physical findings except minimal erythema that may be associated with a subset of vulvodynia, vulvar vestibulitis. Vulvar vestibulitis is normally asymptomatic, but the pain is associated with touching or pressure on the vestibule such as with vaginal entry or insertion of a tampon.