What is the approach to the workup of dyspareunia (painful intercourse)?

From the Guidelines

The workup of dyspareunia should begin with a thorough history and physical examination to identify the underlying cause, and treatment options may include lubricants, vaginal moisturizers, low-dose vaginal estrogen, and pelvic floor physical therapy, as recommended by the most recent guidelines 1. The history should include onset, duration, and character of pain, relationship to menstrual cycle, sexual history, obstetric history, and psychological factors.

• A comprehensive physical examination should assess for vulvar/vaginal abnormalities, pelvic floor muscle tenderness, cervical motion tenderness, adnexal masses, and signs of endometriosis.
• Laboratory testing may include vaginal pH, wet mount, cultures for infections, and hormone levels if indicated.
• Imaging studies such as pelvic ultrasound or MRI may be necessary for suspected structural abnormalities or endometriosis. Treatment depends on the identified cause and may include:
• Topical estrogen for atrophic vaginitis
• Antibiotics for infections
• Pelvic floor physical therapy for muscle dysfunction
• Lubricants for inadequate lubrication
• Surgical intervention for conditions like endometriosis
• Psychological counseling may benefit patients with contributing psychological factors. A multidisciplinary approach involving gynecologists, physical therapists, and mental health professionals often yields the best outcomes, as dyspareunia frequently has multiple contributing factors that require comprehensive management 1. Vaginal dilators may be of benefit in the management of vaginismus and/or vaginal stenosis and can be offered to anyone having pain with examinations and/or sexual activity, particularly for women treated with pelvic radiation therapy 1. Cognitive behavioral therapy and pelvic floor exercises may be useful to decrease anxiety and discomfort and can lower urinary tract symptoms 1. The Expert Panel believes that pelvic floor physiotherapy may be beneficial for patients experiencing symptoms of a potential pelvic floor dysfunction, including persistent pain and urinary and/or fecal leakage 1. Ospemifene, an FDA-approved selective estrogen receptor modulator, has been studied in several large trials and was found to effectively treat vaginal dryness and dyspareunia, and may be considered as an option for dyspareunia in survivors without a history of estrogen-dependent cancers 1.

From the Research

Approach to Dyspareunia Workup

The approach to the workup of dyspareunia involves a comprehensive evaluation of the patient's symptoms, medical history, and physical examination findings. The following steps are involved in the workup:

• Identification of the initiating and promulgating factors of dyspareunia 2
• Differential diagnosis of conditions such as vaginismus, inadequate lubrication, atrophy, and vulvodynia (vulvar vestibulitis) 2
• Consideration of less common etiologies such as endometriosis, pelvic congestion, adhesions or infections, and adnexal pathology 2
• Physical examination to reproduce the pain and identify the location of the pain (entry or deep) 2
• Palpation of the lateral vaginal walls, uterus, adnexa, and urethral structures to identify the cause of pain 2

Integrated Approach

An integrated approach to dyspareunia workup is essential, considering both organic and psychologic factors 3. This approach involves:

• Evaluating hormonal, inflammatory, muscular, iatrogenic, neurologic, vascular, connective, and immunitary causes of pain during intercourse 3
• Assessing psychosexual factors such as vaginismus, loss of libido, arousal disorders, and sexual pain-related disorders 3
• Considering the role of musculoskeletal factors and the potential benefits of pelvic floor rehabilitation in treating dyspareunia 4, 5

Treatment Options

Various treatment options are available for dyspareunia, including:

• Pelvic floor rehabilitation techniques such as electrotherapy, manual therapy, and pelvic floor muscle exercises 4
• Physical therapy interventions such as thermotherapy, myofascial release, and pelvic training 5
• Pharmacological treatments such as oral desipramine with 5% lidocaine cream, intravaginal diazepam tablets, and botulinum toxin type A 6
• Alternative therapies such as acupuncture, hypnotherapy, and cognitive behavioral therapy 6