What is the workup for dyspareunia in a patient sexually active for 5 months?

Workup for Dyspareunia in a Patient Sexually Active for 5 Months

The workup for dyspareunia in a recently sexually active patient should begin with a thorough sexual history and focused physical examination to identify the specific type, location, and potential causes of pain, followed by targeted diagnostic testing based on findings. 1

Initial Assessment

Sexual History

• Pain characteristics:
  • Location: Entry pain (superficial) vs. deep pain
  • Timing: During penetration, with thrusting, or after intercourse
  • Quality: Sharp, burning, aching, or throbbing
  • Duration: Since first intercourse or developed over time
  • Alleviating/aggravating factors
  • Impact on sexual function and relationship

Physical Examination

1. External genital inspection:

   • Visual assessment for anatomical abnormalities, inflammation, lesions
   • Cotton swab test: Sequential pressure to identify focal areas of pain or erythema 1

2. Vaginal examination:

   • Single-digit examination to assess pelvic floor muscle tenderness
   • Speculum examination to evaluate vaginal mucosa and cervix
   • Bimanual examination to check for uterine position, masses, or adnexal tenderness 1

Common Causes and Specific Evaluation

Superficial (Entry) Pain

1. Inadequate lubrication:

   • Assess for vaginal dryness
   • Consider contributing factors: anxiety, insufficient arousal, medications

2. Vulvodynia/Vestibulodynia:

   • Cotton swab test to identify localized pain at vestibule
   • Evaluate for erythema or other visible changes

3. Vaginal atrophy:

   • Assess vaginal mucosa for thinning, pallor, decreased rugae
   • Consider hormonal status (breastfeeding, medications)

4. Vaginismus:

   • Evaluate for involuntary pelvic floor muscle spasm during examination
   • Assess anxiety response to examination

Deep Pain

1. Endometriosis:

   • Check for deep dyspareunia, dysmenorrhea, chronic pelvic pain
   • Bimanual examination for nodularity, fixed uterus

2. Pelvic inflammatory disease:

   • Assess for cervical motion tenderness, adnexal tenderness
   • Check for vaginal discharge

3. Pelvic floor dysfunction:

   • Evaluate for tenderness of levator ani muscles
   • Assess for trigger points

4. Anatomical factors:

   • Check for uterine retroversion
   • Evaluate for pelvic masses

Laboratory and Imaging Studies

• For suspected infection:

  • Vaginal/cervical cultures
  • Testing for STIs
  • Urinalysis if UTI symptoms present

• For suspected endometriosis:

  • Consider pelvic ultrasound
  • Referral for laparoscopy if clinically indicated

• For suspected hormonal factors:

  • Consider hormonal evaluation if clinically indicated

Special Considerations for Recently Sexually Active Patients

For patients who have only been sexually active for 5 months:

• Assess for anatomical factors that may cause pain with initial sexual activity
• Evaluate psychological factors including anxiety, expectations, and relationship dynamics
• Consider education about sexual techniques and adequate foreplay
• Assess for history of trauma or abuse which may contribute to pain

Common Pitfalls to Avoid

1. Failure to create a safe environment for discussion:

   • Use neutral, non-judgmental language
   • Ensure privacy during history and examination

2. Attributing pain solely to psychological factors:

   • Always perform a thorough physical examination
   • Consider multiple contributing factors

3. Missing concurrent conditions:

   • Pain may have multiple causes requiring different treatments
   • Consider both physical and psychological factors

4. Inadequate follow-up:

   • Dyspareunia often requires ongoing management
   • Schedule appropriate follow-up to assess treatment response

By following this systematic approach to the workup of dyspareunia in a recently sexually active patient, clinicians can identify the underlying causes and develop an appropriate treatment plan to address both physical and psychological factors contributing to sexual pain.