What to do for a patient with pelvic pain during sexual intercourse with a normal transvaginal ultrasound?

Management of Pelvic Pain During Sexual Intercourse with Normal Transvaginal Ultrasound

When a patient presents with pelvic pain during sexual intercourse and has a normal transvaginal ultrasound, further evaluation should focus on non-structural causes including pelvic floor dysfunction, vulvodynia, vaginal atrophy, and chronic pelvic inflammatory disease, which may not be visible on standard imaging. 1

Initial Assessment After Normal Ultrasound

• Perform a thorough bimanual examination to assess for uterine tenderness, cervical motion tenderness, and adnexal tenderness that may indicate underlying inflammation or infection despite normal imaging 2
• Distinguish between deep dyspareunia (pain with deep penetration) and superficial dyspareunia (pain at the vaginal entrance), as this helps narrow the differential diagnosis 1
• Evaluate for pelvic floor muscle hypertonicity, which can cause pain during intercourse but may not be visible on standard ultrasound 1
• Consider "soft markers" during transvaginal ultrasound examination, such as site-specific pelvic tenderness during the scan, which may indicate underlying pathology despite normal-appearing structures 3

Diagnostic Considerations

• Even with a normal transvaginal ultrasound, chronic pelvic inflammatory disease may still be present, as it can manifest with subtle findings or adhesions that are difficult to visualize on standard imaging 1
• Pelvic adhesions are notoriously difficult to diagnose non-operatively and may require dynamic ultrasound assessment to document abnormal adherence or lack of mobility of pelvic structures 1, 3
• Pelvic venous disorders (commonly termed pelvic congestion syndrome) should be considered, especially if pain worsens with prolonged standing and improves with lying down 1
• Vaginal atrophy, vaginismus, vulvodynia, or pelvic myofascial pain may be underlying causes of dyspareunia despite normal imaging 1

Advanced Imaging Considerations

• If symptoms persist despite normal transvaginal ultrasound, MRI pelvis may provide additional anatomic detail and evaluation of soft tissue components 1
• MRI enables accurate depiction of pelvic floor muscular anatomy, integrity, and function, which is particularly useful for assessment of muscular hypertonicity in chronic pelvic pain syndromes 1
• Color and spectral Doppler evaluation should be included as part of the standard ultrasound examination to evaluate internal vascularity and distinguish between fluid/cysts and soft tissue 1
• A combined transabdominal and transvaginal approach provides the most comprehensive evaluation of pelvic structures 1, 4

Management Approach

• Physical examination remains the foundation of clinical evaluation for suspected pathology in the perineum, vulva, or vagina 1
• For patients with suspected pelvic floor dysfunction, referral to a pelvic floor physical therapist may be beneficial 1
• If pelvic venous disorders are suspected, color and spectral Doppler evaluation may document engorged periuterine and periovarian veins 1
• Consider empiric treatment for chronic pelvic inflammatory disease when other etiologies are ruled out, as the presentation can be variable and the prevalence is high (20-50% of women presenting with pelvic pain) 5

Common Pitfalls to Avoid

• Do not dismiss a patient's symptoms simply because the ultrasound is normal; many causes of dyspareunia will not be visible on standard imaging 6, 7
• Avoid assuming that a normal ultrasound excludes all significant pathology; the pre-test probability of pelvic disease in women with chronic pelvic pain only falls from 58% to 20% with a normal ultrasound 3
• Remember that transvaginal ultrasound is operator-dependent, and experience is a key factor in the ability to characterize common gynecological disorders with accuracy 7
• Do not overlook non-gynecological causes of pelvic pain, which may require additional imaging modalities such as CT or MRI for proper evaluation 8