What are the causes of dyspareunia in a young patient?

Causes of Dyspareunia in Young Patients

In young patients, dyspareunia is most commonly caused by inadequate lubrication, provoked vulvodynia, pelvic floor dysfunction, postpartum changes (if applicable), and infections, with less frequent causes including endometriosis, vaginismus, and dermatologic conditions like lichen sclerosus. 1, 2

Primary Causes by Category

Vulvovaginal Causes (Most Common in Young Patients)

• Provoked vulvodynia (vulvar vestibulitis) is a leading cause of superficial dyspareunia in young women, characterized by localized pain at the vaginal entrance that can be reproduced with cotton swab testing 1, 2

• Inadequate lubrication frequently causes entry pain and can result from insufficient arousal, hormonal factors, or medications 1, 2, 3

• Vaginismus presents as involuntary spasm of the pelvic floor muscles, preventing or making vaginal penetration extremely painful, and may be noted during examination when inserting a finger or speculum 1, 2, 3

Postpartum-Related Causes

• Postpartum dyspareunia affects approximately 35% of women after childbirth, with 43% experiencing pain at 2-6 months postpartum, 22% at 6-12 months, and 40% at 12-24 months 4, 5

• Postpartum causes include perineal trauma, episiotomy scars, vaginal dryness from breastfeeding-induced hypoestrogenism, and pelvic floor dysfunction 4

Pelvic Floor Dysfunction

• Pelvic floor muscle dysfunction can cause both superficial and deep dyspareunia, with tender pelvic floor muscles identifiable on single-digit vaginal examination 2

• This condition may cause urinary and bowel symptoms alongside sexual pain 4

Infectious and Inflammatory Causes

• Vaginal or vulvar infections (candidiasis, bacterial vaginosis, sexually transmitted infections) can cause acute dyspareunia with associated discharge, odor, or visible inflammation 2

• Urethral disorders and cystitis may present as pain during intercourse, particularly with deep penetration 3

Dermatologic Conditions

• Lichen sclerosus presents with porcelain-white papules and plaques, causing dyspareunia through erosions, fissures, or introital narrowing, and has a bimodal distribution affecting prepubertal girls and postmenopausal women 4

• In young girls, lichen sclerosus may present with striking ecchymosis that can be mistaken for sexual abuse 4

Deep Dyspareunia Causes

• Endometriosis is a less common but important cause of deep dyspareunia in young women, associated with cyclic pelvic pain 2, 3, 6

• Pelvic adhesions from prior surgery or infection can cause deep pain with intercourse 3

• Uterine retroversion may contribute to deep dyspareunia and can be identified on bimanual examination 2

Hormonal Causes

• Estrogen deprivation from hormonal contraceptives, breastfeeding, or premature ovarian insufficiency causes vaginal atrophy, dryness, and dyspareunia 4

• Young cancer survivors treated with chemotherapy, radiation, or endocrine therapy frequently experience dyspareunia from vaginal dryness, scarring, and hormonal changes 4

Critical Diagnostic Considerations

History Taking Priorities

• Characterize pain location (superficial vs. deep), timing (with penetration, during thrusting, or after intercourse), duration, and associated symptoms 2, 3

• Assess for relationship to menstrual cycle, suggesting endometriosis if pain worsens premenstrually 6

• Identify postpartum status, contraceptive use, medications, and history of infections or trauma 1, 2

Physical Examination Approach

• Cotton swab testing of the vulvar vestibule identifies focal areas of tenderness characteristic of provoked vulvodynia 2, 3

• Single-digit vaginal examination assesses for pelvic floor muscle tenderness and involuntary spasm of vaginismus 2, 3

• Bimanual examination evaluates for uterine position, adnexal masses, and pelvic tenderness suggesting endometriosis or infection 2, 3

Common Pitfalls to Avoid

• Do not assume psychogenic etiology until organic causes are thoroughly excluded, as dyspareunia in young patients typically has identifiable physical causes 1, 3, 7

• Do not overlook lichen sclerosus in young patients, as it has a prepubertal peak and may be asymptomatic or mistaken for other conditions 4

• Do not dismiss postpartum dyspareunia as normal or temporary, as it persists beyond 12 months in 40% of affected women and requires specific treatment 4, 5

• Recognize that multiple factors often coexist, such as inadequate lubrication combined with pelvic floor dysfunction or vaginismus secondary to chronic pain from vulvodynia 1, 2