What causes abdominal pain during intercourse?

Abdominal Pain During Intercourse: Causes and Diagnostic Approach

In sexually active women presenting with abdominal pain during intercourse (dyspareunia), pelvic inflammatory disease (PID) should be the primary diagnostic consideration, and empiric antibiotic treatment must be initiated immediately if cervical motion tenderness, uterine tenderness, or adnexal tenderness is present on examination. 1, 2

Primary Gynecologic Causes in Women

Pelvic Inflammatory Disease

• PID is the most critical diagnosis to consider because delayed treatment increases risk of tubal infertility, ectopic pregnancy, and chronic pelvic pain 1
• Empiric treatment should be initiated when minimum criteria are met: lower abdominal tenderness AND adnexal tenderness AND cervical motion tenderness in sexually active women at risk for STDs 1
• Additional supportive findings include: oral temperature >101°F (>38.3°C), abnormal cervical or vaginal discharge, elevated ESR or CRP, and laboratory documentation of cervical infection with N. gonorrhoeae or C. trachomatis 1
• Critical pitfall: Many cases present with mild or atypical symptoms such as dyspareunia alone, and providers should maintain a low threshold for diagnosis 1
• If cervical discharge appears normal and no white blood cells are found on wet prep, PID is unlikely and alternative causes should be investigated 2

Endometriosis and Ovarian Pathology

• Endometriosis commonly causes deep dyspareunia (pain with deep penetration) and should be considered when pain is cyclical or worsens with menses 1
• Ovarian cysts, particularly when ruptured or causing torsion, can cause acute pain during intercourse 3
• Adnexal torsion has 74-95% sensitivity on CT imaging when ultrasound is inconclusive 3

Interstitial Cystitis/Bladder Pain Syndrome

• IC/BPS is characterized by suprapubic pain and pressure that extends throughout the pelvis including the urethra, vulva, vagina, and rectum 1
• Sexual dysfunction occurs at high rates in IC/BPS patients, with women reporting significantly more pain and fear of pain with intercourse compared to controls 1
• Pain appears to mediate sexual dysfunction and its associated effects on quality of life 1

Causes in Men

Chronic Prostatitis/Chronic Pelvic Pain Syndrome

• CP/CPPS is characterized by pain in the perineum, suprapubic region, testicles, or tip of the penis, often exacerbated by ejaculation 4
• Ejaculatory pain is a common feature of chronic prostatitis/CPPS 5
• The diagnosis of IC/BPS should be strongly considered in men whose pain is perceived to be related to the bladder 4

Epididymitis

• Characterized by pain, swelling, and elevated temperature of the epididymis, with pain that can radiate to the lower abdomen 4
• In up to 90% of cases, pathogens migrate from the urethra or bladder, with predominant organisms being Enterobacterales, Chlamydia trachomatis, and Neisseria gonorrhoeae 4

Musculoskeletal and Pelvic Floor Causes

• Pelvic floor dysfunction and muscle spasm can cause pain during intercourse in both men and women 6
• Insufficiency or fatigue fractures of the pubic rami can cause localized pain, with MRI being the most sensitive imaging modality when radiographs are negative 4
• Abnormal mobility of the rectal mucosa associated with pelvic floor abnormalities can rarely cause pain during intercourse 7

Diagnostic Algorithm

Initial Assessment

1. Obtain pregnancy test (beta-hCG) in all women of reproductive age to rule out ectopic pregnancy before pursuing other diagnoses 2, 3
2. Perform pelvic examination looking specifically for cervical motion tenderness, uterine tenderness, or adnexal tenderness 2, 3
3. Obtain cervical cultures for N. gonorrhoeae and C. trachomatis in sexually active patients 1
4. Check wet prep for white blood cells on saline microscopy of vaginal secretions 2

Imaging When Diagnosis is Unclear

• Ultrasound is the initial imaging modality of choice for acute pelvic pain in reproductive-age women 3
• If ultrasound is inconclusive and patient is not pregnant, CT abdomen and pelvis with IV contrast is the imaging modality of choice 2, 3
• In postmenopausal women, CT abdomen and pelvis is first-line imaging due to broader differential including malignancy 3

Treatment Priorities

For Suspected PID

• Begin empiric broad-spectrum antibiotics immediately covering N. gonorrhoeae, C. trachomatis, Gram-negative facultative bacteria, anaerobes, and streptococci 1
• Do not delay treatment while awaiting culture results, as this increases risk of long-term sequelae 2, 3
• Reassess within 72 hours, and hospitalize for parenteral antibiotics if no clinical improvement 3

Epidemiology and Context

• About 30% of women and 7% of men report pain during vaginal intercourse, with most reports being mild and of short duration 8
• About 72% of women and 15% of men report pain during anal intercourse, with more events including moderate or severe pain 8
• Large proportions of patients do not tell their partner when sex hurts, making clinical history-taking essential 8
• Post-coital burning pain and pain during micturition may be early symptoms of partial vaginismus with or without vulvar vestibulitis, described by 70% of affected women 6

Critical Pitfalls to Avoid

• Failing to obtain pregnancy testing before imaging can lead to delayed diagnosis of ectopic pregnancy, which is life-threatening 2
• Assuming normal-appearing cervical discharge rules out PID—must check for white blood cells on wet prep 2
• Delaying antibiotic treatment for PID while awaiting test results increases risk of tubal infertility and chronic pelvic pain 2, 3
• Dismissing mild or atypical symptoms as many PID cases present with dyspareunia as the primary complaint 1