What are the diagnosis and treatment options for vaginal pain?

Vaginal Pain: Diagnosis and Treatment

Vaginal pain requires a systematic diagnostic approach starting with β-hCG testing in reproductive-age women, followed by targeted evaluation for infectious causes (vaginitis, PID), structural/hormonal causes (atrophic vaginitis, pelvic floor dysfunction), and non-gynecological etiologies, with treatment directed at the specific underlying cause identified. 1

Initial Diagnostic Workup

Mandatory First Steps

• Obtain serum β-hCG in all reproductive-age women presenting with vaginal or pelvic pain, as this fundamentally alters the diagnostic pathway and imaging choices 1
• Document specific pain characteristics: constant versus intermittent, relationship to intercourse (dyspareunia), urination (dysuria), menstruation, and presence of vaginal discharge or odor 1, 2
• Perform pelvic examination looking for: cervical motion tenderness, uterine/adnexal tenderness, abnormal discharge (color, consistency, odor), vulvar lesions, and vaginal atrophy 3, 2
• Check vaginal pH and perform wet mount microscopy with saline and potassium hydroxide preparations to identify infectious causes 2, 4

Laboratory Testing

• Obtain urine culture even with negative urinalysis to detect clinically significant bacteria 1
• Perform nucleic acid amplification testing (NAAT) for Neisseria gonorrhoeae and Chlamydia trachomatis in sexually active women, especially if cervical motion tenderness or mucopurulent discharge present 3, 2
• Consider DNA probe testing or vaginal fluid sialidase activity testing for bacterial vaginosis if Gram stain unavailable 2

Common Infectious Causes and Treatment

Bacterial Vaginosis (40-50% of vaginitis cases)

• Diagnosed by Amsel criteria (3 of 4: thin gray-white discharge, pH >4.5, positive whiff test, clue cells on microscopy) or Gram stain 2
• Treat with oral metronidazole 500 mg twice daily for 7 days, OR intravaginal metronidazole gel 0.75% once daily for 5 days, OR intravaginal clindamycin cream 2% once daily for 7 days 2, 4

Vulvovaginal Candidiasis (20-25% of cases)

• Diagnosed by clinical signs plus potassium hydroxide microscopy showing budding yeast or pseudohyphae; culture helpful for recurrent/complicated cases 2, 4
• Treat with oral fluconazole 150 mg single dose OR topical azole antifungals (clotrimazole, miconazole) for 1-7 days 2, 4
• Use only topical azoles during pregnancy; avoid oral fluconazole 2

Trichomoniasis (15-20% of cases)

• Diagnosed by NAAT (preferred) or wet mount showing motile trichomonads 2, 4
• Treat with oral metronidazole 2 g single dose OR tinidazole 2 g single dose; treat sexual partners concurrently 2, 4

Pelvic Inflammatory Disease

• Initiate empiric treatment when sexually active women have uterine/adnexal tenderness OR cervical motion tenderness, with no other identifiable cause 3
• Supporting criteria: fever >101°F, mucopurulent cervical discharge, white blood cells on wet prep, elevated ESR/CRP 3
• Requires broad-spectrum antibiotics covering N. gonorrhoeae, C. trachomatis, anaerobes, gram-negative bacteria, and streptococci 3

Non-Infectious Causes and Treatment

Atrophic Vaginitis (Postmenopausal/Hypoestrogenic)

• Vaginal estrogen is the most effective treatment for vaginal dryness and painful intercourse in postmenopausal women 3
• Options include: estradiol-releasing vaginal ring, intravaginal estrogen cream, or vaginal estrogen tablets 3
• Alternative prescription options: ospemifene (oral selective estrogen receptor modulator) or intravaginal DHEA 3
• Over-the-counter vaginal moisturizers, gels, and oils can provide symptomatic relief 3

Pelvic Floor Dysfunction

• Refer for pelvic physical therapy (pelvic floor muscle training) when pain associated with muscle tension, dyspareunia, or difficulty with penetration 3
• Pelvic floor training improves sexual pain, arousal, lubrication, and satisfaction 3
• Consider vaginal dilators for women with pain during sexual activity or vaginal stenosis from radiation 3

Dyspareunia/Sexual Pain

• Apply topical lidocaine to the vulvar vestibule before vaginal penetration for immediate pain relief 3
• Address multifactorial contributors: physiologic (menopause, illness), psychological (anxiety, depression), medication-induced, and interpersonal factors 3
• Refer to sexual health specialists, psychotherapy, or couples counseling when appropriate 3
• Cognitive behavioral therapy has proven effective for improving sexual function 3

Imaging When Diagnosis Unclear

Ultrasound (First-Line)

• Perform transvaginal ultrasound combined with transabdominal approach for suspected gynecological causes (ovarian cysts, masses, hydrosalpinx, pelvic inflammatory disease) 3, 1
• Include Doppler evaluation to assess pelvic vascularity and rule out pelvic congestion syndrome (engorged periuterine/periovarian veins >8mm) 3
• Ultrasound mandatory if β-hCG positive; CT contraindicated due to fetal radiation 1

CT Abdomen/Pelvis with IV Contrast

• Use CT when non-gynecological causes strongly suspected (appendicitis, diverticulitis, urinary calculi, pyelonephritis) with 88% overall accuracy 1
• CT has 89% sensitivity versus 70% for ultrasound in urgent abdominopelvic diagnoses 1

Critical Pitfalls to Avoid

• Never skip β-hCG testing in reproductive-age women—inadvertent CT in pregnancy causes unnecessary fetal radiation exposure 1
• Do not rely on urinalysis alone; obtain urine culture to detect bacteria not visible on dipstick 1
• Maintain low threshold for diagnosing PID—mild or atypical symptoms can still cause reproductive damage 3
• If cervical discharge appears normal and no WBCs on wet prep, PID is unlikely; investigate alternative causes 3
• Do not overlook vascular causes like pelvic congestion syndrome requiring Doppler protocols 3, 1
• Avoid plain radiographs—they have extremely limited utility for vaginal/pelvic pain 1

Referral Indications

• Refer to gynecology for: suspected endometriosis/adenomyosis, complex adnexal masses, persistent pain despite empiric treatment 3, 5, 6
• Refer to sexual health specialist or pelvic pain specialist for: refractory dyspareunia, complex sexual dysfunction, suspected vulvodynia 3, 5
• Refer to urogynecology for: suspected interstitial cystitis/bladder pain syndrome, high-tone pelvic floor dysfunction 5