From the Guidelines
The workup for dyspareunia should begin with a thorough history and physical examination, including a comprehensive pelvic examination and laboratory testing, and treatment should be guided by the specific type of problem, with consideration of pelvic physical therapy, vaginal dilators, and topical prescription medications, as recommended by the most recent guidelines 1. The initial evaluation should include a detailed history of the pain, including location, timing, and quality, as well as associated symptoms and exacerbating/relieving factors. A comprehensive pelvic examination should be performed, including visual inspection of external genitalia, speculum examination to assess the vagina and cervix, and bimanual examination to evaluate the uterus and adnexa. Laboratory testing should include vaginal pH, wet mount microscopy, vaginal cultures for infections, and STI screening. For postmenopausal women, a vaginal maturation index may be helpful. Imaging studies like transvaginal ultrasound can identify structural abnormalities, endometriosis, or pelvic inflammatory disease. Some key considerations in the workup and treatment of dyspareunia include:
- Pelvic physical therapy, which can improve sexual pain, arousal, lubrication, orgasm, and satisfaction, as shown in a small study of 34 survivors of gynecologic cancers 1
- Vaginal dilators, which can be used for survivors with pain during sexual activity and those with vaginal stenosis from pelvic radiation, although evidence for their effectiveness is limited 1
- Topical prescription medications, such as vaginal estrogen, which has been shown to be effective in treating vaginal dryness, itching, discomfort, and painful intercourse in postmenopausal women 1
- Vaginal androgens, such as DHEA, which can be considered for vaginal dryness or pain with sexual activity, although the evidence for their effectiveness is uncertain 1 It is essential to tailor the workup and treatment to the patient's age, medical history, and specific symptoms to effectively diagnose and treat the underlying cause of dyspareunia. Psychological factors should also be addressed, and referral to a sex therapist may be appropriate. The most recent guidelines, such as those from the National Comprehensive Cancer Network (NCCN) 1, should be consulted to ensure that the workup and treatment are evidence-based and up-to-date.
From the Research
Workup for Dyspareunia
The workup for dyspareunia involves a comprehensive approach to identify the underlying cause of the condition.
- A detailed history is essential to understand the characteristics of the pain, including location, intensity, and duration 2, 3, 4.
- Physical examination of the external genitalia includes visual inspection and sequential pressure with a cotton swab to assess for focal erythema or pain 2.
- A single-digit vaginal examination may identify tender pelvic floor muscles, and a bimanual examination can assess for uterine retroversion and pelvic masses 2.
- Laboratory or imaging studies are not routinely indicated but may be helpful to rule out infectious etiologies or evaluate pelvic organ pathology in cases of deep dyspareunia 3.
Common Diagnoses
Common diagnoses associated with dyspareunia include:
- Vulvodynia 2, 3
- Inadequate lubrication 2
- Vaginal atrophy 2
- Postpartum causes 2
- Pelvic floor dysfunction 2, 3
- Endometriosis 2
- Vaginismus 2, 3
Treatment Approach
Treatment is focused on the underlying cause and may include: