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Dyspareunia is pain during attempted or completed vaginal penetration.
Dyspareunia may occur at the moment of penetration (superficial or introital), with deeper entry, with penile movement, or postcoitally. Some pelvic muscle hypertonicity, manifested as both voluntary guarding and involuntary high muscle tension, is common in all types of chronic dyspareunia.
Etiology
Causes may involve psychologic and physical factors (see Sexual Dysfunction in Women: Etiology).
Superficial dyspareunia may result from provoked vestibulodynia (PVD), atrophic vaginitis, vulvar disorders (eg, lichen sclerosus, vulvar dystrophies), congenital malformations, genital herpes simplex, radiation fibrosis, postsurgical introital narrowing, or recurrent tearing of the posterior fourchette.
Deep dyspareunia may result from pelvic muscle hypertonicity or uterine or ovarian disorders (eg, fibroids, chronic pelvic inflammatory disease, endometriosis).
Penile size and depth of penetration influence presence and severity of symptoms.
A subgroup of women with dyspareunia due to PVD (see Sexual Dysfunction in Women: Provoked Vestibulodynia (Vulvar Vestibulitis)) have high self-expectations and fear of negative evaluation by other people, increased somatization, catastrophizing (gross exaggeration of possible consequences), and hypervigilance to pain.
Diagnosis
Diagnosis is based on symptoms and a pelvic examination.
For superficial dyspareunia, evaluation focuses on inspecting all the vulvar skin, including the creases between the labia minora and majora (eg, for fissures typical of chronic candidiasis), and the clitoral hood, urethral meatus, hymen, and openings of major vestibular gland ducts (for atrophy, signs of inflammation, and skin lesions typical of lichen sclerosus). PVD can be diagnosed using a cotton swab to elicit allodynia; nonpainful external areas are touched before moving to more typically painful areas (ie, outer edge of the hymenal ring, clefts adjacent to the urethral meatus). Pelvic muscle hypertonicity may be suspected if pain similar to the pain that occurs during intercourse can be elicited by palpating the deep levator ani muscles, particularly around the ischial spines. Palpating the urethra and bladder may identify abnormal tenderness.
For deep dyspareunia, evaluation requires a careful bimanual examination to determine whether cervical motion or uterine or adnexal palpation causes pain and to check for nodules in the cul-de-sac or vaginal fornices. A rectovaginal examination is usually indicated to check the rectovaginal septum and posterior surface of the uterus and adnexa. Suspected uterine and ovarian disorders are evaluated with imaging studies as clinically indicated.
Treatment
Management should include the following:
Topical estrogen is helpful for atrophic vaginitis (see Vaginitis and Pelvic Inflammatory Disease (PID): Treatment) and recurrent posterior fourchette tearing.
Women with pelvic muscle hypertonicity, including some with PVD, may benefit from pelvic physical therapy using pelvic floor muscle training, possibly with biofeedback, to teach pelvic muscle relaxation. Sometimes a change in sexual position helps.
Provoked Vestibulodynia (Vulvar Vestibulitis)
Provoked vestibulodynia (vulvar vestibulitis, localized vulvar dysesthesia) is the most common type of superficial (introital) dyspareunia. Pain starts and stops precisely with introital pressure. Treatment may include measures used in chronic pain syndromes as well as topical lidocaine or cromoglycate, but efficacy of the latter is unproved.
Provoked vestibulodynia develops when the nervous system—from peripheral receptors to the cerebral cortex—is sensitized and remodeled. With sensitization, discomfort due to a stimulus that might otherwise be perceived as mild or trivial (eg, touch) is instead perceived as significant pain (allodynia). This disorder is probably a form of chronic pain syndrome (see Pain: Chronic Pain) of the vulva. The peripheral sensitization leads to a neurogenic inflammatory response. Some women also have GU disorders (eg, vulvovaginal candidiasis, hyperoxaluria), but the etiologic role of these disorders is unproved. Some women also have other pain disorders (eg, irritable bowel syndrome—see Irritable Bowel Syndrome (IBS); interstitial cystitis—see Voiding Disorders: Interstitial Cystitis).
Symptoms and Signs
In vestibulodynia, introital pressure, penile movement, or a man's ejaculation typically causes immediate pain. Pain typically stops when penile movement stops and resumes when it starts again. Vestibulodynia may also cause postcoital vulvar burning and dysuria.
Diagnosis
Diagnosis is based on symptoms and confirmed by the Q-tip test for allodynia. Vaginismus causes similar pain with introital pressure and penile containment and movement. However, unlike vestibulodynia, there is no allodynia. Also, pain due to vaginismus continues after penile movement stops but may progressively fade during intercourse despite continued penile movement.
Treatment
Optimal treatment of provoked vestibulodynia is unclear; many approaches are currently used, and there are probably still undefined subtypes that require different treatment. Because this disorder involves chronic pain, treatments are becoming more comprehensive, including management of stress and emotional reactions to pain.
Commonly used but unproven approaches involve avoiding topical irritants and using systemic drugs (eg, tricyclic antidepressants, anticonvulsants) or topical drugs (eg, 2% cromoglycate or 2 or 5% lidocaine in glaxal base) to interrupt chronic pain circuits. Cromoglycate stabilizes WBC membranes, including those of mast cells, interrupting the neurogenic inflammation thought to underlie vestibulodynia. Cromoglycate or lidocaine must be placed precisely on the area of allodynia using a 1-mL syringe without a needle. Physician supervision and use of a mirror (at least initially) are helpful. Psychologic therapies, including cognitive-behavioral therapy and sex therapy, may also help some women with vestibulodynia. Women with pelvic muscle hypertonicity may benefit from pelvic physical therapy using pelvic floor muscle training, possibly with biofeedback. Surgery (eg, excision of the hymen, proximal edge of the lower vagina, and innermost portion of the labia minora) is sometimes indicated to remove proliferated nerve endings. However, pain may recur as nerves regenerate. Investigational treatment includes botulinum toxin type A injection.
Last full review/revision January 2009 by Rosemary Basson, MD
Content last modified January 2009
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