Definition and Epidemiology

Dyspareunia is defined as recurrent or persistent genital pain associated with sexual intercourse. The condition is not unique to women; men can have dyspareunia from a variety of causes, including dermatologic infections, structural abnormalities, exposure to alloplastic materials via partners who have had pelvic floor surgery,¹ and anodyspareunia in men who have receptive anal sex. However, it is much more commonly encountered in women and is therefore almost exclusively described as a women’s health issue. Dyspareunia can develop secondary to other vulvar problems, such as localized provoked vulvodynia (LPV), vaginismus, or vulvodynia. LPV, formerly known as vulvar vestibulitis, refers to severe pain on vestibular contact or with attempted vaginal entry, tenderness to pressure within the vestibule, and vulvar erythema. Vaginismus is involuntary spasm of the muscles surrounding the outer third of the vagina brought on by real, imagined, or anticipated attempts at vaginal penetration. Vulvodynia refers to chronic vulvar discomfort that may involve complaints of rawness, burning, stinging, or irritation; it is not necessarily related to sexual activity.

Dyspareunia is a common gynecologic complaint, with a widely varying estimated prevalence of 4.7% to 39.5% of women,^2,3 and can be thought of as either superficial (pain around the vaginal opening) or deep (pain in the lower abdomen or pelvic organs). Factors influencing dyspareunia include spontaneous and postabortive pelvic inflammatory disease; early postpartum or perimenopausal status; generalized urogenital sensitivity⁴; history of sexual abuse or cervical cancer; and psychosocial factors, such as rigid religious upbringing, low physical and emotional satisfaction, decreased general happiness, or previous painful sexual experience. Dyspareunia has not been consistently associated with factors such as age, parity, marital status, race, income, or education, and there is no increase in prevalence among women seeking fertility treatment.³ Hormonal and sexual history factors including oral contraception use⁵ (especially before age 17 years) and first intercourse before age 15 years have been proposed as causes of LPV. Women with LPV have demonstrated lower pain threshold, higher magnitude estimation of pain, higher trait anxiety, increased somatization, poorer body image than controls, hypervigilance for coital pain, and selective attentional bias toward pain stimuli.

Pathophysiology

Pain in the vulvar area can result from inflammatory or atrophic dermatologic conditions, assorted pelvic pathologies, neoplasm, neurologic dysfunction, trauma (horseback riding, sexual abuse, genital mutilation), chemotherapy, and genital manifestations of other systemic diseases such as discoid lupus erythematosus, nonalcoholic liver disease (by decreasing vaginal lubrication), Ehlers-Danlos syndrome,⁶ and Charcot-Marie-Tooth disease.⁷ Vulvar pain may be a sequela of iatrogenesis (pelvic radiation, chemotherapy, graft-versus-host reaction, pelvic surgery) or an acute or chronic infectious process (human semen carries the irritating toxin in ciguatera), or the result of psycho-social-sexual disturbance. Although the Diagnostic and Statistical Manual of Mental Disorders currently classifies dyspareunia as a sexual pain disorder, there is debate⁵ as to whether dyspareunia reflects a predominant psychopathology, a condition of sexual dysfunction, or a physical pain syndrome. However it is classified academically, there is evidence of high levels of psychological distress in some women with dyspareunia,^8–10 particularly those with provoked vestibulodynia (PVD) and vulvodynia.

Dyspareunia is often a result of inadequate vaginal lubrication. This can be attributable to insufficient stimulation or arousal during sexual activity or can be related to decreased estrogen, a condition noted in postmenopausal women, women taking tamoxifen for chemoprevention of breast cancer, and breast cancer survivors. Superficial dyspareunia has been associated with lichen planus and lichen sclerosis,¹¹ factitious urticaria, vulvovaginal candidal infection and recurrent candidiasis,¹² bacterial vaginosis, herpes simplex virus (HSV) types 1 and 2 infection, human papillomavirus (HPV) infection, urinary tract infections,¹³ urinary incontinence, occlusion of Bartholin gland duct, Bowen disease, and interstitial cystitis. Tiny mucosal tears have been implicated in focal vulvitis, and perivascular inflammation has been proposed as a mechanism causing dyspareunia in women with Sjögren syndrome. Dyspareunia after a normal pelvic examination has been linked with overexertion of the levator ani muscles and subsequent myalgia after the initiation of Kegel exercises. When the levator ani muscles are hypertonic, vaginismus can result.

In PVD, a conditioned, protective, muscle-guarding response has been proposed, leading to a pelvic floor pathologic condition. Vaginismus cannot easily be distinguished from vestibulitis or PVD by vaginal spasm and pain alone, but women with vaginismus demonstrate significantly greater vaginal and pelvic muscle tone and lower muscle strength, have a higher frequency of defensive and avoidant distress behaviors during pelvic examinations, and recall past attempts at intercourse with more affective distress.

By far the most common cause of deep dyspareunia in premenopausal women is endometriosis, especially when it involves the rectovaginal area.¹⁴ One of the key factors recently proposed for the promotion of nerve fiber growth and for the onset and maintenance of pain in this condition is nerve growth factor (NGF).¹⁵ Women with deep infiltrating endometriosis of the uterosacral ligament can have severe impairment of sexual function, and many have had deep dyspareunia for their entire sex lives. Structural abnormalities that can cause dyspareunia include glomus tumors; leiomyomas of the uterus and urethra; vaginal, urethral, and hymenal abnormalities; bladder stones; postobstetric or postoperative vulvar outlet stenosis; and stenosing lichen planus. Aortoiliac or atherosclerotic disease can diminish pelvic blood flow and lead to vaginal wall and clitoral smooth muscle fibrosis. Pelvic floor surgery can either ameliorate preexisting dyspareunia or cause it.^16,17 Episiotomies, particularly those involving the mediolateral technique and glycerol-impregnated chromic catgut, have been tied to significant increases in dyspareunia.¹⁸ Obstetric instrumentation and perineal trauma during delivery contribute to postpartum dyspareunia.

Clinical Presentation

Health care providers need to take an active role in inquiring specifically about discomfort during or after sexual intercourse and not simply assume that women will raise the issue if it is a problem. Women often will not voice this concern even if it is the main reason for their visit. Although some women will discuss dyspareunia with their partner, far fewer consult a health care provider for the problem.²

A thorough symptom analysis will guide the physical examination and should specifically include questioning about the onset of the discomfort and its relationship to particular partners, positions, times in the menstrual cycle, contraceptive devices and substances (such as latex condoms, spermicides, or lubricants), and products (such as douches, soaps, tampons, or detergents). Women may report pain with tampon use or pelvic examinations. Important information to gather includes number of pregnancies and type of delivery, surgical history, history of rape or sexual abuse, and menopausal signs and symptoms. Knowing whether the pain is on entry, postcoital, generalizable to the entire vulva, felt only with deep thrusting, or localized to a particular anatomic structure or area is helpful in determining the cause of the discomfort. Several symptom-related scales have been proposed, such as the Female Sexual Function Index, but are not widely used in clinical practice.

Examination

A thorough pelvic examination is necessary for all complaints of dyspareunia. The experience can be educational for the woman and more informative for the provider if the patient sits somewhat upright and holds a small hand mirror; this allows the woman to see what is happening and feel more in control. It is important to correlate the discomfort elicited during the pelvic examination with specific physical findings whenever possible. In addition, clarification should be sought for pain elicited to determine whether it is similar to what the woman has been experiencing during intercourse because many women find pelvic examinations generally uncomfortable.

The external genitals should be examined for erythema, pigment changes, lesions (including herpes and condyloma), and indications of trauma or abuse. Touching of the vestibule and the hymen with a moistened cotton swab (the Q-tip test) may elicit the pain of PVD, a condition in which there is exquisite tenderness to pressure at specific sites, often accompanied by erythema.

A finger inserted gently into the introitus and gradually pressed in a posterior direction may elicit the spasms of vaginismus; conscious control of the pelvic floor musculature can be evaluated by asking the woman to squeeze and relax the muscles around the examiner’s finger. Bartholin glands, which are normally not palpable, may be tender and enlarged. A narrow, well-lubricated speculum should be used to evaluate the vagina. A bimanual examination can assess for uterine and ovarian size, fibroids, ovarian cysts, other pelvic masses, cervical motion tenderness (seen with pelvic inflammatory disease), and position of the uterus. Hemorrhoids or prolapse of the uterus, bladder, or rectum may be evident. A rectal or rectovaginal examination is generally not necessary.