Evaluation and Differential Diagnosis of Dyspareunia

American Family Physician,  April 15, 2001  by Lori J. Heim

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Dyspareunia is genital pain associated with sexual intercourse. Although this condition has historically been defined by psychologic theories, the current treatment approach favors an integrated pain model. Identification of the initiating and promulgating factors is essential to reaching a successful diagnosis. The differential diagnoses include vaginismus, inadequate lubrication, atrophy and vulvodynia (vulvar vestibulitis). Less common etiologies are endometriosis, pelvic congestion, adhesions or infections, and adnexal pathology. Urethral disorders, cystitis and interstitial cystitis may also cause painful intercourse. The location of the pain may be described as entry or deep. Vulvodynia, atrophy, inadequate lubrication and vaginismus are associated with painful entry. Deep pain occurs with the other conditions previously noted. The physical examination may reproduce the pain, such as localized pain with vulvar vestibulitis, when the vagina is touched with a cotton swab. The involuntary spasm of vaginismus may be noted with insertion of an examining finger or speculum. Palpation of the lateral vaginal walls, uterus, adnexa and urethral structures helps identify the cause. An understanding of the present organic etiology must be integrated with an appreciation of the ongoing psychologic factors and negative expectations and attitudes that perpetuate the pain cycle. (Am Fam Physician 2001:63:1535-44,1551-2.)

Dyspareunia is genital pain experienced just before, during or after sexual intercourse.(1) Although this condition has historically been classified as a sexual disorder, an integrated and pain-model approach to the problem is gaining support. The current thinking about pain initiation and promulgation suggests an initial instigating factor that is then perpetuated by confounding factors.(2-6) These factors may be physical or psychologic. Patients with dyspareunia may complain of a well-defined and localized pain, or express a general disinterest in and dissatisfaction with intercourse that stems from the associated discomfort. Although dyspareunia is present in both sexes, it is far more common in women, with the pain initiating in several areas, from vulvar surfaces to deep pelvic structures.

This article reviews the various causes of dyspareunia and describes the historical and physical clues leading to these diagnoses. Treatment options are beyond the scope of this article.

Epidemiology

There are few reports of clinical trials relating to dyspareunia, and much of the literature derives from expert opinion. The lack of a single etiology for the pain contributes to the diagnostic difficulty. The incidence of dyspareunia depends on the definition used and the population sampled. In a national probability sample(7) assessing the prevalence of sexual dysfunction in the United States, women with dyspareunia comprised a smaller group than women with decreased interest in sex, orgasmic difficulties, lack of pleasure or arousal difficulties. The prevalence of dyspareunia in this sample was 7 percent. In a study of primary care practices,(8) the prevalence of dyspareunia was 46 percent among sexually active women, with dyspareunia defined as pain during or after intercourse. In a recent study(9) involving 62 women, postpartum dyspareunia was noted in 45 percent.

As many as 60 percent of women experience dyspareunia when the term is broadly defined as episodes of pain with intercourse.(10) Women with symptoms severe enough to require medical attention comprise a much smaller group. Many of those with persistent symptoms do not seek medical attention.(8,10)

PATIENT CHARACTERISTICS

Consistent characteristics of patients with dyspareunia are lacking. In one study,(7) increasing age and college education were associated with a lower likelihood of dyspareunia. In another study,(8) the incidence of dyspareunia was not associated with age, parity, marital status, race, income or educational level.

The most common pain with dyspareunia occurs during coitus, but some women experience pain afterward, while others report pain at both times.(8) Pain before coitus may result from irritation of the external genitalia or the vasocongestion that occurs during the excitement phase. Patients with dyspareunia are more likely than the general population to report pain with insertion of a tampon or digit, or during a gynecologic examination.(6)

Psychologic Issues and Considerations

Psychologic theory historically treats dyspareunia as a symbol of unconscious conflict, stemming from phobic reactions, major anxiety conflicts, hostility or sexual aversions.(4) The Diagnostic and Statistical Manual of Mental Disorders, 4th ed. (DSM-IV),(11) defines dyspareunia as a sexual pain disorder, a subcategory of sexual dysfunction. Dyspareunia is differentiated from vaginismus or problems resulting from inadequate lubrication. The pain must be persistent or recurrent, and cause marked distress or interpersonal difficulty. In one study,(5) only the onset of pain and its location were useful discriminators.