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Dyspareunia in gynaecological practice
REVIEW
Dyspareunia in gynaecological practice
associated discomfort. This can often be associated with relationship problems. This article reviews the various causes of dyspareunia and outlines assessment and management of the problem.
Vladimir Revicky
Epidemiology
Sambit Mukhopadhyay Sexual problems can occur in heterosexual and homosexual relationships. They are reported by almost 43% of women. Between 16% and 75% of females have problems with desire, 16e48% with orgasm, 12e64% with arousal and 7e58% with dyspareunia. The incidence of dyspareunia is difficult to determine as many women do not seek medical attention. Incidence also depends on the population sampled and the definition used. A study from the United States looking at the prevalence of sexual dysfunction found only a small proportion of women with dyspareunia compared to women with other sexual dysfunctions such as decreased interest in sex, orgasmic difficulties and arousal difficulties. However in a study within a primary care setting, the prevalence of dyspareunia was as high as 46% among sexually active women. Women with symptoms severe enough to seek medical attention comprise a much smaller group.
Edward Morris
Abstract Dyspareunia is a form of sexual dysfunction that can significantly affect quality of life and cause relationship difficulties. It is a symptom of a variety of disease states with components of both physical and organic dysfunction. Obtaining a comprehensive sexual history in an outpatient setting requires a high level of professionalism. A systematic examination of the lower genital tract is necessary to rule out any obvious cause, though further investigations such as ultrasound infrequently provides additional information. Diagnostic laparoscopy is an invasive procedure that is of limited use in the first line investigation of dyspareunia but may help detect pelvic adhesions or endometriosis in those where this condition is suspected. Before embarking on a laparoscopy it is important for the patient to be aware of a management plan in the event that the laparoscopy is negative. There are data to suggest that empirical medical treatment after a clinical diagnosis of endometriosis is effective and has the advantage of avoiding any invasive procedures. Psychosexual causes are important to consider during the assessment of the patient experiencing dyspareunia.
Aetiology Dyspareunia is a symptom of variety of disease states with components of both organic and psychological dysfunction. Onset Primary (onset with the first sexual experience): Congenital abnormalities Psychosocial causes Sexual abuse in childhood Feeling of guilt or shame towards sex Fear of intercourse or painful first intercourse
Keywords dyspareunia; chronic pelvic pain; endometriosis; vulvodynia; vaginismus
Introduction
Secondary (previously normal sexual function): usually physical causes but psychological causes should also be considered (Box 1).
Dyspareunia is defined as sexual dysfunction manifested by genital pain experienced just before, during or after sexual intercourse. It is present in both sexes but is more common in women. The combinations of biological, psychological and interpersonal factors can play a part in development of dyspareunia. Usually an initial instigating factor causes pain but many patients cannot recall a specific moment when the pain started. Patients with dyspareunia can present with well-defined and localized pain or with a general dissatisfaction with sex due to
Frequency Persistent: symptoms occur with all partners in all situations. Possible causes include physical or psychosocial factors. Conditional: symptoms occur with certain positions, type of stimulation or a specific partner. Possible causes include both physical and psychological factors. Location Superficial or insertional: sharp, burning or stinging pain at or near the vaginal introitus. Commonly found in patients with vulvodynia and vaginismus. Can also be a conditioned response to unpleasant previous sexual experiences. Frequent cause of superficial dyspareunia is thrush or vaginal atrophy.
Vladimir Revicky MRCOG is a Specialty Registrar Obstetrics and Gynaecology at Norfolk and Norwich University Hospital NHS Foundation Trust, Norwich, Norfolk, UK. Conflicts of interest: none declared. Sambit Mukhopadhyay FRCOG is a Consultant Obstetrics and Gynaecology at Norfolk and Norwich University Hospital NHS Foundation Trust, Norwich, Norfolk, UK. Conflicts of interest: none declared.
Deep: pain felt within the pelvis with penile thrusting deep within the vagina. Possible causes include gynaecological conditions such as pelvic tumours, endometriosis, previous surgery and infections. Different sexual positions may also be relevant in aetiology.
Edward Morris FRCOG is a Consultant Obstetrics and Gynaecology at Norfolk and Norwich University Hospital NHS Foundation Trust, Norwich, Norfolk, UK. Conflicts of interest: none declared.
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Common causes Chronic pelvic pain (CPP) Chronic pelvic pain is defined as any pelvic pain that lasts for more than 6 months. It affects a large proportion of women of reproductive age. Intercourse is compromised, with pain in about 90% of patients with chronic pelvic pain. In the UK, an annual prevalence in primary care of 38/1000 was found in women aged 15e73. This is similar to the prevalence of asthma (37/1000) and back pain (41/1000). In over 60% of patients no etiological factor for CPP was identifiable. One of the most difficult to manage patient groups is those with a negative laparoscopy. There is no consensus on management of patients with no organic pathology and chronic pelvic pain. However, laparoscopy as a diagnostic tool is not always accurate. An empirical approach of treating CPP based on history and structured clinical evaluation will be discussed later.
Physical causes of dyspareunia Abdominopelvic disorders Chronic pelvic disorders Pelvic endometriosis Congenital disorders Imperforate hymen Vaginal septum Other urogenital developmental abnormalities Vulvar disorders Vulvodynia C Organic vulvodynia Infections Dermatological e.g. Lichen sclerosus Hormonal C
Endometriosis Common symptoms of endometriosis include pelvic pain, dysmenorrhoea, dyspareunia, abnormal menstrual bleeding (usually premenstrual spotting), and infertility. Dyspareunia is usually deep and a prominent symptom in association with rectovaginal endometriosis. However, many women with endometriosis are completely asymptomatic. The stage of endometriosis is often not correlated with the presence or severity of symptoms. This paradox may be explained by the hypothesis that symptoms are more related to a local peritoneal inflammatory reaction than the volume of the implants. Rectovaginal endometriosis is recognized as a separate disease entity in comparison to peritoneal endometriosis. On histology, rectovaginal endometriosis includes not only glands and stroma but also a dense fibromuscular reaction, which is more prominent than the fibromuscular reactions noted elsewhere in the pelvis. Treatment differs from peritoneal disease and is discussed below.
Idiopathic Essential vulvodynia Vestibulitis
Female genital mutilation Vaginal disorders Vaginitis Vaginismus Prolapse Trauma Vaginal dryness Menopause Inadequate arousal Inadequate foreplay Hormonal contraception
Chronic pelvic inflammatory disease Chronic pelvic inflammatory disease can give rise to pelvic pain and deep dyspareunia. Pelvic adhesions may form as a result of inflammatory processes in the pelvis. Adhesions can cause fixed retroversion of the uterus and may produce pain during deep penetration. However the role of adhesions deep dyspareunia is controversial. In the absence of fixed retroversion, presence of adhesions may not be the causal factor for dyspareunia. Adhesiolysis often fails to improve deep dyspareunia but may benefit a subgroup of women with severe dense and vascularized adhesions involving the bowel.
Uterine and ovarian factors Pelvic mass e.g. fibroids or ovarian cyst/mass Adenomyosis Prolapsed ovaries Gastrointestinal disorders Chronic constipation Diverticular disease Inflammatory bowel disease/proctitis Scarring Previous pelvic surgery Episiotomy Perineorrhaphy
Vulvodynia Vulvodynia is a chronic pain syndrome that affects the vulvar area and occurs without an identifiable cause or visible pathology. It refers to pain of the vulva unexplained by vulvar or vaginal infection or skin disease and is a diagnosis of exclusion. Vulvodynia has been classified by the International. Society for the Study of Vulvovaginal Diseases (ISSVD) to general vulvodynia, clitordynia, vestibulodynia and then whether it is provoked or unprovoked. The ISSVD recommend the removal of such terms as ‘vestibulitis’ in preference for the term of ‘provoked vulvodynia’ (Box 2).
Urological causes Cystitis Interstitial cystitis Urethritis
Box 1
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20% experience painful sexual intercourse. Sexual satisfaction also depends on sexual activity during pregnancy. Dissatisfaction with sexual relationship at 12 months after childbirth, assessed using a validated questionnaire, is associated with not being sexually active at 12 weeks of gestation and with an older maternal age at delivery.
International Society for the Study of Vulvovaginal Diseases (ISSVD) classification of vulval pain C
C
Vulvar pain related to a specific disorder Infectious (e.g. candidiasis, herpes, etc.) Inflammatory (e.g. lichen planus, immunobullous disorders, etc.) Neoplastic (e.g. Paget’s disease, squamous cell carcinoma, etc.) Neurologic (e.g. herpes neuralgia, spinal nerve compression, etc.)
Dyspareunia with normal pelvic organs Dyspareunia is commonly associated with chronic pelvic pain and clusters of other sensory pelvic symptoms that include dysmenorrhoea, tampon discomfort, urinary urgency, faecal urgency and irritable bowel symptoms. Laparoscopy and other investigations often fail to detect any organic pathology in a significant proportion of patients with chronic pelvic pain and dyspareunia. Myofascial injuries, including complete or partial avulsion of levator ani from its muscular origin and disruption of the endopelvic fascial supports, may be associated with these clinical presentations. Difficult intrapartum episodes such as a complicated operative vaginal delivery, prolonged maternal pushing or a big baby presenting with an occipitoposterior position may give rise to myofascial damage. Myofascial damage may result in denervation injuries of pelvic viscera. The initial denervation injury of any viscus has few clinical manifestations in the puerperium or possibly for several years afterwards. When reinnervation occurs in many cases it can be a chaotic process resulting in atypical nerve fibres within the uterus, cervix, bladder mucosa, rectal mucosa, vulva and uterosacral ligaments. Obstetric denervation and subsequent reinnervation may account for some patterns of sensory pelvic symptoms including dyspareunia. These symptoms usually present in clusters many years after initial obstetric injury.
Vulvodynia Generalized e Provoked (sexual, nonsexual, or both) e Unprovoked e Mixed (provoked and unprovoked) Localized (vestibulodynia, clitorodynia, hemivulvodynia, etc.) e Provoked (sexual, nonsexual, or both) e Unprovoked e Mixed (provoked and unprovoked)
Box 2
Vaginismus Clinically, it is often difficult to separate dyspareunia from vaginismus, since vaginismus may occur secondary to a history of dyspareunia or mild vaginismus is often accompanied by dyspareunia. Vaginismus is relatively rare. It is a physical response of involuntary spasm of the introital muscles (pubococcygeus) to psychological stress. Vaginismus has been reported by 4.2e12% of women attending outpatient clinics. Insertion of fingers, the penis or tampons are common triggers of the spasm. Negative attitudes towards sex and sexual ignorance have been associated with vaginismus. Predisposing factors include environmental factors, childhood sexual trauma and a background of religious orthodoxy.
Psychosexual causes A psychosexual disorder is a common cause of dyspareunia. Sexual desire disorders Hypoactive sexual desire disorder Sexual aversion disorder Sexual arousal disorder Orgasmic disorder Psychosexual medicine is a complex area in which dyspareunia may be a trigger or a symptom. It is therefore important to be aware of it as a problem and to explore potential psychological sources of sexual dysfunction. Frequent issues that may influence sexuality include: Sexual abuse as a child or within current or previous relationships Poor sexual education Physical or psychological domestic violence Cultural issues Relationship problems Work problems
Childbirth Childbirth can have a major impact on the sexual health of women. Many women experience perineal discomfort or pain after childbirth that can persist for a variable length of time, often impairing normal sexual function. Nearly 90% of women resume sexual activity within 3e4 months of childbirth but the sexual morbidity in the first few months is over 80%. Only 15% of women report sexual dysfunction to health professionals. Factors associated with time to resuming sexual intercourse are largely unknown. Resumption of sexual intercourse following childbirth depends on the mode of delivery, degree of perineal trauma, maternal age, breast-feeding, and ethnic background. Women were five times less likely to be sexually active after a third/ fourth degree anal sphincter tear as compared to woman with intact perineum. At 6 months post partum, approximately one quarter of primiparous women report a deficit in sexual sensation, sexual satisfaction, and ability to achieve orgasm, and over
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History taking Women rarely present with the symptom of dyspareunia alone, it is often an accompanying symptom that has to be raised in closed or direct questioning. If the patient volunteers pain with intercourse as her primary problem then this is a good sign for the ease with which further information can be obtained. The norm however is that the issue of dyspareunia may be more difficult to extract.
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General and gynaecological questions During this period of questioning it is important to relate the information obtained from the more specific questions above to many aspects of normal gynaecological history taking. Establish a current menstrual history if relevant including bleeding irregularities which may interfere with sex. At this point it is often useful to find out whether she has any difficulty inserting tampons. Take details of her reproductive history including any difficulties in conception. Details of previous episodes of pelvic infections, endometriosis, cysts, fibroids and surgery should also be taken. Other medical issues such as drug use or misuse, autoimmune, endocrine, neurological, urological and gastrointestinal conditions may be relevant and should also be recorded.
Most patients are happy to freely talk about pelvic pain and it is this avenue that is often the best way to introduce and explore dyspareunia. Asking the patient what her worries or concerns are can often uncover the real problem. This question is very important to ask, especially if it is becoming difficult to find any cause for the problem. It is often very difficult for patients to discuss sexual matters with someone they barely know and it is therefore of immense importance to ensure an understanding professional atmosphere during the consultation. She should feel unhurried and at ease and there should be no more people in the consultation room than are necessary. Permission should be sought for the presence of any additional personnel and if permission is given their presence should be considered if problems develop during history taking. Asking whether a woman is having any difficulties with sexual intercourse or sexual desire is often useful as a tool for establishing whether there is a problem. Patients should not be asked in the opening seconds of the consultation unless they raise it early on. Once it is established that dyspareunia is a problem then further details should be obtained from more systematic questioning. Below is a list of some questions that may be useful. It is important that you are flexible in your questioning and be aware that covering areas such as sexual problems during development, frequency of sex, frequency of sex or numbers of partners are potentially very difficult issues that should be asked only if the consultation appears to be progressing well.
Examination With any gynaecological examination tact and sensitivity to the patient’s problem is of utmost importance. With the examination of the patient complaining of dyspareunia it is very important to be even more aware of the wide range of causes and therefore to adapt the examination accordingly. This is especially relevant when examining a patient in whom a psychosexual causation is suspected. As discussed above an element of prior sexual abuse or sexual dysfunction may accompany the symptomatology which may lead to an examination that is painful for the patient, uninformative for the doctor and could damage the professional relationship, which could impede management strategies. The timing and setting of the examination may need to be flexible and the patient should feel reassured that within limits she has an element of control and can always stop the examination. Try to be aware that this may not be a ‘see and treat’ session, the patient may be stressed enough having raised such sensitive issues and may feel that examination should wait for another day. In practical terms this may be difficult to organize but as long as the patient is aware of the delays this may cause it is unlikely to cause too many problems, indeed she may find your flexibility encouraging. The setting should be private and quiet with no unnecessary staff. The patient should be reassured that no-one else can hear and there should be a chaperone regardless of the sex of the examining practitioner. If at all possible the patient should be offered the opportunity for the chaperone to be present from the beginning of the consultation. Before any physical examination can take place, go over the history again to ensure that it is tailored to the history as much as possible. This is to ensure that the most important areas are examined early on so that the more general examination points can be omitted if the patient becomes uncomfortable later in the process. Do not enter into the physical examination with the aim of reproducing symptomatology e this may unsettle the patient. It is far better to explain to her that the aim of examination is to ensure that there is no serious pathology causing her pain. Explain to her that if her pain is reproduced during examination she should say so and you will stop immediately. This is again to ensure that she feels in control.
Specific questions How long has this been a problem? What sort of pain is it? Has it shown any signs of getting any better or worse? Does it occur on every episode of intercourse? How often (approximately) do you have sex? Does the pain occur in relation to superficial or deep penetration? Does the pain occur on one side more often than the other? Is there any particular sexual position that worsens or improves the pain? Sexual history questioning Do you look forward to sex? Are you able to become aroused or lubricated during foreplay? Is the pain with sex having any effect on the relationship with your partner? When did you last change your sexual partner? Have you had the same pain with other partners? Do you have any similar problems if you masturbate? Did you have any sexual problems whilst growing up? Quantification of the problem is necessary to assess the effect of any treatment or counselling. Several validated instruments are available to elucidate the nature of sexual dysfunction. They address several issues including libido, arousal, orgasm, pain, and relationship factors. Examples include the Female Sexual Function Index (FSFI), the brief index of Sexual Function Questionnaire (SFQ) for women and the Female Sexual Distress Scale (FSDS).
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Abdominal examination Inspect for scars, looking out for evidence of previous laparoscopies or evidence of more major abdominal surgery. Ask before palpation to avoid causing more pain over tender areas. Make
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a note of such painful regions of the abdomen and only palpate there with her permission. Then palpate for any significant masses, especially uterine fibroids or large ovarian cysts, remembering to assess their tenderness and mobility.
of ultrasound is interesting in that as it becomes more widely used more women expect it to be part of the diagnostic process. In the absence of specific symptoms or findings on clinical examination it has not been demonstrated to be of significant merit. Its use as a tool of reassurance should not be underestimated. Laparoscopy, useful as a diagnostic and therapeutic tool when endometriosis or other organic pelvic pathology is suspected, carries significant morbidity and risks and should therefore only be used when it use can be justified. Laparoscopy is thought to be the gold standard for the diagnosis of endometriosis. The lesions of endometriosis have a heterogenous appearance and therefore, the accuracy of the diagnosis depends on the ability of the surgeon. Moreover nearly 60% of histologically documented endometriosis is missed at laparoscopy. In a series of 1300 patients undergoing laparoscopy for chronic pelvic pain, no pathological lesions were found in 40% of cases. Of the remaining 60%, 28% had endometriosis and another 20% had adhesions.
Vaginal examination It is vitally important to consider the presenting complaint during this part of the examination as a woman with superficial dyspareunia or severe vaginismus may stop the examination process if she is first examined with a speculum. For all patients a detailed inspection of the vulva is needed, gently parting the labiae, inspecting for normal anatomy, oestrogenization, dermatoses, candidiasis, cysts, warts, trauma, episiotomies, state of the hymenal ring, prolapse and size of the introitus. A careful inspection of the perineum and perianal area may also be performed at the same time but this should only be pursued if this is easy to do. Gentle palpation of the posterior band of skin at the introitus is also useful, especially in those with postnatal dyspareunia to feel for encapsulated suture knots or granulomata. In patients with severe vaginismus the next step is usually the passage of a small item such as a single finger. If this is tolerated the finger may be used to gently palpate the vaginal walls and if possible the cervix, during which time the presence of cervical motion tenderness can be assessed. Throughout this part of the examination communication with the patient is vital with encouragement and eye contact again with offers to stop if it is uncomfortable. If she tolerates this part of the examination then she should be offered a speculum examination. Hopefully the digital examination should have provided the necessary information to select the correct size of speculum. During speculum examination the speculum should be well lubricated and if possible warmed. Inspect carefully for anatomical abnormalities such as vaginal septae, double cervices and vaginal bands. Again inspection for evidence of infection, oestrogenization and trauma are required. Have available equipment for taking cervical smears and culture swabs as this may be an opportunistic time for these tests in an otherwise reluctant patient. Bimanual examination follows and often provides the most useful information e especially in those with deep dyspareunia. It is important to reassure the patient who feels she cannot tolerate bimanual examination that similar information can be obtained from further investigations. Specific features often obtained from bimanual examination are the presence of any rectovaginal nodules, pelvic masses, tenderness and cervical motion tenderness. If pain is elicited then its location and position should be noted, along with the point of the examination at which it was caused.
Management Treatment of dyspareunia can be a relatively simple process when there is a clearly defined cause; if the problem is corrected the patient’s return to normal sexual activity should be followed up. This is to ensure that resolution of the problems has been maintained but also that it is not assumed that the correction of one issue will be the end of the problem. It is not uncommon that correcting one problem is followed by a different one. Remain vigilant that rectification of many seemingly small potentially aetiological factors without curing the underlying problem may indicate an underlying psychosexual disorder which requires specialist referral. Psychosexual management If psychosexual factors are thought to be relevant it is important to consider a referral for psychosexual assessment. This is usually best presented to the patient as part of the whole management strategy to aid the patients’ acceptance of the need for this referral. Some patients, especially those who have insight, are happy to be referred for psychosexual management. Nevertheless, listening to the woman and understanding the nature of the problem and its impact on her relationship can be therapeutic for her. Medical management Treatment of dyspareunia includes the conservative approaches of ensuring that the patient is allowing sufficient time for arousal and lubrication, modification of technique to avoid painful sexual positions and elimination of other aetiological factors. If she fails to respond to these then it may be necessary to introduce lubricants. Again these should be used only after adequate foreplay and when other causative factors have been eliminated. There are few drugs that have been shown to be of any specific use in the treatment of dyspareunia. Increasing libido with exogenous androgens may help with arousal and clitoral responsiveness but addresses few of the causes of dyspareunia. Sildenafil (ViagraÒ) and similar drugs improve blood flow and may relax vaginal smooth muscle but there is little evidence that they help in the management of dyspareunia.
Further investigations It is rare that further investigations are needed as the history and examination are most likely to lead to a complete assessment or at least reassurance that there are no major problems. Commonly used tests are vaginal swabs and microbiological culture, pelvic ultrasound and diagnostic laparoscopy. Many women will have had swabs taken by their family doctors and unless clinically indicated repeat of these is unnecessary. The use
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Systemic or local oestrogen replacement has been widely demonstrated to improve cellular turnover in the vaginal mucosa in perimenopausal or postmenopausal women with reductions in vaginal dryness, prolapse symptoms, and dyspareunia. There is no evidence to suggest that oestrogen supplementation in premenopausal women is of any help. Medical treatment of endometriosis which results in the reduction of overall disease activity may reduce dyspareunia. For these patients it is also important that they are aware that most drugs to treat endometriosis can result in a hypo-oestrogenic state within the vagina that may require ‘add-back’ with local or systemic drugs with oestrogenic activity.
Recently, Botox injections are used as an alternative treatment for vaginismus. A study from Iran using Botox for vaginismus was reported in 2004. In this study, Dysport (a type of Botox used in Europe) 150e400 mIU was used. Of the 23 patients participating in a study, 75% achieved satisfactory intercourse. Researchers reported that, there were no recurrences during the 24-month follow-up period. Chronic pelvic pain Managing a patient with chronic pelvic pain (CPP) can be very difficult. Though diagnostic laparoscopy allows both diagnosis and treatment recurrence of pain is common after both surgical and medical treatment. It can be difficult to accept mortality from an invasive procedure such as laparoscopy for a chronic condition. It may be prudent to treat patients with CPP with an empiric therapy. Evaluation of patients should begin with structured history and clinical examination and laboratory investigations and sonography. Selected cases with a specific abnormality should then receive tailored therapy. If a specific cause is not found a course of Doxycycline and Metronidazole may be given to rule out pelvic inflammatory disease. Patients should also be evaluated for irritable bowel disease and interstitial cystitis. If nothing is found, it is possible to treat with a course of NSAIDs and the oral contraceptive pill. If there is no improvement a diagnosis of endometriosis should be considered with an empirical trial of GnRh analogues and add back therapy. Patients with CPP who do not have endometriosis may also get better with this approach. This approach of empirical treatment (level II evidence) has been endorsed by the American College of Obstetrician and Gynaecologists.
Surgical management It is rare that surgery is needed for dyspareunia. Its use is generally limited to vulval and vaginal factors such as granulomata and scar tissue after lower genital tract damage following childbirth, developmental abnormalities and female genital mutilation. Pelvic surgery such as ablation of endometriosis, division of adhesions and removal of cysts or other benign tumours may be needed if they are diagnosed during investigations. If resources allow and if it is technically feasible surgery should be performed laparoscopically. This is usually easier for the patient to recover from with less postoperative pain and is less likely to result in significant pelvic adhesions which may further compound the problem. Laparoscopic photographs may be useful to demonstrate the problem before and after any intervention to help the patient understand her problem and how it was dealt with. Excision of rectovaginal endometriosis may be achieved laparoscopically or at laparotomy as it has been shown to be very effective in the reduction of dyspareunia associated with this condition.
Vulvodynia Recent guidelines for the treatment of provoked and unprovoked Vulvodynia have been published by the British Society for the Study of Vulval Disease. Less invasive treatment options such as local hygienic measures, dietary modifications, surface electromyography, biofeedback and medicines should be tried first. Tricyclic antidepressants (amitriptyline 50e100 mg), Gabapentin, and Carbamazepine are medications commonly used for treating idiopathic vulvodynia. Amitriptyline is the most favoured drug but high dose Gabapentin (900e3600 mg daily) may be effective. Surgery, effective for vulvar vestibulitis syndrome is considered in refractory cases only when all other conservative measures have been unsuccessful.
Vaginismus Combinations of behaviour modification, vaginal dilatation using vaginal trainers and emotional counselling form the mainstay of treating vaginismus. Behaviour modification consists of teaching the role of vaginal and pelvic floor muscles. The patient can be taught to contract and relax her pelvic floor and vaginal muscles. Initially the examiner teaches the patient to contract and relax her pelvic floor muscles by placing a finger in the introitus. Subsequently the patient can practice this technique of relaxation and contraction at home using her own finger to monitor muscle contractions. Vaginal capacity is normal in vaginismus and vaginal dilators are used not to increase the vaginal capacity but to facilitate the process of learning that something can be inserted in the vagina without causing pain. Therapy begins by asking the woman to insert the smallest diameter of vaginal trainer. At the outset relaxation may be a serious problem but most patients overcome this problem with sympathetic counselling. Once the patient is comfortable with the use of the trainers, the size can gradually be increased and eventually sexual intercourse is introduced. Initially penile insertion or penetration may be controlled by the patient but eventually full penetration and normal intercourse is achieved in the majority of the cases. Support from the partner and counselling directed towards reassurance and education are additional useful adjuncts of management.
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Conclusions Dyspareunia is a common and significantly under reported condition that has potential to significantly impair quality of life in women. Longstanding dyspareunia may result in avoidance of sex which may then impair relationships. Initiation of the consultation, raising the problem and discussing related issues with her healthcare provider and allowing physical examination may be very difficult for the patient. It is therefore very important to maintain a high level of professionalism, tact and sensitivity during the management of dyspareunia. Psychosexual problems should always be considered and if necessary an appropriate referral made. Management is usually directed to causative factors
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Pauls RN, Keelman SD, Karram MM. Female sexual dysfunction: principles of diagnosis and therapy. Obstet Gynecol Surv 2005; 60: 196e205. Quinn M. Obstetric denervation-gynaecological reinnervation: disruption of the inferior hypogastric plexus in childbirth as a source of gynaecological symptoms. Med Hypothesis 2004; 63: 390e3. Signorello LB, Harlow BL, Chekos AK, Repke JT. Postpartum sexual functioning and its relationship to perineal trauma: a retrospective cohort study of primiparous women. Am J Obstet Gynecol 2001; 184: 881e8. Simpkin S, Oakley A. Clinical review of 202 patients with vulval lichen sclerosus: a possible association with psoriasis. Aust J Dermatol 2007; 48: 28e31. Winkel CA. Role of a symptom e based algorithmic approach to chronic pelvic pain. Int J Obstet Gynecol 2001; 74(suppl): S15e20.
but if no physical problems are found the patient should feel reassured that all possible factors have been considered. Whether treatment has been instigated or advice given it is important to continue care to establish the outcome of any interventions. A
FURTHER READING Barrett G, Pendry E, Peacock J, Thakar R, Manyonda I. Women’s sexual health after childbirth. Br J Obstet Gynecol 2000; 107: 186e95. Dennerstein G, Scurry J. Vulva and vagina manual. CRC Press, 2005. Donnez J, Nisolle M, Squifflet J, Smeats M. Laparoscopic treatment of rectovaginal septum adenomyosis. In: Donnez J, Nisolle M, eds. An atlas of operative laparoscopy and hysteroscopy. London: The Parthenon Publishing Group, 2001; 83e92. Ghazizadeh S, Nikzad M. Botulinum toxin in the treatment of refractory vaginismus. Obstet Gynecol 2004 Nov; 104(5 Pt 1): 922e5. PMID: 15516379. Glazer HI, Ledger W. Clinical management of vulvodynia. Rev Gynecol Pract 2002; 2: 83e90. Haefner HK, Collins ME, Davis GD, et al. The vulvodynia guideline. J Low Genit Tract Dis 2005; 9: 40e51. Hayes RD, Bennett CM, Fairley CK, Dennerstein L. What can prevalence studies tell us about female sexual difficulty and dysfunction? J Sex Med 2006; 3: 589e95. doi:10.1111/j.1743-6109.2006.00241.x. Heim LJ. Evaluation and differential diagnosis of dyspareunia. Am Fam Physician 2001; 63: 1535e44. Heller DS, Wallach RC. Vulvar disease: a clinicopathological approach. CRC Press, 2006. Laumann EO, Paik A, Rosen R. Sexual dysfunction in the United States: prevalence and indicators. JAMA 1999; 281: 537e44. doi: 10.1001/jama.281.6.537. Lynch PJ, Moyal-Barrocco M, Bogliatto F, Micheletti L, Scurry J. 2006 ISSVD classification of vulvar dermatoses: pathologic subsets and their clinical correlates. J Reprod Med 2007; 52: 3e9. Mandal D, Nunns D, Byrne M, et al. British Society for the Study of Vulval Disease (BSSVD) Guideline Group. Guidelines for the management of vulvodynia. Br J Dermatol 2010; 162: 1180e5. Mohissi KS, Winkel CA. ACOG practice bulletin: clinical management guidelines for obstetrician-gynaecologist, number 11. ACOG, 1999. Mathias SD, Huppermann M, Liberman R, Lipschutz RC, Steege JF. Chronic pelvic pain: prevalence, health related quality of life, and economic correlates. Obstet Gynecol 1996; 87: 321.
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Practice points C
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Dyspareunia is a symptom of a variety of disease states with components of both organic and psychosexual dysfunction. Endometriosis, especially with rectovaginal deposits, and chronic PID are important causes of dyspareunia. In a significant proportion of patients no pathology is detected. Longstanding dyspareunia may give rise to avoidance of sex and relationship problems. A high level of professionalism, tact and sensitivity are required to obtain a sexual history in an outpatient setting. Psychosexual causes should be considered and appropriate referral made for counselling and assessment. A thorough clinical examination of the lower genital tract is necessary to exclude organic causes. Ultrasound of pelvis does not always provide additional information. Laparoscopy is a useful invasive procedure to diagnose and treat endometriosis. Endometriotic deposits can be missed at laparoscopy and recurrence is common. An empirical medical treatment after clinical diagnosis of endometriosis is effective and has the advantage of avoiding an invasive procedure. Patients who do not have endometriosis also get better with this approach.
Ó 2012 Elsevier Ltd. All rights reserved.
Dyspareunia in gynaecological practice
associated discomfort. This can often be associated with relationship problems. This article reviews the various causes of dyspareunia and outlines assessment and management of the problem.
Vladimir Revicky
Epidemiology
Sambit Mukhopadhyay Sexual problems can occur in heterosexual and homosexual relationships. They are reported by almost 43% of women. Between 16% and 75% of females have problems with desire, 16e48% with orgasm, 12e64% with arousal and 7e58% with dyspareunia. The incidence of dyspareunia is difficult to determine as many women do not seek medical attention. Incidence also depends on the population sampled and the definition used. A study from the United States looking at the prevalence of sexual dysfunction found only a small proportion of women with dyspareunia compared to women with other sexual dysfunctions such as decreased interest in sex, orgasmic difficulties and arousal difficulties. However in a study within a primary care setting, the prevalence of dyspareunia was as high as 46% among sexually active women. Women with symptoms severe enough to seek medical attention comprise a much smaller group.
Edward Morris
Abstract Dyspareunia is a form of sexual dysfunction that can significantly affect quality of life and cause relationship difficulties. It is a symptom of a variety of disease states with components of both physical and organic dysfunction. Obtaining a comprehensive sexual history in an outpatient setting requires a high level of professionalism. A systematic examination of the lower genital tract is necessary to rule out any obvious cause, though further investigations such as ultrasound infrequently provides additional information. Diagnostic laparoscopy is an invasive procedure that is of limited use in the first line investigation of dyspareunia but may help detect pelvic adhesions or endometriosis in those where this condition is suspected. Before embarking on a laparoscopy it is important for the patient to be aware of a management plan in the event that the laparoscopy is negative. There are data to suggest that empirical medical treatment after a clinical diagnosis of endometriosis is effective and has the advantage of avoiding any invasive procedures. Psychosexual causes are important to consider during the assessment of the patient experiencing dyspareunia.
Aetiology Dyspareunia is a symptom of variety of disease states with components of both organic and psychological dysfunction. Onset Primary (onset with the first sexual experience): Congenital abnormalities Psychosocial causes Sexual abuse in childhood Feeling of guilt or shame towards sex Fear of intercourse or painful first intercourse
Keywords dyspareunia; chronic pelvic pain; endometriosis; vulvodynia; vaginismus
Introduction
Secondary (previously normal sexual function): usually physical causes but psychological causes should also be considered (Box 1).
Dyspareunia is defined as sexual dysfunction manifested by genital pain experienced just before, during or after sexual intercourse. It is present in both sexes but is more common in women. The combinations of biological, psychological and interpersonal factors can play a part in development of dyspareunia. Usually an initial instigating factor causes pain but many patients cannot recall a specific moment when the pain started. Patients with dyspareunia can present with well-defined and localized pain or with a general dissatisfaction with sex due to
Frequency Persistent: symptoms occur with all partners in all situations. Possible causes include physical or psychosocial factors. Conditional: symptoms occur with certain positions, type of stimulation or a specific partner. Possible causes include both physical and psychological factors. Location Superficial or insertional: sharp, burning or stinging pain at or near the vaginal introitus. Commonly found in patients with vulvodynia and vaginismus. Can also be a conditioned response to unpleasant previous sexual experiences. Frequent cause of superficial dyspareunia is thrush or vaginal atrophy.
Vladimir Revicky MRCOG is a Specialty Registrar Obstetrics and Gynaecology at Norfolk and Norwich University Hospital NHS Foundation Trust, Norwich, Norfolk, UK. Conflicts of interest: none declared. Sambit Mukhopadhyay FRCOG is a Consultant Obstetrics and Gynaecology at Norfolk and Norwich University Hospital NHS Foundation Trust, Norwich, Norfolk, UK. Conflicts of interest: none declared.
Deep: pain felt within the pelvis with penile thrusting deep within the vagina. Possible causes include gynaecological conditions such as pelvic tumours, endometriosis, previous surgery and infections. Different sexual positions may also be relevant in aetiology.
Edward Morris FRCOG is a Consultant Obstetrics and Gynaecology at Norfolk and Norwich University Hospital NHS Foundation Trust, Norwich, Norfolk, UK. Conflicts of interest: none declared.
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Common causes Chronic pelvic pain (CPP) Chronic pelvic pain is defined as any pelvic pain that lasts for more than 6 months. It affects a large proportion of women of reproductive age. Intercourse is compromised, with pain in about 90% of patients with chronic pelvic pain. In the UK, an annual prevalence in primary care of 38/1000 was found in women aged 15e73. This is similar to the prevalence of asthma (37/1000) and back pain (41/1000). In over 60% of patients no etiological factor for CPP was identifiable. One of the most difficult to manage patient groups is those with a negative laparoscopy. There is no consensus on management of patients with no organic pathology and chronic pelvic pain. However, laparoscopy as a diagnostic tool is not always accurate. An empirical approach of treating CPP based on history and structured clinical evaluation will be discussed later.
Physical causes of dyspareunia Abdominopelvic disorders Chronic pelvic disorders Pelvic endometriosis Congenital disorders Imperforate hymen Vaginal septum Other urogenital developmental abnormalities Vulvar disorders Vulvodynia C Organic vulvodynia Infections Dermatological e.g. Lichen sclerosus Hormonal C
Endometriosis Common symptoms of endometriosis include pelvic pain, dysmenorrhoea, dyspareunia, abnormal menstrual bleeding (usually premenstrual spotting), and infertility. Dyspareunia is usually deep and a prominent symptom in association with rectovaginal endometriosis. However, many women with endometriosis are completely asymptomatic. The stage of endometriosis is often not correlated with the presence or severity of symptoms. This paradox may be explained by the hypothesis that symptoms are more related to a local peritoneal inflammatory reaction than the volume of the implants. Rectovaginal endometriosis is recognized as a separate disease entity in comparison to peritoneal endometriosis. On histology, rectovaginal endometriosis includes not only glands and stroma but also a dense fibromuscular reaction, which is more prominent than the fibromuscular reactions noted elsewhere in the pelvis. Treatment differs from peritoneal disease and is discussed below.
Idiopathic Essential vulvodynia Vestibulitis
Female genital mutilation Vaginal disorders Vaginitis Vaginismus Prolapse Trauma Vaginal dryness Menopause Inadequate arousal Inadequate foreplay Hormonal contraception
Chronic pelvic inflammatory disease Chronic pelvic inflammatory disease can give rise to pelvic pain and deep dyspareunia. Pelvic adhesions may form as a result of inflammatory processes in the pelvis. Adhesions can cause fixed retroversion of the uterus and may produce pain during deep penetration. However the role of adhesions deep dyspareunia is controversial. In the absence of fixed retroversion, presence of adhesions may not be the causal factor for dyspareunia. Adhesiolysis often fails to improve deep dyspareunia but may benefit a subgroup of women with severe dense and vascularized adhesions involving the bowel.
Uterine and ovarian factors Pelvic mass e.g. fibroids or ovarian cyst/mass Adenomyosis Prolapsed ovaries Gastrointestinal disorders Chronic constipation Diverticular disease Inflammatory bowel disease/proctitis Scarring Previous pelvic surgery Episiotomy Perineorrhaphy
Vulvodynia Vulvodynia is a chronic pain syndrome that affects the vulvar area and occurs without an identifiable cause or visible pathology. It refers to pain of the vulva unexplained by vulvar or vaginal infection or skin disease and is a diagnosis of exclusion. Vulvodynia has been classified by the International. Society for the Study of Vulvovaginal Diseases (ISSVD) to general vulvodynia, clitordynia, vestibulodynia and then whether it is provoked or unprovoked. The ISSVD recommend the removal of such terms as ‘vestibulitis’ in preference for the term of ‘provoked vulvodynia’ (Box 2).
Urological causes Cystitis Interstitial cystitis Urethritis
Box 1
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20% experience painful sexual intercourse. Sexual satisfaction also depends on sexual activity during pregnancy. Dissatisfaction with sexual relationship at 12 months after childbirth, assessed using a validated questionnaire, is associated with not being sexually active at 12 weeks of gestation and with an older maternal age at delivery.
International Society for the Study of Vulvovaginal Diseases (ISSVD) classification of vulval pain C
C
Vulvar pain related to a specific disorder Infectious (e.g. candidiasis, herpes, etc.) Inflammatory (e.g. lichen planus, immunobullous disorders, etc.) Neoplastic (e.g. Paget’s disease, squamous cell carcinoma, etc.) Neurologic (e.g. herpes neuralgia, spinal nerve compression, etc.)
Dyspareunia with normal pelvic organs Dyspareunia is commonly associated with chronic pelvic pain and clusters of other sensory pelvic symptoms that include dysmenorrhoea, tampon discomfort, urinary urgency, faecal urgency and irritable bowel symptoms. Laparoscopy and other investigations often fail to detect any organic pathology in a significant proportion of patients with chronic pelvic pain and dyspareunia. Myofascial injuries, including complete or partial avulsion of levator ani from its muscular origin and disruption of the endopelvic fascial supports, may be associated with these clinical presentations. Difficult intrapartum episodes such as a complicated operative vaginal delivery, prolonged maternal pushing or a big baby presenting with an occipitoposterior position may give rise to myofascial damage. Myofascial damage may result in denervation injuries of pelvic viscera. The initial denervation injury of any viscus has few clinical manifestations in the puerperium or possibly for several years afterwards. When reinnervation occurs in many cases it can be a chaotic process resulting in atypical nerve fibres within the uterus, cervix, bladder mucosa, rectal mucosa, vulva and uterosacral ligaments. Obstetric denervation and subsequent reinnervation may account for some patterns of sensory pelvic symptoms including dyspareunia. These symptoms usually present in clusters many years after initial obstetric injury.
Vulvodynia Generalized e Provoked (sexual, nonsexual, or both) e Unprovoked e Mixed (provoked and unprovoked) Localized (vestibulodynia, clitorodynia, hemivulvodynia, etc.) e Provoked (sexual, nonsexual, or both) e Unprovoked e Mixed (provoked and unprovoked)
Box 2
Vaginismus Clinically, it is often difficult to separate dyspareunia from vaginismus, since vaginismus may occur secondary to a history of dyspareunia or mild vaginismus is often accompanied by dyspareunia. Vaginismus is relatively rare. It is a physical response of involuntary spasm of the introital muscles (pubococcygeus) to psychological stress. Vaginismus has been reported by 4.2e12% of women attending outpatient clinics. Insertion of fingers, the penis or tampons are common triggers of the spasm. Negative attitudes towards sex and sexual ignorance have been associated with vaginismus. Predisposing factors include environmental factors, childhood sexual trauma and a background of religious orthodoxy.
Psychosexual causes A psychosexual disorder is a common cause of dyspareunia. Sexual desire disorders Hypoactive sexual desire disorder Sexual aversion disorder Sexual arousal disorder Orgasmic disorder Psychosexual medicine is a complex area in which dyspareunia may be a trigger or a symptom. It is therefore important to be aware of it as a problem and to explore potential psychological sources of sexual dysfunction. Frequent issues that may influence sexuality include: Sexual abuse as a child or within current or previous relationships Poor sexual education Physical or psychological domestic violence Cultural issues Relationship problems Work problems
Childbirth Childbirth can have a major impact on the sexual health of women. Many women experience perineal discomfort or pain after childbirth that can persist for a variable length of time, often impairing normal sexual function. Nearly 90% of women resume sexual activity within 3e4 months of childbirth but the sexual morbidity in the first few months is over 80%. Only 15% of women report sexual dysfunction to health professionals. Factors associated with time to resuming sexual intercourse are largely unknown. Resumption of sexual intercourse following childbirth depends on the mode of delivery, degree of perineal trauma, maternal age, breast-feeding, and ethnic background. Women were five times less likely to be sexually active after a third/ fourth degree anal sphincter tear as compared to woman with intact perineum. At 6 months post partum, approximately one quarter of primiparous women report a deficit in sexual sensation, sexual satisfaction, and ability to achieve orgasm, and over
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History taking Women rarely present with the symptom of dyspareunia alone, it is often an accompanying symptom that has to be raised in closed or direct questioning. If the patient volunteers pain with intercourse as her primary problem then this is a good sign for the ease with which further information can be obtained. The norm however is that the issue of dyspareunia may be more difficult to extract.
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General and gynaecological questions During this period of questioning it is important to relate the information obtained from the more specific questions above to many aspects of normal gynaecological history taking. Establish a current menstrual history if relevant including bleeding irregularities which may interfere with sex. At this point it is often useful to find out whether she has any difficulty inserting tampons. Take details of her reproductive history including any difficulties in conception. Details of previous episodes of pelvic infections, endometriosis, cysts, fibroids and surgery should also be taken. Other medical issues such as drug use or misuse, autoimmune, endocrine, neurological, urological and gastrointestinal conditions may be relevant and should also be recorded.
Most patients are happy to freely talk about pelvic pain and it is this avenue that is often the best way to introduce and explore dyspareunia. Asking the patient what her worries or concerns are can often uncover the real problem. This question is very important to ask, especially if it is becoming difficult to find any cause for the problem. It is often very difficult for patients to discuss sexual matters with someone they barely know and it is therefore of immense importance to ensure an understanding professional atmosphere during the consultation. She should feel unhurried and at ease and there should be no more people in the consultation room than are necessary. Permission should be sought for the presence of any additional personnel and if permission is given their presence should be considered if problems develop during history taking. Asking whether a woman is having any difficulties with sexual intercourse or sexual desire is often useful as a tool for establishing whether there is a problem. Patients should not be asked in the opening seconds of the consultation unless they raise it early on. Once it is established that dyspareunia is a problem then further details should be obtained from more systematic questioning. Below is a list of some questions that may be useful. It is important that you are flexible in your questioning and be aware that covering areas such as sexual problems during development, frequency of sex, frequency of sex or numbers of partners are potentially very difficult issues that should be asked only if the consultation appears to be progressing well.
Examination With any gynaecological examination tact and sensitivity to the patient’s problem is of utmost importance. With the examination of the patient complaining of dyspareunia it is very important to be even more aware of the wide range of causes and therefore to adapt the examination accordingly. This is especially relevant when examining a patient in whom a psychosexual causation is suspected. As discussed above an element of prior sexual abuse or sexual dysfunction may accompany the symptomatology which may lead to an examination that is painful for the patient, uninformative for the doctor and could damage the professional relationship, which could impede management strategies. The timing and setting of the examination may need to be flexible and the patient should feel reassured that within limits she has an element of control and can always stop the examination. Try to be aware that this may not be a ‘see and treat’ session, the patient may be stressed enough having raised such sensitive issues and may feel that examination should wait for another day. In practical terms this may be difficult to organize but as long as the patient is aware of the delays this may cause it is unlikely to cause too many problems, indeed she may find your flexibility encouraging. The setting should be private and quiet with no unnecessary staff. The patient should be reassured that no-one else can hear and there should be a chaperone regardless of the sex of the examining practitioner. If at all possible the patient should be offered the opportunity for the chaperone to be present from the beginning of the consultation. Before any physical examination can take place, go over the history again to ensure that it is tailored to the history as much as possible. This is to ensure that the most important areas are examined early on so that the more general examination points can be omitted if the patient becomes uncomfortable later in the process. Do not enter into the physical examination with the aim of reproducing symptomatology e this may unsettle the patient. It is far better to explain to her that the aim of examination is to ensure that there is no serious pathology causing her pain. Explain to her that if her pain is reproduced during examination she should say so and you will stop immediately. This is again to ensure that she feels in control.
Specific questions How long has this been a problem? What sort of pain is it? Has it shown any signs of getting any better or worse? Does it occur on every episode of intercourse? How often (approximately) do you have sex? Does the pain occur in relation to superficial or deep penetration? Does the pain occur on one side more often than the other? Is there any particular sexual position that worsens or improves the pain? Sexual history questioning Do you look forward to sex? Are you able to become aroused or lubricated during foreplay? Is the pain with sex having any effect on the relationship with your partner? When did you last change your sexual partner? Have you had the same pain with other partners? Do you have any similar problems if you masturbate? Did you have any sexual problems whilst growing up? Quantification of the problem is necessary to assess the effect of any treatment or counselling. Several validated instruments are available to elucidate the nature of sexual dysfunction. They address several issues including libido, arousal, orgasm, pain, and relationship factors. Examples include the Female Sexual Function Index (FSFI), the brief index of Sexual Function Questionnaire (SFQ) for women and the Female Sexual Distress Scale (FSDS).
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Abdominal examination Inspect for scars, looking out for evidence of previous laparoscopies or evidence of more major abdominal surgery. Ask before palpation to avoid causing more pain over tender areas. Make
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a note of such painful regions of the abdomen and only palpate there with her permission. Then palpate for any significant masses, especially uterine fibroids or large ovarian cysts, remembering to assess their tenderness and mobility.
of ultrasound is interesting in that as it becomes more widely used more women expect it to be part of the diagnostic process. In the absence of specific symptoms or findings on clinical examination it has not been demonstrated to be of significant merit. Its use as a tool of reassurance should not be underestimated. Laparoscopy, useful as a diagnostic and therapeutic tool when endometriosis or other organic pelvic pathology is suspected, carries significant morbidity and risks and should therefore only be used when it use can be justified. Laparoscopy is thought to be the gold standard for the diagnosis of endometriosis. The lesions of endometriosis have a heterogenous appearance and therefore, the accuracy of the diagnosis depends on the ability of the surgeon. Moreover nearly 60% of histologically documented endometriosis is missed at laparoscopy. In a series of 1300 patients undergoing laparoscopy for chronic pelvic pain, no pathological lesions were found in 40% of cases. Of the remaining 60%, 28% had endometriosis and another 20% had adhesions.
Vaginal examination It is vitally important to consider the presenting complaint during this part of the examination as a woman with superficial dyspareunia or severe vaginismus may stop the examination process if she is first examined with a speculum. For all patients a detailed inspection of the vulva is needed, gently parting the labiae, inspecting for normal anatomy, oestrogenization, dermatoses, candidiasis, cysts, warts, trauma, episiotomies, state of the hymenal ring, prolapse and size of the introitus. A careful inspection of the perineum and perianal area may also be performed at the same time but this should only be pursued if this is easy to do. Gentle palpation of the posterior band of skin at the introitus is also useful, especially in those with postnatal dyspareunia to feel for encapsulated suture knots or granulomata. In patients with severe vaginismus the next step is usually the passage of a small item such as a single finger. If this is tolerated the finger may be used to gently palpate the vaginal walls and if possible the cervix, during which time the presence of cervical motion tenderness can be assessed. Throughout this part of the examination communication with the patient is vital with encouragement and eye contact again with offers to stop if it is uncomfortable. If she tolerates this part of the examination then she should be offered a speculum examination. Hopefully the digital examination should have provided the necessary information to select the correct size of speculum. During speculum examination the speculum should be well lubricated and if possible warmed. Inspect carefully for anatomical abnormalities such as vaginal septae, double cervices and vaginal bands. Again inspection for evidence of infection, oestrogenization and trauma are required. Have available equipment for taking cervical smears and culture swabs as this may be an opportunistic time for these tests in an otherwise reluctant patient. Bimanual examination follows and often provides the most useful information e especially in those with deep dyspareunia. It is important to reassure the patient who feels she cannot tolerate bimanual examination that similar information can be obtained from further investigations. Specific features often obtained from bimanual examination are the presence of any rectovaginal nodules, pelvic masses, tenderness and cervical motion tenderness. If pain is elicited then its location and position should be noted, along with the point of the examination at which it was caused.
Management Treatment of dyspareunia can be a relatively simple process when there is a clearly defined cause; if the problem is corrected the patient’s return to normal sexual activity should be followed up. This is to ensure that resolution of the problems has been maintained but also that it is not assumed that the correction of one issue will be the end of the problem. It is not uncommon that correcting one problem is followed by a different one. Remain vigilant that rectification of many seemingly small potentially aetiological factors without curing the underlying problem may indicate an underlying psychosexual disorder which requires specialist referral. Psychosexual management If psychosexual factors are thought to be relevant it is important to consider a referral for psychosexual assessment. This is usually best presented to the patient as part of the whole management strategy to aid the patients’ acceptance of the need for this referral. Some patients, especially those who have insight, are happy to be referred for psychosexual management. Nevertheless, listening to the woman and understanding the nature of the problem and its impact on her relationship can be therapeutic for her. Medical management Treatment of dyspareunia includes the conservative approaches of ensuring that the patient is allowing sufficient time for arousal and lubrication, modification of technique to avoid painful sexual positions and elimination of other aetiological factors. If she fails to respond to these then it may be necessary to introduce lubricants. Again these should be used only after adequate foreplay and when other causative factors have been eliminated. There are few drugs that have been shown to be of any specific use in the treatment of dyspareunia. Increasing libido with exogenous androgens may help with arousal and clitoral responsiveness but addresses few of the causes of dyspareunia. Sildenafil (ViagraÒ) and similar drugs improve blood flow and may relax vaginal smooth muscle but there is little evidence that they help in the management of dyspareunia.
Further investigations It is rare that further investigations are needed as the history and examination are most likely to lead to a complete assessment or at least reassurance that there are no major problems. Commonly used tests are vaginal swabs and microbiological culture, pelvic ultrasound and diagnostic laparoscopy. Many women will have had swabs taken by their family doctors and unless clinically indicated repeat of these is unnecessary. The use
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Systemic or local oestrogen replacement has been widely demonstrated to improve cellular turnover in the vaginal mucosa in perimenopausal or postmenopausal women with reductions in vaginal dryness, prolapse symptoms, and dyspareunia. There is no evidence to suggest that oestrogen supplementation in premenopausal women is of any help. Medical treatment of endometriosis which results in the reduction of overall disease activity may reduce dyspareunia. For these patients it is also important that they are aware that most drugs to treat endometriosis can result in a hypo-oestrogenic state within the vagina that may require ‘add-back’ with local or systemic drugs with oestrogenic activity.
Recently, Botox injections are used as an alternative treatment for vaginismus. A study from Iran using Botox for vaginismus was reported in 2004. In this study, Dysport (a type of Botox used in Europe) 150e400 mIU was used. Of the 23 patients participating in a study, 75% achieved satisfactory intercourse. Researchers reported that, there were no recurrences during the 24-month follow-up period. Chronic pelvic pain Managing a patient with chronic pelvic pain (CPP) can be very difficult. Though diagnostic laparoscopy allows both diagnosis and treatment recurrence of pain is common after both surgical and medical treatment. It can be difficult to accept mortality from an invasive procedure such as laparoscopy for a chronic condition. It may be prudent to treat patients with CPP with an empiric therapy. Evaluation of patients should begin with structured history and clinical examination and laboratory investigations and sonography. Selected cases with a specific abnormality should then receive tailored therapy. If a specific cause is not found a course of Doxycycline and Metronidazole may be given to rule out pelvic inflammatory disease. Patients should also be evaluated for irritable bowel disease and interstitial cystitis. If nothing is found, it is possible to treat with a course of NSAIDs and the oral contraceptive pill. If there is no improvement a diagnosis of endometriosis should be considered with an empirical trial of GnRh analogues and add back therapy. Patients with CPP who do not have endometriosis may also get better with this approach. This approach of empirical treatment (level II evidence) has been endorsed by the American College of Obstetrician and Gynaecologists.
Surgical management It is rare that surgery is needed for dyspareunia. Its use is generally limited to vulval and vaginal factors such as granulomata and scar tissue after lower genital tract damage following childbirth, developmental abnormalities and female genital mutilation. Pelvic surgery such as ablation of endometriosis, division of adhesions and removal of cysts or other benign tumours may be needed if they are diagnosed during investigations. If resources allow and if it is technically feasible surgery should be performed laparoscopically. This is usually easier for the patient to recover from with less postoperative pain and is less likely to result in significant pelvic adhesions which may further compound the problem. Laparoscopic photographs may be useful to demonstrate the problem before and after any intervention to help the patient understand her problem and how it was dealt with. Excision of rectovaginal endometriosis may be achieved laparoscopically or at laparotomy as it has been shown to be very effective in the reduction of dyspareunia associated with this condition.
Vulvodynia Recent guidelines for the treatment of provoked and unprovoked Vulvodynia have been published by the British Society for the Study of Vulval Disease. Less invasive treatment options such as local hygienic measures, dietary modifications, surface electromyography, biofeedback and medicines should be tried first. Tricyclic antidepressants (amitriptyline 50e100 mg), Gabapentin, and Carbamazepine are medications commonly used for treating idiopathic vulvodynia. Amitriptyline is the most favoured drug but high dose Gabapentin (900e3600 mg daily) may be effective. Surgery, effective for vulvar vestibulitis syndrome is considered in refractory cases only when all other conservative measures have been unsuccessful.
Vaginismus Combinations of behaviour modification, vaginal dilatation using vaginal trainers and emotional counselling form the mainstay of treating vaginismus. Behaviour modification consists of teaching the role of vaginal and pelvic floor muscles. The patient can be taught to contract and relax her pelvic floor and vaginal muscles. Initially the examiner teaches the patient to contract and relax her pelvic floor muscles by placing a finger in the introitus. Subsequently the patient can practice this technique of relaxation and contraction at home using her own finger to monitor muscle contractions. Vaginal capacity is normal in vaginismus and vaginal dilators are used not to increase the vaginal capacity but to facilitate the process of learning that something can be inserted in the vagina without causing pain. Therapy begins by asking the woman to insert the smallest diameter of vaginal trainer. At the outset relaxation may be a serious problem but most patients overcome this problem with sympathetic counselling. Once the patient is comfortable with the use of the trainers, the size can gradually be increased and eventually sexual intercourse is introduced. Initially penile insertion or penetration may be controlled by the patient but eventually full penetration and normal intercourse is achieved in the majority of the cases. Support from the partner and counselling directed towards reassurance and education are additional useful adjuncts of management.
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Conclusions Dyspareunia is a common and significantly under reported condition that has potential to significantly impair quality of life in women. Longstanding dyspareunia may result in avoidance of sex which may then impair relationships. Initiation of the consultation, raising the problem and discussing related issues with her healthcare provider and allowing physical examination may be very difficult for the patient. It is therefore very important to maintain a high level of professionalism, tact and sensitivity during the management of dyspareunia. Psychosexual problems should always be considered and if necessary an appropriate referral made. Management is usually directed to causative factors
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Pauls RN, Keelman SD, Karram MM. Female sexual dysfunction: principles of diagnosis and therapy. Obstet Gynecol Surv 2005; 60: 196e205. Quinn M. Obstetric denervation-gynaecological reinnervation: disruption of the inferior hypogastric plexus in childbirth as a source of gynaecological symptoms. Med Hypothesis 2004; 63: 390e3. Signorello LB, Harlow BL, Chekos AK, Repke JT. Postpartum sexual functioning and its relationship to perineal trauma: a retrospective cohort study of primiparous women. Am J Obstet Gynecol 2001; 184: 881e8. Simpkin S, Oakley A. Clinical review of 202 patients with vulval lichen sclerosus: a possible association with psoriasis. Aust J Dermatol 2007; 48: 28e31. Winkel CA. Role of a symptom e based algorithmic approach to chronic pelvic pain. Int J Obstet Gynecol 2001; 74(suppl): S15e20.
but if no physical problems are found the patient should feel reassured that all possible factors have been considered. Whether treatment has been instigated or advice given it is important to continue care to establish the outcome of any interventions. A
FURTHER READING Barrett G, Pendry E, Peacock J, Thakar R, Manyonda I. Women’s sexual health after childbirth. Br J Obstet Gynecol 2000; 107: 186e95. Dennerstein G, Scurry J. Vulva and vagina manual. CRC Press, 2005. Donnez J, Nisolle M, Squifflet J, Smeats M. Laparoscopic treatment of rectovaginal septum adenomyosis. In: Donnez J, Nisolle M, eds. An atlas of operative laparoscopy and hysteroscopy. London: The Parthenon Publishing Group, 2001; 83e92. Ghazizadeh S, Nikzad M. Botulinum toxin in the treatment of refractory vaginismus. Obstet Gynecol 2004 Nov; 104(5 Pt 1): 922e5. PMID: 15516379. Glazer HI, Ledger W. Clinical management of vulvodynia. Rev Gynecol Pract 2002; 2: 83e90. Haefner HK, Collins ME, Davis GD, et al. The vulvodynia guideline. J Low Genit Tract Dis 2005; 9: 40e51. Hayes RD, Bennett CM, Fairley CK, Dennerstein L. What can prevalence studies tell us about female sexual difficulty and dysfunction? J Sex Med 2006; 3: 589e95. doi:10.1111/j.1743-6109.2006.00241.x. Heim LJ. Evaluation and differential diagnosis of dyspareunia. Am Fam Physician 2001; 63: 1535e44. Heller DS, Wallach RC. Vulvar disease: a clinicopathological approach. CRC Press, 2006. Laumann EO, Paik A, Rosen R. Sexual dysfunction in the United States: prevalence and indicators. JAMA 1999; 281: 537e44. doi: 10.1001/jama.281.6.537. Lynch PJ, Moyal-Barrocco M, Bogliatto F, Micheletti L, Scurry J. 2006 ISSVD classification of vulvar dermatoses: pathologic subsets and their clinical correlates. J Reprod Med 2007; 52: 3e9. Mandal D, Nunns D, Byrne M, et al. British Society for the Study of Vulval Disease (BSSVD) Guideline Group. Guidelines for the management of vulvodynia. Br J Dermatol 2010; 162: 1180e5. Mohissi KS, Winkel CA. ACOG practice bulletin: clinical management guidelines for obstetrician-gynaecologist, number 11. ACOG, 1999. Mathias SD, Huppermann M, Liberman R, Lipschutz RC, Steege JF. Chronic pelvic pain: prevalence, health related quality of life, and economic correlates. Obstet Gynecol 1996; 87: 321.
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Practice points C
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Dyspareunia is a symptom of a variety of disease states with components of both organic and psychosexual dysfunction. Endometriosis, especially with rectovaginal deposits, and chronic PID are important causes of dyspareunia. In a significant proportion of patients no pathology is detected. Longstanding dyspareunia may give rise to avoidance of sex and relationship problems. A high level of professionalism, tact and sensitivity are required to obtain a sexual history in an outpatient setting. Psychosexual causes should be considered and appropriate referral made for counselling and assessment. A thorough clinical examination of the lower genital tract is necessary to exclude organic causes. Ultrasound of pelvis does not always provide additional information. Laparoscopy is a useful invasive procedure to diagnose and treat endometriosis. Endometriotic deposits can be missed at laparoscopy and recurrence is common. An empirical medical treatment after clinical diagnosis of endometriosis is effective and has the advantage of avoiding an invasive procedure. Patients who do not have endometriosis also get better with this approach.
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