Dyspareuria

 Dyspareunia can affect all genders, but it is most commonly reported in women. Therefore, this article focuses on dyspareunia in women.

Red flag symptoms

• Dysmenorrhoea
• Intermenstrual bleeding
• Menorrhagia
• Pelvic discharge
• Pelvic pain
• Postcoital bleeding
• Unintentional weight loss
• Fever

Classification

Dyspareunia can be classified as primary or secondary, and as superficial or deep.

• Primary: pain on intercourse since the onset of sexual activity.
• Secondary: development of pain during a patient's sexual lifetime.
• Superficial: symptoms are localised to the introitus, vulva, and vestibule.
• Deep: symptoms relate to the pelvis.

History

There are many causes of dyspareunia. A complete gynaecological history, including sexual history and any history of abuse, is imperative. Although a pelvic examination can be a key element of the work-up, it may not always be necessary.

The consultation may be difficult and clinicians need to be sensitive to the patient in broaching this subject. Creating a rapport with the patient by using open-ended questions may help communication.

Of note, dyspareunia may not be a presenting symptom and may be revealed in response to a screen in a person presenting with other gynaecological symptoms (for example, inter-menstrual bleeding or post-coital bleeding).

The main things to establish in the history are the onset and location of symptoms and any associated complaints.

• Associated pruritus may indicate eczema, candidiasis, or vulvar dystrophy.
• Dysmenorrhoea and sharp pains may indicate endometriosis.
• Pelvic aching may suggest fibroids, and tearing pains may allude to vaginal atrophy.
• A past medical history of cancer that required chemotherapy or radiotherapy may have resulted in vaginal atrophy, fibrosis or adhesions.
• Drugs, such as the contraceptive pill, some antidepressants and antihypertensives, can reduce vaginal lubrication.
• A past obstetric history of traumatic childbirth, or episiotomies, may result in dyspareunia.
• A detailed sexual history may be relevant.
• Any psychological trauma may be very relevant. For example, experiencing sexual assault or abuse. 

Examination

Examination should begin with inspection of the external genitalia. Look out for any dermatological abnormalities or infective lesions, such as herpes simplex virus sores. Pale vaginal mucosa may suggest vaginal atrophy, and candidiasis may also be very obvious on examination.

Depending on the history, an internal exam should also be considered. Mucopurulent discharge may suggest cervicitis or pelvic inflammatory disease. Bimanual examination may show fibroids. Other important features on examination may be a degree of prolapse.

Pale vaginal mucosa may suggest vaginal atrophy.

Investigations

In many cases of dyspareunia, investigations are not necessary. However,  you may wish to consider vaginal swabs for chlamydia and gonorrhoea if pelvic inflammatory disease is suspected. Herpes simplex virus polymerase chain reaction (PCR) swabs may also be pertinent. Other potential investigations are listed below.

• A urinalysis may reveal a urinary tract infection.
• A pelvic ultrasound can be useful to show fibroids or a hydrosalpinx.
• A cystoscopy may be necessary to identify interstitial cystitis.
• A diagnostic laparoscopy may be relevant for suspected endometriosis.

Possible causes of dyspareunia

• Bartholin's cyst
• Cervicitis
• Endometriosis
• Herpes simplex virus
• Iatrogenic causes
• Irritable bowel syndrome
• Inflammatory bowel disease (occasionally)
• Ovarian cysts
• Pelvic inflammatory disease
• Psychosexual syndrome
• Vaginal atrophy (secondary to menopause)
• Vaginismus
• Vaginitis and vulvovaginitis
• Vulvodynia

This article was updated by Dr Pipin Singh, a GP in Northumberland in February 2024. It was written originally by Dr Mehul Mathukia and updated in June 2020 by Dr Anish Kotecha a GP in Gwent.