Dyspareunia is a commonly neglected condition that manifests with persistent or recurrent urogenital pain just before, during or following sexual intercourse, mostly due to physical or psychological causes. This disorder may be generalized, acquired and lifelong, causing substantial personal (and interpersonal) distress.
As both organic and psychosexual components may be responsible for dyspareunia, there is a need for a thorough patient assessment – including medical history, physical examination and psychological evaluation. Such multidisciplinary approach is warranted prior to any treatment interventions.
When evaluating a patient with dyspareunia, thorough medical, surgical, reproductive, psychiatric, sexual and social information should be sought. This should be supplemented with prior medical and reproductive history, current health status, thyroid and endocrine system review, as well as psychiatric evaluation.
Since pain is considered subjective, it is most often measured by using patient’s self-reporting. Moreover, any assessment should encompass a precise description of the location, quality, intensity and duration of the pain, as well as the degree of interference with individual’s sexuality.
Also, drug usage history should be taken, as a myriad of prescribed medications (such as alpha-blockers, beta-blockers, steroids, antipsychotics, antidepressants and anticonvulsants) may have serious sexual side-effects. Hence, it is crucial to make a timeline of drug use and compare it with the timeline of sexual pain occurrence.
Physical examination entails a mandatory visual inspection of both external and internal genital structures to determine potential etiology of pain. The mucosal surfaces have to be inspected in detail for areas of discoloration or redness, which may point to certain dermatological conditions or infections.
Forceful entry or deficient lubrication may present with abrasions or other types of trauma. The use of cotton swab is a way towards exact identification of the source of pain, as it may be used to collect discharge (when present) for further testing. Dry vaginal mucosa suggests atrophic changes or chronic vaginal dryness, while abnormal discharge may point towards an infectious source.
The internal examination procedure should generally be performed by using a single finger in order to maximize the comfort of the affected individual. Muscular tenderness or difficulties with voluntary contractions and relaxations suggest dysfunction of the pelvic floor muscle. The urethra, urinary bladder and cervix should be palpated to exclude potential causes of dyspareunia linked to these organs (e.g. endometriosis).
Such single-finger exams should be followed by a bimanual examination to evaluate structures found in the pelvis (of course, if this procedure is not too uncomfortable for the affected woman). A small speculum is used to visualize internal structures, while tests for sexually transmitted diseases are pursued if there is a discharge present, or a history of unprotected sexual intercourse.
As dyspareunia may include both sensorial and affective aspects, there is a need for meticulous psychological evaluation. This often supplements physical examination and provides useful information about potential predisposing factors (such as familial influences, sexual experiences, and potential history of sexual abuse or trauma).
Moreover, difficulties that arise in a marriage or relationship should always be documented, even though it is often impossible to separate cause from consequence. The main reason is because a patient with dyspareunia often has significantly higher levels of mood disturbances and hypervigilance, as well as lower thresholds of pain tolerance and/or endurance.
Specific sexuality questionnaires that are an indispensable part of self-administered measures play a pivotal role in both the diagnosis and treatment of dyspareunia, primarily by providing specific indicators used to evaluate the treatment outcomes. These questionnaires often reflect characteristic behaviors which are prime targets of clinical interventions.
Reviewed by Afsaneh Khetrapal Bsc (Hons)