Assessment of female dyspareunia

The condition may be revealed by the patients themselves or may be discovered during examination for some other reason e.g. – cervical smear

• many women will find it difficult to inform the clinician directly about dyspareunia and may use another symptom to introduce the subject e.g - recurrent vaginal discharge or pelvic pain
• consultation of these patients may be difficult and one needs to be sensitive and non judgemental when obtaining the history.
  • use open ended questions to obtain more information
  • begin with a general medical and surgical history before moving on to a gynecologic and obstetric history, followed by a comprehensive sexual history (1,2).

History:

• details of pain
  • where and when is the pain felt?
  • “too tight” to allow penetration? may have associated with vaginismus
  • if the pain is secondary, inquire about specific events, such as psychosocial trauma or exposure to infection, that might have triggered the pain
  • is the pain positional? pelvic structural problems, such as uterine retroversion, may be present
  • pain occurring each time she has intercourse?
    • if not, is there a difference when she doesn’t have pain
    • is she more relaxed and if so the possible reason?
  • any relationship,life events, menstrual cycle
  • sudden or chronic problem - an acute onset suggests an organic cause whilst a chronic problem is more suggestive of a psychosexual disorder
• other symptoms
  • vaginal discharge - may indicate infection or other pathology
  • is the patient depressed
  • pruritus may indicate eczema or vulvar dystrophy
• regarding the pregnancy
  • sex before the birth of the baby
  • was intercourse previously free of pain, and did she enjoy sex?
  • affects of pregnancy on sex?
  • the delivery
    • associated trauma during delivery?
    • any tears or episiotomies? Does she feel confident that it healed well?
• feeling about becoming parents
  • ask her what becoming parents has meant to them both
  • did they plan the pregnancy or not?
  • whether the baby sleeps with them? If so how do they feel about this?
  • use of contraceptives and whether she trust it?
  • still breastfeeding the baby?
• foreplay and non penetrative sexual behaviour
  • is she becoming aroused and lubricating? (arousal causes lubrication and expansion of the upper vagina)
  • does the patient reach orgasm?
• relationship with the partner
  • has childbirth affected the relationship with the partner? If so how?
  • do they find time to enjoy themselves as a couple? Are they affectionate?
  • is the patient aware of effect dyspareunia has on their sexual relationship or is it just the husband who views it as a problem (3)

Examination:

• physical examination may be deferred until the clinician establish a rapport with the patient
  • observe the patient's demeanour e.g - if she is tense, nervous or reluctant to have an intimate examination.
  • offer the patient an opportunity to participate during the pelvic examination e.g. – holding a mirror while the physician explain the findings
  • stop the examination immediately if she asks you to do so (1,2)
• physical examination should include:
  • abdominal examination
  • to detect any masses or abdominal wall tenderness
  • external genital examination – look for
    • areas of erythema or discoloration –infection or dermatologic disease, e.g. - lichen sclerosus or lichen planus
    • abrasions or other trauma - inadequate lubrication or forceful entry
    • dryness of the vaginal mucosa - atrophy or chronic vaginal dryness
    • abnormal discharge – infection
    • use a cotton swab to identify any focal areas of tenderness
  • internal examination
    • gentle digital examination should be attempted initially
      • look for muscular tightness, tenderness, or difficulty with voluntary contracting and relaxing - suggests pelvic floor muscle dysfunction
      • palpate the urethra, bladder, and cervix for causes of dyspareunia
    • a gentle bimanual examination
      • carried out after the single-finger examination if it is not too uncomfortable for the patient
      • check for pelvic and adnexal structures
    • a small speculum may be used for visualization of internal structures
• examination may reveal no pain at all and everything may look normal.

Reference:

• (1) Denman M. Investigating dyspareunia. GPonline 2012.
• (2) Seehusen DA, Baird DC, Bode DV. Dyspareunia in women. Am Fam Physician. 2014;90(7):465-70.
• (3) Ryan L, Hawton K. Female dyspareunia. BMJ. 2004;328(7452):1357