Dyspareunia

Question 1

What is dyspareunia?

Answer 1

Pain on intercourse

Question 2

What may happen in unmanaged dyspareunia?

Answer 2

Anticipation of pain leads to tense muscles and lack of lubrication, and so on to further pain (e.g. vaginismus)

Question 3

What types of dyspareunia exist?

Answer 3

Superficial (introital)

Deep (internal)

Question 4

What should be done if true vaginismus is suspected?

Answer 4

Do not examine; consider referral to psychosexual specialist

Question 5

What are the causes of deep dyspareunia?

Answer 5

Endometriosis
Chronic PID
Pelvic mass
IBS
Ovarian cyst

Question 6

What are the causes of superficial dyspareunia?

Answer 6

Vaginal/vulval infection
Surgery, childbirth
Psychological
Also: vulval disease, atrophic vaginitis

Question 7

What may be heard in a Hx of dyspareunia?

Answer 7

Deep/superficial
Timing
Sexual Hx
Other symptoms
Patient reaction to problem

Question 8

What may be found on examination of dyspareunia?

Answer 8

General
-Mental state
Abdominal
-Masses, tenderness
Pelvic
-Superficial = examine vulva and vagina (pinpoint tender areas)
-Deep = Uterine mobility, adnexal/uterosacral tenderness/thickening (?endometriosis)

Question 9

What Ix would be performed in dyspareunia?

Answer 9

Superficial
-High vaginal swab
-Cervical smear
Deep
-USS
-Laparoscopy

Question 10

How is superficial dyspareunia managed?

Answer 10

If painful ulceration
-Often herpes simplex
-Swab, contact tracing, acyclovir
If discolouration
-Vulvar intraepithelial neoplasia
-Biopsy, then treat
If thin red epithelium
-Atrophic vaginitis
-Topical oestrogen, HRT
If mass 
-Vaginal cyst, Bartholin abscess
-Surgery
If normal 
-Psychological/vaginismus
-Gradual dilatation, psychotherapy
If recent surgery/birth
-Perineal trauma
-Unless obvious abnormality, wait 6m before surgery (e.g. Fenton's repair)

Question 11

How is deep dyspareunia managed?

Answer 11

Do laparoscopy
If organic cause found
-treat (fibroids/retroverted uterus are rare as causes)
If pelvis normal
-Treat as chronic pelvic pain, consider psychotherapy

Question 12

What is dermatographism?

Answer 12

Rare cause of dyspareunia
Diagnosed by appearance of itchy vulval wheals after calibrated dermatographometer application
Cause unknown
Commonest physical cause of urticaria (appearance of linear wheal with bright red flare, but no angio-oedema, in response to firm stroke)

Question 13

How can dermatographism be treated?

Answer 13

Relief of dyspareunia achieved with 2% adrenaline cream, and cetirizine 10mg/24hr PO (anti-histimine)