Dyspareunia

1. See Also
   1. Female Sexual Dysfunction
   2. Chronic Pelvic Pain
   3. Vaginismus
   4. Vulvodynia
   5. Atrophic Vaginitis
   6. Vaginal Dryness
2. Definition
   1. Recurrent or persistent pain on vaginal penetration
3. Epidemiology
   1. Prevalence: 10-20% of women in the United States
   2. Age: More common on younger ages
4. Risk Factors: Contributing Psychological Factors (and complications of Dyspareunia)
   1. Female Sexual Dysfunction
      1. Impaired sexual desire (libido)
      2. Decreased sexual arousal
      3. Anorgasmia
   2. Mood Disorder
      1. Major Depression
      2. Anxiety
   3. Sexual abuse history
   4. Comorbidity
      1. Decreased overall health status
      2. Urinary tract symptoms
   5. Psychosocial factors
      1. Younger age
      2. Lower educational status (less than college degree)
      3. Emotional stressors
      4. Decrease in household income >20%
5. History
   1. See Chronic Pelvic Pain
   2. Proceed through history stepwise from least intrusive to most detailed
      1. Medical and surgical history
      2. Gynecologic and obstetric history
      3. Sexual history
      4. Sexually Transmitted Infection history
      5. Physical abuse or sexual abuse
      6. Symptoms with sexual activity
         1. Distinguish entry Dyspareunia from deep Dyspareunia
         2. Distinguish primary (from the first episode of sexual activity) and secondary Dyspareunia (later onset)
      7. Negative impacts of Dyspareunia
         1. Interpersonal relationships
         2. Self esteem
6. Exam
   1. See Chronic Pelvic Pain
7. Causes
   1. Entry or localized pain at the vaginal introitus
      1. Vulvodynia or Vulvar Vestibulitis
         1. Vulvar burning or irritation
      2. Vulvar Dermatitis (Vulvar Dermatoses)
         1. Papulosquamous Vulvar Dermatoses (e.g. Vulvar Lichen Sclerosus et atrophicus, Vulvar Lichen Planus, Contact Dermatitis, Psoriasis)
         2. Bullous Vulvar Dermatoses (e.g. Erythema Multiforme, Bullous Pemphigoid, Pemphigus)
         3. Genital Ulcers
         4. Systemic disease (e.g. Behcet's Disease, Systemic Lupus Erythematosus, Reiter's Syndrome)
      3. Peri-vaginal infection
         1. Vaginitis
         2. Human Papillomavirus
         3. Herpes Simplex Virus
      4. Atrophic Vaginitis or impaired vaginal lubrication
         1. See Vaginal Dryness
      5. Vaginismus
         1. Introitus muscles spasm on entry
      6. Urethral disorders or cystitis
         1. Urethritis symptoms
      7. Postpartum Dyspareunia
         1. Present after first deliveries in 41% at 3 months and 22% at 6 months
         2. Due to sclerotic healing (e.g. perineal Stretching and Lacerations, operative vaginal deliveries)
         3. Exacerbated by hypoestrogenic states (e.g. Breast Feeding) and psychosocial factors leading to decreased arousal
         4. Treat Vaginal Dryness as a first-line therapy
         5. Revision perineoplasty has been used in severe, refractory cases
   2. Pain on deep vaginal penetration
      1. Chronic Cervicitis
      2. Endometriosis
      3. Uterine Fibroids
      4. Pelvic adhesions
      5. Pelvic congestion
      6. Retroverted Uterus
      7. Interstitial Cystitis
      8. Pelvic infection
         1. Endometritis
         2. Pelvic Inflammatory Disease
8. Diagnosis
   1. DSM 5 now combines Dyspareunia with Vaginismus
   2. Dyspareunia diagnosis (and Vaginismus diagnosis) per DSM 5
      1. Pelvic Pain, anxiety or vaginal penetration problems for at least 6 months
9. Management
   1. See Specific causes
   2. See Female Sexual Dysfunction
   3. See Chronic Pelvic Pain Management
   4. See Vaginismus
   5. See Vulvodynia
   6. See Atrophic Vaginitis
   7. See Vaginal Dryness
10. References
    1. Heim (2001) Am Fam Physician 63(8):1535-44 [PubMed]
    2. Seehusen (2014) Am Fam Physician 90(7): 465-70 [PubMed]