Dyspareunia resident survival guide

Jump to navigation Jump to search
Dyspareunia Resident Survival Guide Microchapters
Overview
Causes
Diagnosis
in Female
in Male
Treatment
Do's
Don'ts


Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Roghayeh Marandi

Synonyms and Keywords: Dyspareunia management guide, pain, sexual activity, counseling

Overview

Dyspareunia is recurrent or persistent pain with sexual activity that causes marked distress or interpersonal conflict. It can affect men but more common among women. It can be due to psychological factors, physical factors, or combined factors among both males and females. Dyspareunia and vaginismus have been grouped as genito-pelvic pain/penetration disorder in DSM-5. This is defined as persistent or recurrent difficulty in vaginal penetration, marked pelvic or vulvovaginal pain during or while attempting penetration, fear or anxiety about pain before, during, or after penetration, and tightening or tensing of the pelvic floor muscles when penetration is attempted.[1]. It may be classified into two types among women that include superficial and deep dyspareunia. Causes are divided into three groups according to onset and frequency. Onset can be divided primary or secondary. Primary causes often include psychological issues. Based on the frequency, dyspareunia can be persistent, and possibly due to physical or psychological factors, or conditional dyspareunia. Abdomino-pelvic disorders such as endometriosis, imperforate hymen, vaginal septum, vulvar and vaginal infections, lichen sclerosis, prolapse, trauma, or vaginal dryness can cause dyspareunia. It may also be caused by gastrointestinal disorders and scarring from previous pelvic surgery. Male dyspareunia is divided into broad categories based on the underlying causes, and ranges from anatomic anomalies to psychosocial problems. Male dyspareunia can be divided into four broad categories: Isolated painful ejaculation, Chronic prostatitis/chronic pelvic pain, medical causes, and psychological causes. The management is based on identifying the underlying cause. Treatment ranges from psychosexual therapy, medications or surgery. Multimodal sex therapy, consisting of individual and couples therapy and other interventions such as cognitive–behavior techniques, is an important part of the multidisciplinary approach to these disorders.

Causes

Causes of dyspareunia in females[2][3][4][5][6][7]

Causes of dyspareunia in males[8]

Diagnosis

Shown below is an algorithm summarizing the diagnosis of dyspareunia.[9][10][11][12][13]

Dyspareunia in Female

 
 
 
 
 
 
 
Assessment of dyspareunia in female
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
History and physical exam
❑ Ask about the pain characteristics:
❑ Timing, duration, quality, location

Ask about associated vulvovaginal symptoms:

Itching
❑ Burning
Irritation
❑ Abnormal discharge

Take musculoskeletal history:

Pelvic floor surgery, trauma, obstetrics

Take bowel and bladder history:

Constipation, diarrhea, urgency, frequency

Obtain sexual hsitory:

❑ Frequency, desire, arousal, satisfaction, relationship

Obtain psychological history:

Mood disorder, anxiety, depression

Inquire about any history of abuse:

❑ Sexual, physical, neglect

Physical exam:

❑ Look for any abnormal areas of erythema or edema, white patches, vulvular scarring, ulcers on external genitalia

Vagina and cervix examination:

❑ Look for any erythema, erosions, atrophy, discharge

Evaluation of external musculoskeletal:

❑ complete lower back, abdomen, and pelvic examination

external visual and sensory examination
internal single digit palpation of the pelvic floor
bimanual examination for evaluation of:

uterus, cul-de-sac, and adnexal regions
❑ the internal vaginal tissue, cervix

Work up:
❑ Vaginal secretions:

❑ vaginal pH and saline wet mount and 10% KOH microscopy

If history is suggestive, perform:

NAAT test for gonorrhea, chlamidia,trichomonas
herpes simplex virus (HSV) culture, HSV-1 and HSV-2 type specific IgG antibodies
rapid plasma reagent (RPR)

Vulvar or vaginal biopsy for dermatological problems, malignancy
Urine analysis,culture for urological problems
CBC
Glucose
Hormones:
Prolactin, TSH, FSH,LH, Testosterone
Ultrasound of plevis
Laproscopy

More detail evaluations for systemic disorders
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Genital alterations

Atrophic vaginitis
Endometrial conditions:
Endometriosis
Episiotomy
Estrogen deficiency
❑ Estrogen-based contraceptives

Gynaecological conditions:

❑ Atrophic vulvitis
Atrophic vulvovaginitis
Premenopause
Menopause
❑ Autoimmune interstitial cystitis
❑ Bartholin gland cyst
Bartholinitis
❑ Chronic pain syndromes
Congenital absence of lower part of vagina
Prolactin secreting tumor
❑ Female genital mutilation
❑ Genital system cancer
Genital tract tumor
❑ Genital ulcers
Gonorrhea
❑ Gynecologic surgery
❑ Healed perineal lacerations
Hemorrhoids
❑ Imperforate hymen
Inflamed hymeneal orifice
Lactation
Prolactinoma
Prolactin secreting tumors
❑ Myofascial pelvic pain syndrome
❑ Narrow vagina
❑ Obstetric perineal injury
❑ Obstetric surgery
Ovarian tumour
❑ Poor vaginal lubrication
❑ Post-childbirth
❑ Provoked vulvar pain
❑ Unruptured hymen
❑ Remnants of the hymen
Vaginal cancer
Vaginal abnormality
Vaginal dryness
Vaginal surgery
Postradiation therapy
Vaginismus or Genito-Pelvic/Penetration disorder
❑ Vulvar infection
❑ Vulval dystrophy
❑ Vulval neoplasia
❑ Vulvar vestibulitis syndrome
❑ Vulvitis
Vulvodynia
Vulvovaginitis

Pelvic disorders::

❑ Pelvic adhesions
❑ Pelvic infection
Pelvic inflammatory disease
❑ Pelvic malignancy
Pelvic organ prolapse
Interstitial cystitis
Renal nutcracker syndrome
Pelvic tumor
❑ Prolapsed tender ovaries with retroverted uterus
❑ Uterine sarcoma
Salpingo-oophoritis
❑ Virilising ovarian tumour

Dermatological problems:

Contact dermatitis
Allergic dermatitis
Lichen sclerosis
Lichen planus
 
 
Systemic disorders/Comorbid conditions/Medications
 
Psychological problems

Anxiety
Depression
❑ Reduced libido
❑ Relationship dysfunction
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Dyspareunia in Male

 
 
 
 
 
 
 
Assessment of dyspareunia in male
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
History and physical exam

Ask about Pain Characteristics:
❑ Timing, duration, quality, location
Ask about associated symptoms:
Itching
❑ Burning
Irritation
❑ Abnormal discharge
Take musculoskeletal history:
Surgery, trauma
Take bowel and bladder history:
urgency, frequency
Obtain sexual hsitory:
❑ Frequency, desire, arousal, satisfaction, relationship
Obtain psychological history:
Mood disorder, anxiety, depression
Inquire about any history of abuse:
❑ Sexual, physical, neglect
Physical exam:
❑ Look for any abnormal areas of erythema or edema, white patches,deformity, scarring, ulcers on external genitalia
Look for:
Peyronie's plaques
superficial lesions
short frenulum
phimosis
bulbocavernosus reflex for initial diagnosis of pudendal nerve entrapment
Evaluation of external musculoskeletal:
❑ complete lower back, abdomen, and pelvic examination
external visual and sensory examination
Medication history
Work up:
If history is suggestive of sexually transmitted disease, perform: ❑ NAAT test for gonorrhea, chlamydia on discharge
herpes simplex virus (HSV) culture, HSV-1 and HSV-2 type specific IgG antibodies
rapid plasma reagent (RPR)
❑ penile biopsy for dermatological problems, malignancy
Urine analysis, culture for urological problems
blood count
Glucose
cystoscopy
transrectal ultrasonography (TRUS)
abdominal ultrasonography
computerized tomography
uroflowmetry
specialized tests to rule out
a neurogenic origin
abdominal masses
congenital anomalies
More detailed evaluations for systemic disorders
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Genital alterations

A:
❑ Tight foreskin (Phimosis)
❑ Growths, cysts, warts, and lumps in the penis
❑ little tears in the foreskin
Peyronie's disease
❑ Thrush or male [[]]candidiasis
❑ Sexually transmitted infections ( STIs) including herpes
Skin irritation caused by an allergic reaction to a particular brand of condom or spermicide
❑ Sharp pain during penetration can be caused by threads of an intrauterine contraceptive device (for birth control) that protrude from the woman’s cervix
Isolated painful ejaculation due to:
Urethritis
Prostatitis
Epididymitis
Orchitis
❑ Abdominal abscess
Penile prosthesis
Bladder cancer
❑ Intra-abdominal tumors
Prostate cancer
Vesical calculi
Benign prostatic hyperplasia (BPH)
Urethral stricture
❑ Pelvic musculature spasm
Radical prostatectomy
❑ Transurethral resection of the prostate (TURP)
Vasectomy
Frenulum breve

❑ Several dermatologic conditions of the penis such as:

lichen planus
lichen sclerosis
Zoon's (plasma cell) balanitis
balanoposthitis
 
 
Comorbid conditions/Medications
 
Psychological problems

Anxietyaround sex or guilt
Depression
❑ A strict religious upbringing
❑ Relationship dysfunction
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Treatment

Shown below is an algorithm summarizing the treatment of dyspareunia.[3][14]

 
 
 
 
 
 
 
 
 
 
 
 
 
 
Treatment of dyspareunia:
❑ It depends on the underlying cause and subsequent therapy (see table below for details)
❑ Educating patients about pelvic anatomy, physiology, and lifestyle modifications
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Medical Treatment

❑ Specific treatment for the identified cause
Topical anesthetics
❑ Oral anti-inflammatory agents
Botox and trigger point injections
❑ Topical hormonal treatments
Pelvic floor physical therapy & kegel excercise
Alpha-blockers for idiopathic painful ejaculation
 
 
 
 
Psychosexual Therapy:
❑ Oral tricyclic antidepressants
❑ Referral for couple sexual counseling or therapy to explore non-penetrating pleasuring techniques (as appropriate)
Cognitive behavioral therapy
 
 
Surgical Treatment

Surgery is performed as a last resort when all conservative and medical management options have failed or when surgery is indicated in situations such as:
Endometriosis
Adhesion
pelvic organ prolapse
Tumors
Peyronie's disease in males
❑ Circumcision for phimosis and frenulum
Neurectomy for post-herniotomy pelvic pain
❑Vulvar vestibulectomy in provoked vestibu-lodynia (PVD)
❑ Release of Alcock's canal, sacro-spinal, and sacro-tuberous ligaments in Pudendal nerve entrapment
 
 
 
 
 
 
 

Do's

Don'ts

References

  1. https://doi.org/10.18192/uojm.v7i2.2198
  2. https://www.acog.org/patient-resources/faqs/gynecologic-problems/when-sex-is-painful
  3. 3.0 3.1 Sorensen J, Bautista KE, Lamvu G, Feranec J (March 2018). "Evaluation and Treatment of Female Sexual Pain: A Clinical Review". Cureus. 10 (3): e2379. doi:10.7759/cureus.2379. PMC 5969816. PMID 29805948.
  4. Yong PJ, Williams C, Yosef A, Wong F, Bedaiwy MA, Lisonkova S, Allaire C (September 2017). "Anatomic Sites and Associated Clinical Factors for Deep Dyspareunia". Sex Med. 5 (3): e184–e195. doi:10.1016/j.esxm.2017.07.001. PMC 5562494. PMID 28778678.
  5. Thomas HM, Bryce CL, Ness RB, Hess R (February 2011). "Dyspareunia is associated with decreased frequency of intercourse in the menopausal transition". Menopause. 18 (2): 152–7. doi:10.1097/gme.0b013e3181eeb774. PMC 3026887. PMID 20962696.
  6. Kumar K, Robertson D (June 2017). "Superficial dyspareunia". CMAJ. 189 (24): E836. doi:10.1503/cmaj.161337. PMC 5478410. PMID 28630360.
  7. Shum LK, Bedaiwy MA, Allaire C, Williams C, Noga H, Albert A, Lisonkova S, Yong PJ (September 2018). "Deep Dyspareunia and Sexual Quality of Life in Women With Endometriosis". Sex Med. 6 (3): 224–233. doi:10.1016/j.esxm.2018.04.006. PMC 6085224. PMID 29801714.
  8. Krassioukov A, Elliott S (2017). "Neural Control and Physiology of Sexual Function: Effect of Spinal Cord Injury". Top Spinal Cord Inj Rehabil. 23 (1): 1–10. doi:10.1310/sci2301-1. PMC 5340504. PMID 29339872.
  9. Meana M, Binik YM, Khalife S, Cohen DR (October 1997). "Biopsychosocial profile of women with dyspareunia". Obstet Gynecol. 90 (4 Pt 1): 583–9. doi:10.1016/s0029-7844(98)80136-1. PMID 9380320.
  10. Mulherin DM, Sheeran TP, Kumararatne DS, Speculand B, Luesley D, Situnayake RD (September 1997). "Sjögren's syndrome in women presenting with chronic dyspareunia". Br J Obstet Gynaecol. 104 (9): 1019–23. doi:10.1111/j.1471-0528.1997.tb12060.x. PMID 9307528.
  11. Bhadauria S, Moser DK, Clements PJ, Singh RR, Lachenbruch PA, Pitkin RM, Weiner SR (February 1995). "Genital tract abnormalities and female sexual function impairment in systemic sclerosis". Am. J. Obstet. Gynecol. 172 (2 Pt 1): 580–7. doi:10.1016/0002-9378(95)90576-6. PMID 7856689.
  12. Clayton AH, Croft HA, Handiwala L (March 2014). "Antidepressants and sexual dysfunction: mechanisms and clinical implications". Postgrad Med. 126 (2): 91–9. doi:10.3810/pgm.2014.03.2744. PMID 24685972.
  13. Luzzi GA, Law LA (November 2006). "The male sexual pain syndromes". Int J STD AIDS. 17 (11): 720–6, quiz 726. doi:10.1258/095646206778691220. PMID 17062172.
  14. https://doi.org/10.18192/uojm.v7i2.2198
  15. Slowinski J (2001). "Multimodal sex therapy for the treatment of vulvodynia: a clinician's view". J Sex Marital Ther. 27 (5): 607–13. doi:10.1080/713846805. PMID 11554226.