Dyspareunia resident survival guide

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.. 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

• Superficial dyspareunia: Occurs in or around the vaginal entrance, and is characterized by initial discomfort in initial or attempted penetration of the vaginal introitus. Causes include:
  • Vaginismus, infections (such as HSV and candidiasis), trauma, vaginal septum, or organic vulvodynia due to infection, or vestibulitis, prolapse, lichen sclerosis, vaginal infections, and imperforate hymen.
  • Scarring due to previous pelvic surgery, episiotomy, and perineorraphy, or urological causes such as cystitis, interstitial cystitis, or urethritis can cause dyspareunia as well.
• Deep dyspareunia is caused by pelvic thrusting during intercourse. The causes are divided into three groups according to the onset and frequency.
• Based on the onset:
  • Primary (onset with the first sexual experience): Psychological, such as sexual abuse during childhood, feeling of guilt or shame toward sex, fear of intercourse, or painful first intercourse.
  • Secondary: Begins after a painless previous sexual activity. Causes include pelvic inflammatory disease, vaginal dryness in perimenopause and menopause.
• Based on the frequency:
  • Persistent dyspareunia: could have physical or psychological factors.
  • Conditional dyspareunia: Occurs in certain situations. Causes include: Endometriosis, chronic constipation, diverticular diseases, inflammatory bowel disease and proctitis.

Causes of dyspareunia in males

• The causes of male dyspareunia can be classified into four broad categories:
  • Isolated painful ejaculation
  • Chronic prostatitis/chronic pelvic pain
  • Medical causes
  • Psychological causes.

Diagnosis

Shown below is an algorithm summarizing the diagnosis of dyspareunia.

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 ❑ Sjögren's syndrome ❑ Systemic sclerosis ❑ Vulvar Crohn's disease ❑ Inflammatory bowel disease ❑ Irritable bowel syndrome ❑ Parkinson's disease ❑ Peripheral neurpathies ❑ Fibromyalgia ❑ Behçet's syndrome ❑ Diabetes ❑ Medications: ❑ Some antidepressants ❑ antihistamines ❑ antihypertensive ❑ birth control, or sedatives can decrease lubrication, potentially making intercourse painful

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 ❑ chronic prostatitis/chronic pelvic pain ❑ Hernia repair ❑ Pudendal nerve entrapment ❑ Medications: ❑ Trycyclic antidepressants ❑ Selective serotonin re-uptake inhibitors (SSRIs) ❑ Monoamine oxidase inhibitors (MAOIs) ❑ Antipsychotics

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

Treatment

Shown below is an algorithm summarizing the treatment of dyspareunia.

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

• Use of a water-based lubricant with intercourse.
• Women with chronic dyspareunia who feel that the pain is having a significant impact on libido or psychosexual self-image should be referred for counseling.
• 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.

Don'ts

• Avoiding soaps and chemical irritants to decrease vulvar or vestibular inflammation.