Dyspareunia

Differential Diagnosis

To reach the exact diagnosis of dyspareunia is a tricky one as it can be confused with other disorders of similar complaints. Several disorders must be ruled out based upon the history and physical examination before making the diagnosis of dyspareunia. Some of these are listed below:

• Vulvodynia
• Vaginismus
• Atrophic vaginitis
• Vulvar vestibulitis
• Endometriosis and pelvic adhesions 
• Uterine fibroids
• Pelvic congestion
• Pelvic inflammatory disease, endometritis
• Other urogenital tract infections

Vaginismus

• Experience of pain with penetration, with or without associated muscle spasm
• Often perpetuating cycle
• Treatment can include
  • Vaginal dilatation
  • Desensitisation and relaxation techniques
  • Psychology/sex therapy/ CBT
  • Pelvic floor physiotherapist

Consider

• Details of pain during intercourse, location, age of onset, tampon use
• Sexual history
• Menstrual cycle
• Pelvic pain history
• Obstetric history
• STI screening
• CST
• Medical/surgical history
• Mental health history – ?contributing factors

Causes

• Vaginismus – primary or secondary
• Vulvodynia
• Endometriosis
• STI and PID
• Anxiety, sexual assault

Examination

• Abdominal
• External genitalia/vulva for lesions, lichen sclerosis, atrophy
• Pelvic examinatoin – vulvodyniea, adnexal tenderness, cervical motion
• Speculum if tolerated

Investigations

• STI testing
• Consider urine MCS

Treatment and Management of Dyspareunia

Multimodal Treatment Approach:

• A comprehensive treatment strategy is essential, addressing physical, emotional, and behavioral aspects of pain.
• The treatment team should include a gynecologist, pain management expert, physical therapist, sexual therapist, and mental health professionals specializing in chronic pain.

Initial Steps:

1. Acknowledgment: The physician must validate the patient’s pain and counsel them on the potential duration and challenges of treatment.
2. Education: Inform the patient about all available treatment options, assisting them in selecting the most suitable one.
3. Conservative Approach: Begin with nonsurgical treatments.

Medical Treatment Options:

• Oral Tricyclic Antidepressants: Useful for neuropathic pain.
• Hormonal Replacement Therapy (HRT): Both oral and topical HRT can be effective, particularly for post-menopausal vaginal atrophy. Options include systemic and topical hormone therapy, selective estrogen receptor modulators, and vaginal dehydroepiandrosterone.
• Nonsteroidal Anti-Inflammatory Drugs (NSAIDs): Can help manage pain and inflammation.
• Botox Injections: Effective for dyspareunia due to pelvic floor myalgia and contracture.
• Cognitive Behavioral Therapy (CBT): Highly recommended for reducing anxiety and fear associated with dyspareunia.
• Brain-Based Therapies: Other therapeutic approaches targeting the brain’s response to pain.

Specific Treatments Based on Etiology:

• Infectious Causes: Treat with appropriate antibiotics, antifungals, or antivirals based on culture results.
• Post-Menopausal Atrophy: Manage with HRT and other hormonal therapies.
• Post-Partum Dyspareunia: Responds to vaginal lubricants, scar tissue massage, or surgery if persistent.
• Pelvic Floor Myalgia: Botox injections and pelvic floor physical therapy are beneficial.

Adjuvant Treatments:

• Pelvic Floor Physical Therapy: Helps relax pelvic floor muscles and re-educate pain receptors.
• CBT: Proven to reduce anxiety and fear related to dyspareunia, commonly used as a behavioral intervention.

Surgical Treatment:

• Reserved as a last resort when conservative medical and behavioral treatments fail.
• Useful for identifying and treating pelvic adhesions, endometriosis, and pelvic organ prolapse.

Prognosis of Dyspareunia

The prognosis of dyspareunia largely depends on its underlying cause:

• Curable Causes: When the cause is identified and treatable, the prognosis is generally favorable. Conditions such as infections, hormonal imbalances, or anatomical issues can often be managed effectively with appropriate treatment.
• Idiopathic Dyspareunia: The prognosis is poorer when the cause is unknown (idiopathic). In these cases, treatment may focus on symptom management rather than a cure.

Treatment Duration and Outcomes:

• Treatment can last for several months, and complete resolution is not guaranteed.
• Improvement is typically observed after at least three months of consistent treatment, with ongoing reduction in distress and enhanced quality of life.
• A follow-up period of 24 months is recommended for optimal outcomes.

Complications of Dyspareunia

While dyspareunia is generally treatable and does not lead to major physical complications, it can have significant psychological and relational impacts if not managed promptly and appropriately.

Potential Complications:

• Loss of Sexual Interest: Ongoing pain can lead to a decreased interest in sexual activity, potentially causing strain in relationships.
• Relationship Problems: The physical and emotional distress associated with dyspareunia can result in conflicts and difficulties within partnerships.
• Psychiatric Issues: Untreated dyspareunia can contribute to psychiatric conditions such as major depression, particularly in younger women.
• Fear of Pain and Infertility: In rare cases, the fear of pain during sexual activity can contribute to difficulties with conception, potentially leading to female infertility.