Dyspareunia

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This article is currently under review and may not be up to date. Please come back soon to see the finished work! (11/09/2023)

Definition

Dyspareunia is defined as persistent genital pain that occurs during sexual intercourse. It can be classified into two types based on the location of the pain – entry or deep dyspareunia. While entry dyspareunia is associated with pain upon an attempt at vaginal penetration at the introitus, deep dyspareunia is pain perceived upon vaginal penetration and causes include adenomyosis, endometriosis, vaginal scarring, interstitial cystitis, and pelvic adhesions.

Prevalence

The prevalence of  dyspareunia varies from 8% to 21.1% globally, as reported by the World Health Organization in 2006.

A recent systematic review concluded the prevalence of dyspareunia as 42% at 2 months, 43% at 2–6 months, and 22% at 6–12 months postpartum. Given these high prevalence as well as impact on a woman's life, the study highlighted to give special attention to the dyspareunia during the postpartum period.

Clinically Relevant Anatomy

Pelvic diaphragm (superior view)

Weakness in deep pelvic floor muscles (levator ani muscle group and coccygeus) can cause deep dyspareunia.

The pudendal nerve (composed of somatic branches from the sacral plexus, specifically S2 to S4 ) is one of most important nerves associated with dyspareunia or pelvic pain. Due to its location in the pelvis, it is susceptible to injury during pelvic surgeries and parturition.

Entry dyspareunia usually involves the vulva and its surrounding structures

Deep dyspareunia is characterized by pain experienced during deep vaginal penetration and might involve the inner pelvic structures such as the urinary bladder and cervix.

Please see the page "Pelvic Floor Anatomy" for further details regarding anatomy.

Aetiology

Dyspareunia could be a symptom stemming from one or more of the following:

• skin irritation (i.e. eczema or other skin problems in the genital region)
• endometriosis
• vestibulodynia
• vulvodynia
• vaginismus
• interstitial cystitis
• fibromyalgia
• irritable bowel syndrome
• pelvic inflammatory disease
• depression and/or anxiety
• post-menopause
• postpartum dyspareunia
• inadequate vaginal lubrication or arousal
• anogenital causes such as hemorrhoids and anal fissures
• Bartholin gland infection
• vulvovaginitis
• vaginal atrophy
• adenomyosis
• vaginal scarring
• pelvic adhesions

Clinical Presentation

Individuals may present with pain that occurs at entry during penetration, with deep penetration or pain post-penetration. The patient may also describe pain associated with the insertion of a tampon or during a Pap exam. Words used to describe pain may be (but are not limited to): "throbbing" "burning" or "aching."

Diagnostic Procedures

History Taking

A recent study summarised important findings related to the history taking:

• Accurate clinical diagnosis requires detailed information about the location, onset, duration, severity, nature of pain, precipitating factors, and positions associated with the pain.
• It is particularly helpful to know the specific location of the pain, especially if it is localized to the vulva, vagina introitus, or inside of the vagina, as this can help narrow down the possible causes.
• In his article on the clinical approach to dyspareunia, Graziottin provides a comprehensive guide to the necessary questions for a thorough history and physical examination.

Another study listed the important elements to discuss during clinical evaluation of female sexual pain as below:

• Pain characteristics: Timing, duration, quality, location, provoked, or unprovoked
• Musculoskeletal history: Pelvic floor surgery, trauma, obstetrics
• Bowel and bladder history: Constipation, diarrhea, urgency, frequency
• Sexual history: Frequency, desire, arousal, satisfaction, relationship
• Psychological history: Mood disorder, anxiety, depression
• History of abuse: Sexual, physical, neglect.

Physical Examination

The gold standard to assess the pelvic floor muscles is through an internal exam, performed by a trained medical professional with the informed consent of the patient. This exam allows for the assessment of the health of the tissue, the tonicity of the pelvic floor muscles, the ability to contract and relax these muscles and to assess for vulvodynia and/or vestibulodynia.

Outcome Measures

When quantifying the pain, validated self-report questionnaires such as the Female Sexual Function Index, the McGill Pain Questionnaire, or the Patient Reported Outcomes Measurement Information System (PROMIS) vulvar discomfort scale may be more helpful instead of asking a patient to rate their pain on one to 10.

The Female Sexual Destress Scale-Revised (FSDS-R): A single item from this scale may be a useful tool in quickly screening for sexual distress in middle-aged women.

Management / Interventions

Multidisciplinary Approach

The use of a multidisciplinary approach with the inclusion of a gynaecologist, urologist, psychiatrist, pain management expert, physical therapist, sexual therapist, and mental health professionals with a specialization in chronic pain is advantageous to address all the aspects of pain (physical, emotional, and behavioural).

The first step towards treating a patient's pain is for the physician to acknowledge that the patient is experiencing it. The physician should counsel the patient that pain management might take time and that it may not completely go away even after treatment. The patient should be informed about all the available treatment options and should be helped in selecting the best possible option. The initial step should be a conservative, nonsurgical approach. Treatment options depend on the aetiology of the patient's complaint and can include:

• Oral tricyclic antidepressants
• Oral or topical hormonal replacement
• Oral NSAIDs, and botox injections: Botulinum toxin injection is effective in treating dyspareunia caused by pelvic floor myalgia and contracture.
• Cognitive-behavioural therapy, and other brain-based therapies: Cognitive-behavioral therapy is the most commonly used behavioural intervention and is strongly recommended. It is an effective behavioural intervention in reducing anxiety and fear associated with dyspareunia.
• Systemic and topical hormone replacement therapy, selective estrogen receptor modulator therapy, and the use of vaginal dehydroepiandrosterone: For the patients with dyspareunia due to post-menopausal vaginal atrophy.
• Appropriate antibiotic, antifungal, or antiviral therapy based upon culture results: For dyspareunia due to infectious causes.
• Vaginal lubricants, scar tissue massage: Post-partum dyspareunia can respond to these options.
• Pelvic floor rehabilitation: According to the result of a recent randomised control study , pelvic floor rehabilitation is an important part of a multidisciplinary treatment approach to dyspareunia. It can serve as an adjuvant treatment option in most cases of dyspareunia. It relaxes the pelvic floor muscles and re-educates the pain receptors.
• Surgical treatment: Only adopted as a last option when all conservative treatment options have failed. It is usually useful in identifying and/or treating pelvic adhesions, endometriosis, and pelvic organ prolapse.

Physiotherapy Management

Physiotherapists can address factors contributing to dyspareunia with the following tools and techniques.

Contributing factor	Tool/Technique
Lack of awareness of pelvic floor muscles	Assess the patient's ability to connect with their pelvic floor muscles through their ability to correctly contract and relax their pelvic floor muscles. If the patient is unable to correctly recruit these muscles, whether it be due to lack of strength or neuromotor connection, this should be addressed.
Hypertonic pelvic floor muscles	Teaching relaxation techniques for the pelvic floor muscles: Yoga positions, such as a supported extended child's pose or garland pose Mindfulness and/or 4 square breathing techniques can be used to draw awareness to tension held in the pelvic floor muscles and actively allowing the tension to decrease. The use of inserts can be beneficial along with these techniques. Teach the patient to move the dilator or insert past the entrance of the vaginal canal in conjunction with relaxing the pelvic floor muscles.
Pain centralization	If this has been a chronic issue, addressing principles of centralized pain and explaining this to the patient can be helpful and informative. Additionally, pain at the entrance or through the vaginal canal can elicit a spasm or hypertonic response by the pelvic floor muscles.

Additional Considerations

• The use of a multidisciplinary approach with the inclusion of a physician and a counselling therapist could be beneficial, depending on the reason for experiencing dyspareunia.
• Issues such as fatigue, depression/anxiety, stress or history of abuse can contribute to the tension of the pelvic floor muscles, and this may be addressed through counselling.
• Ensure that the patient has been screened by a physician to rule out any differential diagnoses or address co-existing diagnoses that are out of the physiotherapy scope of practice.

Resources

• To see the recommended measurement tools prepared by the Pelvic Floor Disorders Consortium: "Measuring Pelvic Floor Disorder Symptoms Using Patient-Reported Instruments"
• A webinar by "Jean Hailes for Women’s Health" ( a national not-for-profit organisation) on dyspareunia and the physiotherapist's perspective:

• A presentation was created by Carolyn Vandyken, a physiotherapist who specializes in the treatment of male and female pelvic dysfunction. She also provides education and mentorship to physiotherapists who are similarly interested in treating these dysfunctions. In the presentation, Carolyn reviews pelvic anatomy, the history of Kegel exercises and what the evidence tells us about when Kegels are and aren't appropriate for our patients.