Dyspareunia

Original Editor - User Name Top Contributors - Nicole Sandhu, Sehriban Ozmen, Kim Jackson, Temitope Olowoyeye, Nicole Hills, Ewa Jaraczewska and Muskan Rastogi

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Definition

Dyspareunia is defined as persistent genital pain that occurs during sexual intercourse.

Clinically Relevant Anatomy

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

Clinical Presentation

Subjective History

Symptoms

Individuals may present with pain that occurs at entry during penetration, with deep penetration or lasting post-penetration. Pain associated with the insertion of a tampon or a medical examination with the use of a spectrum, could also be another subjective report. Words used to describe pain may be (but are not limited to): "throbbing" "burning" or "aching."

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

• skin irritation (ie. eczema or other skin problems in the genital region)
• endometriosis
• vestibulodynia
• vulvodynia
• interstitial cystitis
• fibromyalgia
• irritable bowel syndrome
• pelvic inflammatory disease
• depression and/or anxiety
• post-menopause

Objective Assessment

A pelvic assessment, including an internal exam, performed by a trained medical professional with the informed consent of the patient. Through this exam the

Outcome Measures

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.

Level of dyspareunia pain (0-10)

Management / Interventions

Physiotherapy

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 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.

Additional Considerations

• The use of a multidisciplinary approach with the inclusion of a physician and a counselling therapist could be beneficial.
• Issues such as stress or history of abuse can contribute to the tension of the pelvic floor muscles and this may be addressed through counselling.

Medical management

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. This could include women in the post-menopausal phase of life, may be dealing with dyspareunia due to changes in hormone levels which affects the genital tissue. If this is a contributing factor, it should be addressed by a physician.

Resources

Pelvic Physiotherapy - to Kegel or Not?

This 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.