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Dyspareunia

Definition

(Show Disclaimer) Note: I copy the "definition" of something straight from the book. I find it's best to have an all-encompassing definition in order to better orient myself when I am studying.

Show Definition Dyspareunia is genital or pelvic discomfort associated with sexual intercourse (entry or deep penetration) and interferes with sexual satisfaction. Dyspareunia may be superficial, relating to vulvar and vaginal pain, or it may be deep, relating to deep, pelvic pain. Vaginismus is the involuntary (often painful) contraction of the pelvic floor muscles in response to pressure or attempted penetration.

Incidence/Prevalance

Up to 6% of women have vaginismus, and up to 22% of postmenopausal women have general dyspareunia.

Predisposing factors

Related to pathogenesis.

Pathogenesis

There is a very long list of predisposing factors, they are listed directly from the book (below), but these are few I want to remember for the test:

  1. Structural abnormality - lesion (e.g. cancer, PID, adenomyosis/endometriosis, scarring) or congenital (e.g.short vagina, thick hymen).
  2. Atrophic vaginitis - whether from menopause or hypoestrogen d/t premature ovarian failure.
  3. Psychosocial - Prior rape, molestation, domestic violence.
(Full list - click to expand)
  1. Physical:
    1. Vulvovaginal anomalies:
      1. Thick hymen.
      2. Short vagina.
      3. Vaginal agenesis.
      4. Vaginal septum.
    2. Organic dyspareunia:
      1. Episiotomy scars.
      2. Bartholin’s gland cyst.
      3. Vulvar dystrophy.
      4. Inflammation or infection, sexually transmitted infection (STI).
      5. Vulvovaginal cancer.
      6. Pelvic disease:
        1. Pelvic inflammatory disease (PID).
        2. Uterine or ovarian tumours.
        3. Adenomyosis.
        4. Pelvic scarring or adhesions versus endometriosis.
    3. Musculoskeletal anomalies:
      1. Disc disease.
      2. Myofascial pain.
      3. Coccygodynia.
    4. Extensive prolapse or organ displacement.
    5. Urethral syndrome or other urinary tract disorders.
    6. Vulvodynia.
    7. Gastrointestinal (GI) anomalies:
      1. Constipation.
      2. Irritable bowel syndrome (IBS).
      3. Inflammatory bowel disease (IBD).
      4. Anorexia.
    8. Hormonal factors:
      1. Hypo-oestrogenaemia causing atrophic vaginitis.
      2. Breastfeeding.
      3. Menopause.
  2. Psychosocial:
    1. Childhood molestation.
    2. Fear of pain, infection, or pregnancy.
    3. Pelvic congestion syndrome.
    4. Poor partner communication.
    5. History of sexual assault, including date rape.
    6. Previous trauma during intercourse.
    7. Domestic violence.

Common Findings

Irritation/Burning with penetration, lack of lubrication, postcoital bleeding.

Other Signs and Symptoms

Vulvar pain, vaginal pain/burning, vaginal dryness.

History

  1. HPI: Nature of pain - is it with every sexual encounter? with periods?
  2. ROS:
  3. ALL/MEDS/HIITS: (What are HIITS? - Click to expand)
  4. PMH/FAMHx/OBGYN:
  5. SOCHx: complete sexual history, including but not limited to: orgasm, hx of sexual abuse, time spent on foreplay, age onset of menarche/puberty/coitus.

Physical Exam

Coming soon.

However: Look for signs of physical or sexual abuse, cuts, bruises, and lacerations. For pain greatest on deep penile penetration, suspect PID, ovarian cyst, endometriosis, pelvic adhesions, relaxation of pelvic support, or uterine fibroids.

Diagnostic Tests

DDx

See pathogenesis.

Plan

Follow-up

To ensure resolution of symptoms.

Consultation/Referral

Gynecology if structural issue. May need sexual therapy consultation in the absence of organic pathology.

Individual Considerations

Sex may continue during pregnancy provided no leakage of fluid, discomfort.

May need to also ask the partner to participate in sexual therapy counselling.


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