Dyspareunia: Difference between revisions – Physiopedia

Dyspareunia is defined as persistent genital pain that occurs during sexual intercourse.[1] Its often associated with sexual function problems such as; Vaginal dryness, anxiety during sexual intercourse, Difficultly in reaching climax and so on.[2] 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. [3]

The prevalence of  dyspareunia varies from 8% to 21.1% globally, as reported by the World Health Organization in 2006. [4]

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 the impact on a woman’s life, the study highlighted the need for special attention to dyspareunia during the postpartum period. [5]

Clinically Relevant Anatomy[edit | edit source]

Pelvic diaphragm (superior view)

Weakness in deep pelvic floor muscles (levator ani muscle group and coccygeus) can cause deep dyspareunia. [6][7][8]

The pudendal nerve (composed of somatic branches from the sacral plexus, specifically S2 to S4 [9] [10] [11][12]) is one of the 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. [9][11]

Entry dyspareunia usually involves the vulva and its surrounding structures [8]

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. [8][7]

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

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

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.” [17]

History Taking[edit | edit source]

A recent study [3] 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. [8][7]
  • 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. [18]

Another study [4] 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, diarrhoea, urgency, frequency
  • Sexual history: Frequency, desire, arousal, satisfaction, relationship
  • Psychological history: Mood disorder, anxiety, depression
  • History of abuse: Sexual, physical, neglect.

Physical Examination[edit | edit source]

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 assessment of vulvodynia and/or vestibulodynia.

Before starting the physical examination, since the patient may have anxiety about genital examinations, it can be helpful to explain to the patient why it is essential and how it may be useful for the diagnosis and the treatment. [19] The physical examination may include the following elements:

  • Inspection: Includes visual examination of the external genitals for atrophy, discolouration, erythema, lesions, or trauma. [20]
  • Palpation: Includes systemically pressing on the external genital tissue (including the hymen) with the use of a small cotton to localize the pain for patients reported focal pain; performing single-digit examination with a lubricated single finger to detect any narrow introitus / pain with palpation of the pelvic floor / pelvic floor muscle tension or pain / uterine prolapse or retroversion (may cause pain when the uterus is gently moved cephalad) / tenderness with uterine manipulation / bladder base tenderness / pelvic masses; and rectovaginal examination especially for those with rectal pain or dyschezia to check any rectovaginal or uterosacral nodularity that is palpable during the test. [20]

Additional Testing[edit | edit source]

Additional tests that can be useful in the diagnostic process are listed according to the causes of the dyspareunia:

  • Vaginitis: Speculum examination [20], pH testing, microscopy, polymerase chain reaction swab as indicated
  • Sexually transmitted infections: Cervical cytology testing [20]
  • Interstitial cystitis: Interstitial cystitis questionnaire, bladder instillation, cystoscopy
  • Ovarian masses: Transvaginal ultrasonography
  • Uterine retroversion: Usually unnecessary but transvaginal ultrasonography can be used to exclude myomas
  • Adhesions or chronic pelvic inflammatory disease: Pelvic imaging to exclude other diagnoses
  • Endometriosis: Laparoscopy (unless the diagnosis is uncertain or patient desires)

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. [19]

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.[21]

Outcome measures used in a randomised control study were:

  • Modified Oxford Scale: A 0-5 grade scale to assess the strength and endurance of the pelvic floor muscles.
  • Female Sexual Function Index (FSFI): A questionnaire including six parts that evaluate desire, arousal, lubrication, orgasm, satisfaction, and painless intercourse. The total score ranges from 2 to 95.
  • Visual Analogue Scale (VAS)

Management / Interventions[edit | edit source]

Multidisciplinary Approach[edit | edit source]

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). [22]

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: [23]

  • 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. [24][25]
  • 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. [26]
  • 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. [27]
  • 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 previous studies [28][29][30][31] [32][33][34] [35] it is an effective approach in the treatment of dyspareunia. Although most of the studies were retrospective or observational, a recent randomised control study [36] concluded that 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. [37]
  • 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. [38]

Physiotherapy Management[edit | edit source]

A pelvic floor rehabilitation led by a physiotherapist can include;

  • Patient education: It plays an important role in the treatment of dyspareunia. [32][33] Instructing the patient about the anatomy and function of the pelvic floor muscles (PFM) and guiding the patient on how to self-control the activity of these muscles are very important parts of the treatment. In this way, the patient can relax and contract them when required. [36]
  • Manual techniques: Since trigger and tender points have been reported to be one of the musculoskeletal sources of dyspareunia, manual techniques can play an important role in rehabilitation. As well as releasing the trigger and render points, they increase the awareness of the patient’s PFM, normalize the overactivity, and increase the strength of the PFM. Among the techniques, myofascial release and intravaginal massage can be useful in improving vascularization, and releasing muscle trigger points in the pelvic floor and, thus, can be efficient in treating pain and sexual dysfunction. [36]
  • Modalities: Electrotherapeutic modalities such as transcutaneous electrical neural stimulation (TENS) and functional electrical stimulation (FES), or heat and cold modalities can be used. [36]
  • Pelvic floor muscle exercises: They can be implemented with or without biofeedback. Biofeedback is an important adjunct for the physiotherapist to instruct and educate the patient to find and feel their PFM, realize the normal activity of the PFM, and then later force/strengthen the pelvic floor if needed. [36]

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:

  1. Yoga positions, such as a supported extended child’s pose or garland pose
  2. Mindfulness and/or 4 square breathing techniques can be used to draw awareness to tension held in the pelvic floor muscles and actively allow 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 the 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[edit | edit source]

  • 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 a 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.

Occupational Therapy[edit | edit source]

Occupational therapy can be applied by an occupational therapist as part of pelvic floor rehabilitation. [39][40]

It is an important part of the multidisciplinary approach since the pelvic floor dysfunction symptoms limiting effect on the patient’s occupational performance, specifically sexual activity and exercise, after childbirth is proved. [41]

Dyspareunia may be a result of many factors as listed above. To elicit the cause, the combination of the patient’s history and physical examination findings should be considered. [20]

A recent study [20] summarised some of the causes of dyspareunia with associated history and physical examination findings:

Diagnosis Historical clues Examination findings
Dermatologic diseases Burning, dryness, pruritus Visible skin changes (dependent on condition)
Inadequate lubrication Dryness; history of Diabetes Mellitus; history of chemotherapy or use of progestogens, aromatase inhibitors, tamoxifen, or gonadotropin-releasing hormone agonists Vulva may be normal or appear dry
Pelvic floor dysfunction Difficulty evacuating stool or emptying the bladder; aching after intercourse; pain in lower back, thighs, or groin Painful vaginal muscles just inside of the hymen during single-digit examination
Vaginal atrophy Burning, dryness Tissue may appear pale and dry (although may appear normal in early menopause)
Vaginismus Difficulty achieving penetration; possible history of anxiety, sexual abuse or trauma, or other causes of painful penetration; sometimes no prior risk factors are present Involuntary contraction of pelvic floor muscles with attempted insertion of finger or small speculum
Vaginitis Discharge, burning, or odour Vaginal discharge
Vulvodynia Chronic burning, tearing, aching, or stabbing vulvar pain of at least three months duration Vulva may be visually normal or may have focal areas of erythema around the vestibule and hymen that are painful, as elicited by a cotton swab
Interstitial cystitis Urinary urgency, frequency, and nocturia Pain with palpation of bladder base
Ovarian masses Lateralized pain with intercourse Pain with adnexal palpation
Uterine retroversion Pain may be related to sexual position; and may be associated with endometriosis Retroverted uterus, may be painful when moved cephalad
Adhesions or chronic pelvic inflammatory disease May have lateralized, sharp pain; history of pelvic inflammatory disease or pelvic surgery Possible fixation of pelvic organs on bimanual examination
Endometriosis Family history; dysmenorrhea common Generalized pelvic tenderness; nodularity may be noted in cul-de-sac during rectovaginal examination
  • 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.


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