Red flag symptoms - Dyspareunia in women

There are many causes of dyspareunia and a complete gynaecological history is the imperative starting point in diagnosis, by Dr Mehul Mathukia.

Bartholin’s abscess is a possible cause of dyspareunia (Photograph: SPL)
Bartholin’s abscess is a possible cause of dyspareunia (Photograph: SPL)

Dyspareunia is a common complaint among women but can also affect a minority of men. This article focuses on dyspareunia in women.

Dyspareunia can be classified as primary or secondary, superficial or deep. Primary dyspareunia is characterised by pain on intercourse since the onset of sexual activity, while secondary refers to the development of pain during a patient's sexual lifetime.

Superficial dyspareunia tends to be localised to the intro-itus and related to the vulva and the vestibule. Deep symptoms are often related to the pelvis.

History
There are many causes for dyspareunia. A complete gynaecological history, including sexual history as well as any history of abuse, is imperative. Pelvic examination is also a key element of the work up.

The consultation may be difficult and one needs to be sensitive to the patient in broaching this subject. Creating a rapport and the use of open-ended questions may open the doors of communication.

The main things to establish in the history are the onset of the symptoms, the location of the symptoms and any associated symptoms.

Associated pruritus may indicate eczema or vulvar dystrophy. Dysmenorrhoea two to three days prior to menses may indicate endometriosis.

A sharp pain may indicate endometriosis while aching pain may suggest fibroids and tearing pain may indicate vaginal atrophy.

A past medical history of cancer that required chemotherapy or radiotherapy may have resulted in vaginal atrophy, fibrosis or adhesions. Drugs, such as the contraceptive pill, some antidepressants and anti-hypertensives, can reduce vaginal lubrication. A past obstetric history of traumatic birth deliveries, or episiotomies may result in dyspareunia.

Examination
Examination should begin with inspection of the external genitalia. One may see dermatological abnormalities or infective lesions, such as HSV sores. Pale vaginal mucosa may suggest vaginal atrophy. An internal exam should be performed.

Mucopurulent discharge may suggest cervicitis or PID.

Bimanual examination may show fibroids or endometriosis.

Investigations
In many cases of dyspareunia investigations are not necessary. One may wish to consider vaginal swabs for chlamydia and gonorrhoea if PID disease is suspected. HSV PCR swabs may also be pertinent. A urinalysis may reveal a UTI.

A pelvic ultrasound can be useful to show fibroids or a hydrosalpinx. A cystoscopy may be necessary for interstitial cystitis, or a diagnostic laparoscopy for endometriosis.

  • Dr Mathukia is a GP principal in Ilford, Essex
Possible Causes
  • Vaginitis and vulvovaginitis.
  • Endometriosis.
  • PID.
  • Cervicitis.
  • Bartholin's abscess.
  • Vulvodynia.
  • HSV.
  • Vaginismus.
  • Psychosexual syndrome.
  • Vaginal atrophy.
  • Iatrogenic causes.

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