Dyspareunia - red flag symptoms

Causes of dyspareunia (painful intercourse) in women and red flag symptoms that GPs should look out for.

(Photo: Bymuratdeniz/Getty Images)
(Photo: Bymuratdeniz/Getty Images)

Red flag symptpms

  • Pelvic pain
  • Menorrhagia
  • Painful periods
  • Postcoital bleeding
  • Intermenstrual bleeding
  • Unintentional weight loss
  • Pelvic discharge
  • Fevers

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 as well as 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 introitus, vulva and vestibule. Deep symptoms are often related to the pelvis.

History and examination

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

The consultation may be difficult and we need to be sensitive to the patient in broaching this subject. Creating a rapport with the patient by using open-ended questions may help communication.

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

  • Associated pruritus may indicate eczema or vulvar dystrophy.
  • Dysmenorrhoea and sharp pains may indicate endometriosis.
  • Pelvic aching may suggest fibroids and tearing pains may allude to 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 antihypertensives, can reduce vaginal lubrication.
  • A past obstetric history of traumatic childbirth, or episiotomies may result in dyspareunia.

Examination should begin with inspection of the external genitalia. Look out for any dermatological abnormalities or infective lesions, such as herpes simplex virus sores. Pale vaginal mucosa may suggest vaginal atrophy.

An internal exam should also be performed. Mucopurulent discharge may suggest cervicitis or pelvic inflammatory disease. Bimanual examination may show fibroids or endometriosis.

Investigations and possible causes

In many cases of dyspareunia, investigations are not necessary. You may wish to consider vaginal swabs for chlamydia and gonorrhoea if pelvic inflammatory disease is suspected. Herpes simplex virus PCR swabs may also be pertinent.

A urinalysis may reveal a urinary tract infection. 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

Possible causes

  • Vaginitis and vulvovaginitis
  • Endometriosis
  • Pelvic inflammatory disease
  • Cervicitis
  • Bartholin's abscess
  • Vulvodynia
  • Herpes simplex virus
  • Vaginismus
  • Psychosexual syndrome
  • Vaginal atrophy
  • Iatrogenic causes

Dr Anish Kotecha is a GP in Gwent, Wales. This article, originally by Dr Mehul Mathukia, first appeared on 2 September 2010 and was updated in June 2020.

Visit MIMS Learning for an interactive version of this article and a CPD certificate.

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