PROBLEM-ORIENTED DIAGNOSIS Evaluation and Differential Diagnosis of Dyspareunia LORI J. HEIM, LTC, USAF, MC, Eglin Air Force Base, Florida Dyspareunia is genital pain associated with sexual intercourse. Although this con- dition has historically been defined by psychologic theories, the current treatment O A patient infor- approach favors an integrated pain model. Identification of the initiating and pro- mation handout on dyspareunia, written mulgating factors is essential to reaching a successful diagnosis. The differential by the author of this diagnoses include vaginismus, inadequate lubrication, atrophy and vulvodynia article, is provided (vulvar vestibulitis). Less common etiologies are endometriosis, pelvic congestion, on page 1551. adhesions or infections, and adnexal pathology. Urethral disorders, cystitis and interstitial cystitis may also cause painful intercourse. The location of the pain may be described as entry or deep. Vulvodynia, atrophy, inadequate lubrication and vaginismus are associated with painful entry. Deep pain occurs with the other con- ditions previously noted. The physical examination may reproduce the pain, such as localized pain with vulvar vestibulitis, when the vagina is touched with a cotton swab. The involuntary spasm of vaginismus may be noted with insertion of an examining finger or speculum. Palpation of the lateral vaginal walls, uterus, adnexa and urethral structures helps identify the cause. An understanding of the present organic etiology must be integrated with an appreciation of the ongoing psycho- logic factors and negative expectations and attitudes that perpetuate the pain cycle. (Am Fam Physician 2001:63:1535-44,1551-2.) Members of various yspareunia is genital pain ex- Epidemiology family practice depart- perienced just before, during ments develop articles There are few reports of clinical trials relat- 1 for “Problem-Oriented or after sexual intercourse. ing to dyspareunia, and much of the literature Diagnosis.” This article Although this condition has derives from expert opinion. The lack of a sin- is one in a series coor- historically been classified as a gle etiology for the pain contributes to the dinated by the Depart- Dsexual disorder, an integrated and pain-model diagnostic difficulty. The incidence of dys- ment of Family Medi- approach to the problem is gaining support. cine at the Uniformed pareunia depends on the definition used and Services University of The current thinking about pain initiation and the population sampled. In a national proba- the Health Sciences, promulgation suggests an initial instigating bility sample7 assessing the prevalence of sex- Bethesda, Md. Guest factor that is then perpetuated by confounding ual dysfunction in the United States, women editors of the series are factors.2-6 These factors may be physical or psy- with dyspareunia comprised a smaller group Francis G. O’Connor, chologic. Patients with dyspareunia may com- LTC, MC, USA, and than women with decreased interest in sex, Jeannette E. South- plain of a well-defined and localized pain, or orgasmic difficulties, lack of pleasure or Paul, COL, MC, USA. express a general disinterest in and dissatisfac- arousal difficulties. The prevalence of dyspare- tion with intercourse that stems from the asso- unia in this sample was 7 percent. In a study of ciated discomfort. Although dyspareunia is primary care practices,8 the prevalence of dys- present in both sexes, it is far more common in pareunia was 46 percent among sexually women, with the pain initiating in several active women, with dyspareunia defined as areas, from vulvar surfaces to deep pelvic pain during or after intercourse. In a recent structures. study 9 involving 62 women, postpartum dys- This article reviews the various causes of pareunia was noted in 45 percent. dyspareunia and describes the historical and As many as 60 percent of women experi- physical clues leading to these diagnoses. ence dyspareunia when the term is broadly Treatment options are beyond the scope of defined as episodes of pain with intercourse.10 this article. Women with symptoms severe enough to APRIL 15, 2001 / VOLUME 63, NUMBER 8 www.aafp.org/afp AMERICAN FAMILY PHYSICIAN 1535 Diagnostic and Statistical Manual of Mental 11 Patients with dyspareunia are more likely than the general Disorders, 4th ed. (DSM-IV), defines dys- pareunia as a sexual pain disorder, a subcate- public to report pain with use of a tampon or digit, or dur- gory of sexual dysfunction. Dyspareunia is ing a gynecologic examination. differentiated from vaginismus or problems resulting from inadequate lubrication. The pain must be persistent or recurrent, and require medical attention comprise a much cause marked distress or interpersonal diffi- smaller group. Many of those with persistent culty. In one study,5 only the onset of pain and symptoms do not seek medical attention.8,10 its location were useful discriminators. Because of the differences in classification PATIENT CHARACTERISTICS and the multiple etiologies, it has been diffi- Consistent characteristics of patients with cult to accurately and consistently describe dyspareunia are lacking. In one study,7 comorbid psychologic characteristics. Dys- increasing age and college education were pareunia has been associated with a more neg- associated with a lower likelihood of dyspare- ative attitude toward sexuality, with more sex- unia. In another study,8 the incidence of dys- ual function impairment and with lower levels pareunia was not associated with age, parity, of relationship adjustment.6 Women with dys- marital status, race, income or educational pareunia, not surprisingly, were found to have level. a lower frequency of intercourse and lower The most common pain with dyspareunia levels of desire and arousal, and to be less occurs during coitus, but some women expe- orgasmic with oral stimulation and inter- rience pain afterward, while others report pain course.7 Complaints of pain with sexual inter- at both times.8 Pain before coitus may result course were also associated with low physical from irritation of the external genitalia or the and emotional satisfaction, as well as de- vasocongestion that occurs during the excite- creased general happiness. Depression and ment phase. Patients with dyspareunia are phobic anxiety were noted more often in more likely than the general population to patients with dyspareunia compared with report pain with insertion of a tampon or control subjects,6 but other studies found no digit, or during a gynecologic examination.6 difference from norms with regard to psycho- pathology, marital adjustment or attitudes Psychologic Issues and Considerations towards intercourse.5,12 Psychologic theory historically treats dys- Marital discord has been suggested as a pareunia as a symbol of unconscious conflict, major cause of dyspareunia, but whether the stemming from phobic reactions, major anxi- marital relationship suffered secondarily ety conflicts, hostility or sexual aversions.4 The because of difficulty with sexual intercourse is unclear.12 The results of one study13 revealed that marital adjustment was inversely associ- The Author ated with dyspareunic pain rating and that only anxiety and marital adjustment were sig- LORI J. HEIM, LTC, USAF, MC, is currently program director and flight commander in the Family Practice Department, Eglin Air Force Base, Fla., She earned her medical nificant independent predictors of dyspare- degree at the Uniformed Services University of the Health Sciences, Bethesda, Md. She unic pain rating. Depression was not found to completed a residency in family medicine at Andrews Air Force Base, Md., and a fel- be a predictor when patients with dyspareunia lowship in faculty development and research at the University of North Carolina at 13 Chapel Hill School of Medicine. were evaluated as a whole. Compared with patients with pelvic pain,2 Please address correspondence to Lt. Col. Lori J. Heim, Flight Commander/Program Director, 96 MDOS/SGOL, 307 Boatner Rd., Ste. 114, Eglin, AFB, FL 32542. Reprints patients with dyspareunia did not report a cur- are not available from the author. rent or previous history of physical or sexual 1536 AMERICAN FAMILY PHYSICIAN www.aafp.org/afp VOLUME 63, NUMBER 8 / APRIL 15, 2001 Dyspareunia abuse.6,12 The role of previous sexual abuse in dyspareunia has been the subject of much Unlike descriptions of patients with pelvic pain, patients study, but the results lack consistency because with dyspareunia usually do not have a history of physical or of methodologic flaws. There may be subsets of sexual abuse. patients, such as those with sexual arousal dis- orders, with a higher sexual victimization rate.7 Given the lack of consistent study results, it is unlikely that currently available psychologic include pain descriptors: duration, intensity, screening instruments would have a promi- location, exacerbating and ameliorating fac- nent role in the diagnosis of dyspareunia and tors, and any associated physical or psycho- related pain syndromes. A discussion of exter- logic components15 (Tables 1 and 2).16 The nal factors, overall relationship satisfaction physician distinguishes between primary and and current psychologic status may prove secondary dyspareunia based on whether the fruitful in certain patients, but its value is dif- woman has ever had a history of successful ficult to predict. sexual experiences. Previous treatments and the degree of response to them are important BIOPSYCHOSOCIAL APPROACH information. Not all physicians