REVIEW

Dyspareunia: a difficult
symptom in gynaecological
practice

assessment however the management of the variety diseases

which cause dyspareunia is discussed in other articles.

Epidemiology
Sexual problems can occur in heterosexual and homosexual relationships. They are reported by almost 43% of women. Between
16% and 75% of women have problems with desire, 16%e48%
with orgasm, 12%e64% with arousal, 7%e58% with dyspareunia and 21% with genital lubrication. A recent study found twothirds of over-60s in the United States were sexually inactive. From
the remaining third, 12% who were married had difficulty with
intercourse and about 13% experienced dyspareunia. Studies of
middle-aged women estimated sexual dysfunction at 33% in the
UK. A third of these had at least one defined sexual dysfunction but
only 10% thought they had a sexual problem. If few women
perceive sexual dysfunction to be a problem, it may explain in part
why not many seek medical attention for these conditions, making
it difficult to determine the incidence.

Hayser M Lucena
Sambit Mukhopadhyay
Edward Morris

Abstract
Dyspareunia is pain genital pain associated with sexual function. It is a
symptom that has a significant impact on womens health, relationships
and quality of life. It is caused by different diseases and has organic
and psychosexual components. Despite the high prevalence of sexual
pain, few guidelines exist for its evaluation. Obtaining a comprehensive
sexual history in an outpatient setting requires professionalism. A systematic and thorough examination of the lower genital tract is necessary
to rule out anatomical causes. Other organ systems may need to be
assessed from the medical history. Ultrasound may be appropriate to
evaluate pelvic organs followed in some cases by diagnostic laparoscopy
if there is evidence of endometriosis or utero-vaginal pathology that does
not respond to conservative management. Psychosexual causes must be
considered when assessing these patients. This article considers the diagnosis and investigation of women complaining of dyspareunia.

Aetiology
Dyspareunia is a symptom of a variety of disease states with
components of organic and psychological dysfunction.
Onset
Primary (onset with the first sexual experience):
 Congenital abnormalities
 Psychosocial causes
 Sexual abuse in childhood
 Fear of intercourse or painful first intercourse
Secondary (previously normal sexual function):
Causes are usually physical but often investigations find no
cause. Psychological support may be needed.

Keywords chronic pelvic pain; dyspareunia; endometriosis; pelvic inflammatory disease; vaginismus; vulvodynia

Introduction
Dyspareunia is defined as recurrent genital pain during, before,
or after intercourse in either the man or the woman, though it is
more common in women. It can be superficial or deep, the latter
sometimes associated with endometriosis or pelvic inflammatory
disease. The combinations of biological, psychological and
interpersonal factors can play a part in the development of
dyspareunia.
Usually an initial instigating factor causes pain but patients
cannot recall a specific moment when the pain started. Patients
can present with well-defined pain or a general dissatisfaction
with sex due to discomfort. Obtaining a psychosexual history can
provide key information about predisposing factors such as cultural influences on sexuality and possible relationship problems.
This article reviews the causes of dyspareunia and outlines

Frequency
Persistent: Symptoms occur with all partners in all situations.
Conditional: Symptoms occur with certain positions, type of
stimulation or specific partner.
Possible causes for both include physical and psychological
factors.
Location
Superficial or insertional: Defined as sharp, burning or stinging
pain at or near the vaginal introitus on penetration. Commonly
found in patients with vulvodynia and vaginismus. Superficial
dyspareunia may be also associated with myofascial dysfunction
of the perineal body. Other frequent causes include infections
such as monilia, herpes, trichomonal vulvovaginitis or menopausal changes (vaginal atrophy). A Bartholins abscess, previous surgery and childbirth may also cause dyspareunia.
Deep: Defined as pain felt within the pelvis with penile
thrusting deep within the vagina. Possible causes include pelvic
tumours, endometriosis, previous surgery, pelvic inflammatory
diseases and/or retroverted uterus. Different sexual positions
may be relevant in aetiology. Some patients felt pain when the
penis made contact with the cervix, which can become sensitised
by chronic cervicitis and repeated procedures (e.g. biopsies and/
or conisation). Pain that comes with orgasm or lasts for several

Hayser M Lucena MRCOG is a Specialty Registrar in Obstetrics and

Gynaecology at West Suffolk Hospital NHS Foundation Trust, Suffolk,
UK. Conflicts of interest: none declared.
Sambit Mukhopadhyay FRCOG is a Consultant Gynaecologist at Norfolk
and Norwich University Hospital NHS Foundation Trust, Norwich,
Norfolk, UK. Conflicts of interest: none declared.
Edward Morris FRCOG is a Consultant Gynaecologist at Norfolk and
Norwich University Hospital NHS Foundation Trust, Norwich, Norfolk,
UK. Conflicts of interest: none declared.

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an annual prevalence in primary care of 38/1000 was found in

women aged 15 to 73, similar to asthma and back pain. In over
60% of patients no etiological factor for CPP was identifiable and
there is no consensus on the management of such patients. This
is the hardest group to manage as unidimensional treatments are
not helpful and can cause frustration and mistrust, which can
lead to a breakdown of the patient-doctor relationship.

days may suggest obturator internus related myofascial

dysfunction (Box 1).

Common causes
Chronic pelvic pain (CPP)
CPP is defined as any pelvic pain lasting over six months. It is a
common complex symptom that can result from multiple urological, gastroenterological, musculoskeletal or gynaecological
aetiologies. It affects women of reproductive age. For some, the
pain has no clear identifiable cause or can persist despite treatment for a known underlying disorder. Intercourse is often
compromised, with pain in about 90% of CPP patients. In the UK,

Endometriosis
This is one of the most common benign gynaecological conditions, defined as endometrial glands and stroma located outside
the uterine cavity. This endometrial tissue responds to hormonal
changes and so undergoes cyclical bleeding and local inflammatory reaction. Repeated bleeding and healing leads to fibrosis,
causing adhesions. Prevalence is difficult to determine, firstly
because of variability in clinical presentation and, secondly,
because the only reliable diagnostic test is laparoscopy, when
endometriotic deposits can be visualised and histologically
confirmed. Population-based studies report a prevalence of 1.5%
compared with 6%e15% in hospital-based studies. Endometriosis may be present in about 77% of women with CPP. Common
symptoms include pelvic pain, dysmenorrhoea, dyschezia,
abnormal menstrual bleeding and infertility. Dyspareunia is
usually deep and a prominent symptom in association with
uterosacral and/or rectovaginal lesions. Between 60% and 78%
of women with deep dyspareunia had positive uterosacral ligament pathology. However, many women with endometriosis are
asymptomatic. Often the stage of endometriosis does not correlate with the presence or severity of symptoms. This may be due
to symptoms being more related to a local peritoneal inflammatory reaction than the volume of implants.

Causes according to location of dyspareunia

Superficial

Deep

Infection
Vulvovaginitis (monilial,
herpes and trichomonal)

Infection
Pelvic inflammatory disease
(pyosalpinx and salpingooophoritis)
Chronic cervicitis
Repeated cervical trauma
Pelvic disease
Endometriosis
Fibroids Ovarian cysts/
tumours
Pelvic congestion

Vulval disease
Generalized Vulvodynia
Vestibulodynia Bartholins cyst
Vulval dystrophies/
dermatoses
Lichen sclerosis Carcinoma of
vulva
Postmenopausal
Atrophic changes
Psychosexual
Vaginismus
Post surgery
Obstetric sequelae (narrowing
of the introitus, episiotomy
scar)
Pelvic floor repair
Perineorraphy
Congenital Vaginal atresia
Vaginal septum
Urological disorders
Urethritis
Interstitial cystitis/Painful
bladder syndrome
Bowel disorders
Irritable bowel syndrome
Proctitis

Chronic pelvic inflammatory disease (PID)

PID is usually caused by sexually transmitted infections that have
ascended to the upper genital tract and intraperitoneal cavity.
Recent data suggest the rate of definite PID diagnosis in primary
care is about 280/100,000. PIDs main sequelae include infertility, ectopic pregnancy, chronic pelvic pain and deep dyspareunia. Pelvic adhesions may form after inflammatory processes
in the pelvis. Adhesions can cause fixed retroversion of the
uterus and may produce deep dyspareunia. But the role of adhesions and deep dyspareunia is controversial. In the absence of
fixed retroversion, adhesions may not be the causal factor.
Adhesiolysis often fails to improve deep dyspareunia but may
benefit a subgroup of women with severe dense and vascularised
adhesions involving the bowel.

Post surgery
Related to childbirth
Pelvic floor repair
Vaginal mesh
Total hysterectomy
Congenital
Incomplete vaginal septum
Urological disorders
Interstitial cystitis/Painful
bladder syndrome

Vulvodynia
Vulvodynia is a chronic pain that affects the vulvar area and
occurs without identifiable cause or visible pathology. Vulvodynia is a diagnosis of exclusion and has been classified by the
International Society for the Study of Vulvovaginal Diseases
(ISSVD) as generalised or localised (e.g. clitorodynia, vestibulodynia) and then whether provoked or unprovoked. It is akin to a
neuropathic pain syndrome. Provoked vestibulodynia is the most
common cause in premenopausal women and can be associated
with a history of genital-tract infections, former use of oral
contraceptives and psychosexual disorder. Generalised vulvodynia, as with patients with neuropathic pain, exhibits

Bowel disorders
Irritable bowel syndrome
Chronic constipation
Diverticular disease

Neurologic disorders/
Muscular abnormalities
Pudendal nerve lesions
Pelvic floor hyper-hypotonicity

Box 1

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dysaesthesia, allodynia, hyperpathia, and hyperalgesia. This type

of vulvodynia can be associated with pudendal nerve injury and/
or sexual abuse (Box 2).

experience of childbirth than with perineal trauma. It found

27.6% of the women studied had late dyspareunia. Interestingly,
there was no relation between late post-partum dyspareunia and
mode of delivery or state of the perineum. The analysis showed
late post-partum dyspareunia was associated with dyspareunia
before pregnancy, low satisfaction with delivery, and employment status.

Vaginismus
Vaginismus may occur secondary to a history of dyspareunia or
vaginismus is often accompanied by dyspareunia. Vaginismus is
a relatively rare involuntary contraction of the musculature of the
outer third of the vagina interfering with intercourse or insertion
of tampons, causing interpersonal difficulty. It has been reported
in between 4.2% and 12% of women. Primary vaginismus is due
to fear of penetration. Secondary vaginismus is likely to be the
result of pain with intercourse after infection, sexual assault, a
difficult delivery or surgery. Insertion of fingers, the penis or
tampons are common triggers of the spasm. Negative attitudes
about vaginal penetration and sexual ignorance have been
associated with vaginismus.

Dyspareunia with normal pelvic organs

Only one in five women with CPP has a condition that is primarily gynaecological. Dyspareunia is associated with CPP and
clusters of viscerosomatic symptoms. If laparoscopy fails to
determine the organic cause of pain, myofascial injuries should
be considered. Either complete or partial avulsion of levator ani
from its muscular origin and disruption of the endopelvic fascial
support may be associated with dyspareunia. A complicated
operative vaginal delivery, prolonged maternal pushing or a big
baby may cause myofascial damage. This can result in denervation injuries of pelvic viscera and manifest in the puerperium
or even years afterwards. When re-innervation occurs, it can be a
chaotic process, resulting in atypical nerve fibres within the
uterus, cervix, bladder mucosa, rectal mucosa, vulva and uterosacral ligaments. Obstetric re-innervation may account for
some patterns of sensory pelvic symptoms, including
dyspareunia.

Childbirth
Childbirth can have a big impact on sexual function. Many
women experience perineal pain after childbirth that can persist.
Pain is less when subcuticular vicryl sutures have been used in
the suturing of the perineum after trauma. Nearly 90% of women
resume sexual activity within three months of childbirth but the
sexual morbidity in the first three months is above 80%, which
declines to 64% at six months. Only 15% of women report
postnatal sexual dysfunction to health professionals. There is
also lack of awareness among professionals of this issue.
Resumption of sexual intercourse after childbirth depends on
mode of delivery, degree of perineal trauma, maternal age,
breastfeeding, and ethnic background. Women are five times less
likely to be sexually active after a third/fourth degree anal
sphincter tear compared to women with an intact perineum.
In a study published in 2012, late post-partum dyspareunia
(after 12 months) seemed to be linked more with the mothers

Urological disorders
Dyspareunia can also be experienced by patients suffering with
urological illnesses such as recurrent urinary-tract infections and
interstitial cystitis (IC) or painful bladder syndrome (PBS). About
75% of women with IC/PBS report such difficulties.
Post-surgical dyspareunia
Intraperitoneal adhesions are the most common complication of
obstetric and gynaecological surgery. Adhesions can cause dyspareunia but also cause CPP, subfertility and bowel obstruction.
In women with adhesions, subsequent surgery is more difficult
and can bring more complications. The problem of adhesions has
led to the development of anti-adhesion agents, although
disagreement remains as to which is most effective.
Dyspareunia can also be associated with the use of mesh and
non-absorbable sutures in the surgical treatment of pelvic prolapse or stress urinary incontinence. A recent systematic review
and classification of complications after anterior, apical or posterior and combined vaginal mesh implantation for prolapse
revealed de novo dyspareunia in about 11%e17% of patients
who underwent repair with mesh.

Classification of vulval pain according to the International Society for the Study of Vulvovaginal Diseases
(ISSVD)
Vulvar disorders
C
Vulvodynia
 Generalized
- Provoked (sexual, non sexual, or both)
- Unprovoked
- Mixed

Psychosexual causes
A psychosexual disorder is a common cause of dyspareunia,
especially if no obvious organic pathology has been found.
 Sexual desire disorders
 Hypoactive sexual desire disorder
 Sexual aversion disorder
 Sexual arousal disorder
 Orgasmic disorder
Psychosexual medicine is a complex area in which dyspareunia may be a trigger or a symptom, so it is important to be
aware of it as a problem and explore potential psychological

 Localized (vestibulodynia, clitorodynia)

- Provoked (sexual, non sexual, or both)
- Unprovoked
- Mixed
C

Vulvar pain related to a specific disorder






Infections (Candidiasis, herpes)

Inflammatory (Lichen sclerosis, lichen planus)
Neoplastic (pagets diasease, squamous cell carcinoma)
Neurological (herpes neuralgia, spinal nerve compression)

Box 2

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Quantification of the problem is necessary to assess the effect of

treatment or counselling. Several validated instruments are
available to evaluate sexual dysfunction, including libido,
arousal, orgasm, pain and relationship factors. Examples include
the Female Sexual Function Index (FSFI), the brief index of
Sexual Function Questionnaire (SFQ) for women, the Female
Sexual Distress Scale (FSDS) and the Changes in Sexual Functioning Questionnaire (CSFQ). In addition to self-report measures, hands-on techniques that quantify pain sensitivity by
Quantitative Sensory Testing (QST) can help explore potential
mechanisms involved in dyspareunia and the pain responses.

sources of sexual dysfunction. Women with dyspareunia also

experience higher levels of erotophobia (feelings of guilt and fear
related to sex). Frequent issues that may influence sexuality
include:
 Sexual abuse as a child or within relationships
 Poor sexual education
 Chronic emotional distress
 Physical or psychological domestic violence
 Cultural issues
 Work problems

History taking
General and gynaecological questions
During questioning relate the information obtained from the
specific questions above to many aspects of normal gynaecological history-taking. Establish a current menstrual history,
including bleeding irregularities that may interfere with sex. Take
details of difficulties in conception, episodes of pelvic infections,
endometriosis, cysts, fibroids and surgery. Drug use/misuse,
auto-immune, endocrine, neurological, urological and gastrointestinal conditions may be relevant and need recording. For
example, long-term antibiotics use predisposes women to yeast
infection, which may cause pain. Interestingly, some studies
suggest low doses of ethinylestradiol in premenopausal women
were more likely to develop vulvodynia.

Women rarely present with dyspareunia symptoms alone, it is

often an accompanying symptom that has to be raised in closed
or direct questioning. If the patient volunteers pain with intercourse as her primary problem, it is a good sign that further information can be obtained. The norm, however, is that the issue
of dyspareunia may be harder to extract.
A patients narrative of her illness provides essential information for diagnosis. As well as her pain, she may feel embarrassment, guilt, loss of self-esteem, frustration, depression and
anxiety. Asking the patient what her concerns are often uncovers
the real problem.
It can be difficult for patients to discuss sexual matters with
someone they barely know, so creating an understanding, professional atmosphere during consultation can enhance openness
and confidence. She should feel unhurried and at ease, with no
more people in the consultation room than necessary.
Patients should not be asked straightaway if they are having
difficulties with sexual intercourse unless they raise it early on.
Once it is established that dyspareunia is a problem, start with
more systematic questioning. Below is a list of useful questions.
Be flexible and cover further areas only if the consultation appears to be going well.

Examination
With any gynaecological examination, tact and sensitivity are
key. With patients complaining of dyspareunia the clinician must
be even more aware of the range of causes and adapt the examination, particularly with patients in whom a psychosexual
causation is suspected. An element of prior sexual abuse may
accompany the symptomatology, which may make the examination painful for the patient and uninformative for the doctor. It
could even damage the professional relationship and so impede
management strategies.
The patient must be told that the examination is to identify the
cause of the pain and may be uncomfortable but can be stopped
at any time. Clinicians should know this may not be a see and
treat session as the patient may be stressed already and feel an
examination should wait for another day. This may be difficult to
organise but if the patient is made aware of the delays this may
cause she may decide to continue. The setting should be private
and quiet with no unnecessary staff. There should be a chaperone regardless of the sex of the examining practitioner. Tailor
the physical examination to the problem as much as possible.
Look at the most important areas first, leaving relevant general
examination for the end, especially if the patient becomes uncomfortable later on. Do not enter into the physical examination
aiming to reproduce symptomatology e this may unsettle the
patient. Explain that if her pain is experienced during examination she should say so and you will stop immediately.

Specific questions
 How long has this been a problem?
 Is the pain sharp, dull, burning, cutting, or throbbing?
 Is it getting any better or worse?
 Have you had pain since the first time you had intercourse
or did it develop later on?
 Does it occur in every episode of intercourse?
 How often (approximately) do you have sex?
 Does the pain occur during superficial or deep penetration?
 Is there any sexual position that worsens or improves the
pain?
 Do painkillers offer relief?
 Do you have genital or pelvic pain with other sexual or
non-sexual contact (e.g. tampon insertion, pelvic examination, finger insertion, oral sex, urination)?
Sexual history questioning
 Do you look forward to sex?
 Are you able to become aroused or lubricated during
foreplay?
 Is the pain with sex having an effect on your relationship?
 When did you last change your sexual partner?
 Have you had the same pain with other partners?

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Abdominal examination
Inspect for scars, evidence of previous laparoscopies or more
major abdominal surgery. Ask before palpation to avoid causing
more pain over tender areas. Make a note of such painful regions
of the abdomen and only palpate there with her permission.

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high vaginal/endocervical and urethral swabs for microbiological culture, pelvic ultrasound scan and diagnostic laparoscopy.
Many women will have had swabs taken by their family doctors
and, unless clinically indicated, a repeat is unnecessary. These
days more women expect ultrasound to be part of the diagnostic
process although it may not contribute much to the diagnostic
process. If endometriosis is suspected, transvaginal ultrasonography can reliably identify endometriomas and show pelvic fluid
and ovarian endometriosis. MRI can help in the diagnosis of deep
infiltrating endometriosis, with contrast enema helping to detect
low colorectal invasion.
Serum testing for estradiol, total/free testosterone, sex hormone binding globulin (SHBG), follicle stimulating hormone and
prolactin can be considered, especially as hormonal abnormalities
are common causes of sexual pain. For example, an elevated
SHBG and decreased free testosterone and estradiol are frequently
found in women with vestibulodynia caused by hormonal contraceptives. Serum testing is not necessary in all cases of dyspareunia, but may help when the aetiology of the pain is unclear.
Laparoscopy, useful as a diagnostic and therapeutic tool when
endometriosis or other organic pelvic pathology is suspected,
carries significant morbidity so should be used only if justified.
The woman must be made aware of surgical risks and the possibility of finding no abnormality. Laparoscopy is thought to be
the gold standard for diagnosing endometriosis. The lesions of
endometriosis have a heterogenous appearance (red, black
matchstick or white fibrous lesions) and the accuracy of the
diagnosis depends upon the ability of the surgeon. Nearly 60% of
histologically documented endometriosis is missed at laparoscopy. The advantage of laparoscopy is that it affords concurrent
surgical ablation and/or excision of the endometriotic lesions
and also a staging of the disease.
Vulvoscopy may have a role in the evaluation of dyspareunia.
It enhances the ability to detect subtle colour changes associated
with inflammatory or neoplastic diseases. If the vulva appears
abnormal, biopsy is indicated. Chronic pain in the urethra or
bladder associated with dyspareunia should warrant additional
tests such as cystoscopy and bladder biopsies. An electromyelogram may be used to assess the tone and strength of the
levator ani muscles when there is evidence of pelvic floor
dysfunction.

Then palpate for any significant masses, especially uterine fibroids or large ovarian cysts, and assess their tenderness and
mobility.
Vaginal examination
It is important to consider the presenting complaint during this
part of the examination as a woman with superficial dyspareunia
or severe vaginismus may stop the process if she is first examined with a speculum. For all patients a detailed inspection of the
vulva is needed, gently parting the labiae, checking for normal
anatomy, oestrogenisation, dermatoses, candidiasis, cysts, warts,
trauma, episiotomies, state of the hymenal ring, prolapse and
size of the introitus. An inspection of the perineum and perianal
area may be performed at the same time but only if easy to do.
Gentle palpation, with the pulp of the first digit, of the posterior
band of skin at the introitus is useful, especially in those with
postnatal dyspareunia to feel for encapsulated suture knots or
granulomata. Similar bands can be noted in the levator muscles
and obturator muscles.
A cotton-tipped applicator should be used to delineate whether
any cutaneous allodynia is present. Start by applying pressure in
areas not thought to be painful: medial thigh, buttock and mons
pubis. If present in the whole vulva region, it indicates generalised
vulvodynia; if localised in one area it is vestibulodynia.
In those patients with urological symptoms, dyspareunia is
diagnosed when pain can be provoked by palpating the urethra
and base of the bladder e suggestive of a urethral diverticulum
or interstitial cystitis.
In patients with severe vaginismus the next step is usually
examination with a single finger if this is tolerated. Gently
palpate the vaginal walls and, if possible, the cervix. If she tolerates this part of the examination, she should be offered a
speculum examination.
If there are suggestions of pudendal nerve injury, the ischial
spine can also be located and the pudendal nerve palpated.
Tenderness of the pudendal nerve is suggestive of pudendal
neuralgia or entrapment.
The speculum should be well lubricated and, if possible,
warmed. Consider using plastic speculae as they feel more
thermoneutral. Inspect carefully for anatomical abnormalities
such as vaginal septae, double cervices and vaginal bands.
Again, inspections for evidence of infection, oestrogenisation and
trauma are required. Visible mesh, granulation tissue or a sinus
tract may be visible on careful vaginal examination. This may
also be a good time to get consent to do cervical smear tests in an
otherwise reluctant patient.
Bimanual examination follows and often provides the most
useful information e especially in those with deep dyspareunia.
Reassure the patient who feels she cannot tolerate bimanual
examination that similar information can be obtained from
further investigations. Specific findings often include rectovaginal nodules, pelvic masses, tenderness and cervical motion
tenderness.

Conclusions
Dyspareunia is a common and under-reported condition that can
significantly impair womens health, quality of life and relationships. It is a complicated symptom to assess and treat, often
creating frustration in both healthcare professionals and patients.
A combination of thorough medical history, physical examination and appropriate testing should give a clinician enough evidence to establish either a specific diagnosis or a differential
diagnosis of the aetiology of a womans dyspareunia. In addition,
the process of obtaining this history and examination establishes
a rapport between the clinician and the patient, which is essential
in the treatment of this type of disorder.
Management is usually directed to causative factors but if no
physical problems are found, the patient should feel reassured
that all possible factors have been considered and a psychosexual
referral should be considered.
A

Further investigations
It is rare that further investigations are needed as the history and
examination are likely to give a full assessment or reassurance
that there are no big problems. Commonly used tests are vulval/

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FURTHER READING:
Barski D, Otto T, Gerullis H. Systematic review and classification of complications after anterior, posterior, apical, and total vaginal mesh implantation for prolapse repair. Surg Technol Int 2014 Mar; 24: 217e24.
Fageeh WM. Different treatment modalities for refractory vaginismus in
western Saudi Arabia. J Sex Med 2012 Mar; 9: 945.
Frances LA. Review of patients in a psychosexual clinic-how strong is the
relationship between psychosexual problems and a history of sexual
abuse or assault? J Forensic Res 2014; 5: 4.
Ghazizadeh S, Nikzad M. Botulinum toxin in the treatment of refractory
vaginismus. Obstet Gynecol 2004 Nov; 104(5 Pt 1): 922e5. PMID:
15516379.
Goldstein A, Pukall C, Goldstein I. Vaginismus: evaluation and management. In: Reissing E, ed. Female sexual pain disorders: evaluation and
management. Oxford: Wiley- Blackwell, 2009; 229e33.
Hayes RD, Bennett CM, Fairley CK, Dennerstein L. What can prevalence
studies tell us about female sexual difficulty and dysfunction? J Sex Med
2006; 3: 589e95. http://dx.doi.org/10.1111/j.1743-6109.2006.00241.x.
Horton-Szar D, Dalta S, Dutta R. Pelvic pain and dyspareunia. Crash course
obstetrics and gynaecology. China. Mosby e Elsevier, 2014; 43e7.
Mandal D, Nunns D, Byrne M, et al. Society for the Study of Vulval Disease
(BSSVD) Guideline Group. Guidelines for the management of vulvodynia. Br J Dermatol 2010; 162: 1180e5.
Quinn M. Obstetric denervation-gynaecological reinnervation: disruption
of the inferior hypogastric plexus in childbirth as a source of gynaecological symptoms. Med Hypothesis 2004; 63: 390e3.
Vercellini P, Arici A. Bladder pain syndrome and other urological causes of
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pelvic pain. Oxford: Wiley e Blackwell, 2011; 86e96.

OBSTETRICS, GYNAECOLOGY AND REPRODUCTIVE MEDICINE 25:4

Practice points
C

101

Dyspareunia is a symptom of a variety of disease states with

components of both organic and psychological dysfunction
Sexual problems can occur in heterosexual and homosexuals.
They are reported by almost 43% of women. Between 7 and 58%
have problems with dyspareunia
Endometriosis and chronic PID are important causes of
dyspareunia
Longstanding dyspareunia may give rise to avoidance of sex and
relationship problems
A high level of professionalism, tact and sensitivity are required
to obtain a sexual history in an outpatient setting
Psychosexual causes should be considered and appropriate referrals made for counselling and assessment
Provoked vestibulodynia is the most common cause of vulvodynia in premenopausal women
A thorough clinical examination of the lower genital tract is
necessary to exclude organic causes. Ultrasound of pelvis does
not always provide additional information
Laparoscopy is a useful procedure to diagnose and treat
endometriosis
Management is usually directed to causative factors but if no
physical problems are found, the patient should feel reassured
that all possible factors have been considered

2015 Elsevier Ltd. All rights reserved.