dyspareunia

Introduction

Difficult or painful sexual intercourse.

Etiology

• superficial dyspareunia
  • vaginismus/ infectious vaginitis
  • vulvar vestibulitis
  • inadequate lubrication
  • atrophic vaginitis
  • urethritis
  • lichen sclerosus
• deep dyspareunia
  • endometriosis
  • pelvic adhesions
  • pelvic inflammatory disease (fever, vaginal dicharge, pelvic pain)
  • interstitial cystitis (urinary frequency, urinary urgency, nocturia)
  • ovarian mass
  • arthritis

Epidemiology

• under-reported
• common problem
• occurs at least occasionally in 33% of women
• occurs frequently or all of the time in 10% of women

Clinical manifestations

• decreased frequency of sexual activity
• adverse effects on intimate relationships
• pelvic examination in described as atrophic vaginitis &/or vaginal atrophy
  • pale vaginal mucosa with visible veins
  • mildly stenotic introitus
  • diminished vaginal caliber & length

Differential diagnosis

• sexual abuse
• dysfunctional relationship

Management

• specific measures for specific etiology
• general measures
  • lubrication (Replens, Maxilube) for women with adequate vaginal caliper & length without vulvar or vaginaltenderness
  • vaginal estrogen for atrophic vaginitis/vaginal atrophy
• vaginal caliper & length can be improved with use a graduated dilators after vaginal estrogen treatment to rejuvenate vaginal mucosa
• ospemifene is an oral estrogen agonist/antgonist FDA-approved for treatment of dyspareunia
  • contraindicated in patients with increased risk for thromboembolism, history of breast cancer, ovarian cancer, uterine cancer
• prasterone (Intrarosa), once a day vaginal insert for treatment of dyspareunia in postmenopausal women FDA-approved
• vaginoplasty more likely to cause harm than provide benefit except in case of vaginal stricutre due to prior vaginal reconstructive surgery of pelvic radiation

More general terms

• sexual dysfunction

Additional terms

• endometriosis
• ovarian cancer
• pelvic inflammatory disease (PID)
• vaginitis