Makindo Medical Notes

💡 Dyspareunia (painful sexual intercourse) is a common but underreported problem in women, affecting physical health, emotional wellbeing, and relationships. It can result from local genital pathology, pelvic disease, infections, or psychogenic causes. A sensitive, structured clinical approach is vital.

📖 History Taking

• Onset & Duration: When did the pain start? Is it lifelong or acquired?
• Timing of Pain: Superficial (pain at vaginal entry) vs deep (pain with penetration or thrusting).
• Character: Burning, sharp, aching, or pressure-like.
• Associated Symptoms: Vaginal dryness, discharge, bleeding, urinary frequency, dysmenorrhoea, bowel symptoms.
• Sexual History: STI risk, contraception, history of sexual trauma.
• Systemic History: Endocrine, autoimmune, or connective tissue disease.
• Impact: Relationship stress, avoidance of intimacy, psychological distress.

🩺 Clinical Examination

• General exam: Anaemia, thyroid disease, systemic signs.
• Abdominal exam: Tenderness, masses, organomegaly.
• Pelvic exam: External inspection (atrophy, lichen sclerosus, scarring), speculum (discharge, cervical lesions), bimanual (uterus size, adnexal masses, tenderness).
• Special tests: Cotton-swab test for vulvodynia, muscle spasm for vaginismus.

🔬 Investigations

• 🧪 Bloods: FBC, inflammatory markers, hormones (FSH, LH, oestrogen, testosterone, thyroid function).
• 🧫 Microbiology: High-vaginal/cervical swabs for STIs.
• 🖥️ Imaging: Pelvic ultrasound (fibroids, cysts, endometriosis); MRI if complex.
• 🔍 Endoscopy: Diagnostic laparoscopy for suspected endometriosis.
• 🧬 Histology: Vulval/vaginal biopsy if lichen sclerosus or neoplasia suspected.

📊 Causes of Painful Sex

⚠️ Red Flags

• Postcoital bleeding (consider cervical cancer).
• Unexplained weight loss, night sweats, fever.
• Rapidly enlarging pelvic mass.
• Dyspareunia with postmenopausal bleeding.
• Persistent vulval ulceration or skin changes.

🗣️ Clinical Discussion

Dyspareunia often involves an overlap of psychological and organic causes. Superficial pain usually points to vaginal/vulval pathology (atrophy, infections, vulvodynia, vaginismus). Deep pain often suggests pelvic pathology (endometriosis, PID, fibroids, ovarian cysts, interstitial cystitis). Always consider safeguarding in cases of sexual trauma. Good rapport and sensitive history-taking are essential to avoid patient embarrassment and to ensure disclosure of symptoms.

📚 References

• Nice CKS. Dyspareunia (2023 update)
• RCOG Green-top Guidelines
• Berek & Novak’s Gynaecology, 16th Ed.