Painful Sexual Intercourse (Dyspareunia)

💡 Dyspareunia = persistent or recurrent genital pain associated with sexual intercourse. It may be superficial (pain at vaginal entry) or deep (pain on penetration/thrusting). It affects quality of life, relationships, and mental health - a holistic, sensitive approach is vital.

📖 Pathophysiology & Classification

• Superficial dyspareunia: Pain at the introitus (atrophy, infection, vulvodynia, vaginismus, scarring).
• Deep dyspareunia: Pain deeper in the pelvis (endometriosis, PID, ovarian cysts, fibroids, adhesions, interstitial cystitis).
• Psychogenic contributions: Past trauma, anxiety, relationship stress. Chronic pain may cause central sensitisation.

🩺 History Taking

• ⏳ Onset/duration: Lifelong vs acquired; progression.
• 📍 Timing/location: Entry vs deep penetration.
• 📝 Character: Burning, sharp, aching.
• 🤔 Associated symptoms: Vaginal dryness, discharge, bleeding, urinary or bowel pain, dysmenorrhoea.
• ❤️ Sexual history: STI risk, contraception, safeguarding/trauma.
• 🧬 Medical history: Menopause, autoimmune disease, systemic conditions.
• 💬 Impact: Avoidance of intimacy, relationship stress, anxiety.

👩 Clinical Examination

• General: BMI, anaemia, thyroid disease, secondary sexual characteristics.
• Inspection: Vulval erythema, atrophy, scarring, ulcers, lichen sclerosus.
• Speculum: Mucosa (atrophy, discharge, lesions), cervix.
• Bimanual: Uterus size/position, adnexal masses, cervical motion tenderness.
• Special: Cotton-swab test (vulvodynia), pelvic floor tone (vaginismus).

🔬 Investigations

• 🧫 STI screen: Chlamydia, gonorrhoea, syphilis, HIV, HSV.
• 🧪 Bloods: FBC, CRP, hormones (FSH, LH, oestrogen, thyroid profile).
• 🧬 Swabs: Vaginal/cervical swabs for infection.
• 🖥️ Imaging: Pelvic USS (cysts, fibroids, endometriosis), MRI if complex.
• 🔍 Laparoscopy: Gold standard for endometriosis/adhesions.
• 🔬 Biopsy: If vulval/vaginal neoplasia or lichen sclerosus suspected.
• 🚽 Urinalysis/cystoscopy: Exclude UTI, interstitial cystitis.

📊 Causes of Dyspareunia

⚠️ Red Flags

• Postcoital or postmenopausal bleeding (exclude cervical/endometrial cancer).
• Persistent vulval ulceration or new skin changes.
• Unexplained weight loss, night sweats, systemic illness.
• Rapidly enlarging pelvic mass.

💊 Management Principles

• 💬 General: Empathy, validation, explanation; involve partner if appropriate.
• 🌸 Superficial causes: Lubricants, topical oestrogen, antifungals/antibiotics, lidocaine for vulvodynia, physiotherapy/dilators for vaginismus.
• 🦴 Deep causes: Hormonal therapy or laparoscopy for endometriosis; antibiotics ± surgery for PID; surgery for large fibroids/cysts.
• 🧠 Psychological: CBT, trauma therapy, psychosexual counselling.
• 👩‍⚕️ Multidisciplinary approach: GP, gynaecology, pelvic physiotherapy, psychosexual services.

📌 Complications

• Relationship stress, intimacy avoidance.
• Chronic pelvic pain, central sensitisation.
• Depression, anxiety, sexual dysfunction.

🧑‍⚕️ Case Examples

• Case 1 - Menopause (Atrophic Vaginitis): 56F, postmenopausal, progressive vaginal dryness. Exam: thin, pale mucosa. Dx: GSM (atrophic vaginitis). Tx: lubricants + local oestrogen → high success.
• Case 2 - Endometriosis: 29F, deep dyspareunia, worse premenstrually, with dysmenorrhoea + infertility. Exam: pelvic tenderness. Dx: endometriosis. Tx: analgesia, hormonal suppression, laparoscopy if refractory.
• Case 3 - Vaginismus (Psychogenic): 24F, severe pain with attempted penetration, normal exam. Reflex pelvic floor spasm. Dx: vaginismus. Tx: psychosexual therapy, pelvic physio, dilators, partner support.

📚 Key Pearls

• Differentiate entry vs deep pain early in history.
• Dyspareunia often has mixed organic + psychological factors.
• Safeguarding: Always consider past trauma or abuse.
• Care is multidisciplinary, requiring medical, psychological, and physiotherapy input.

📚 References

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