assessment of female dyspareunia
The condition may be revealed by the patients themselves or may be discovered during examination for some other reason e.g. – cervical smear
- many women will find it difficult to inform the clinician directly about dyspareunia and may use another symptom to introduce the subject e.g - recurrent vaginal discharge or pelvic pain
- consultation of these patients may be difficult and one needs to be sensitive and non judgemental when obtaining the history.
- use open ended questions to obtain more information
- begin with a general medical and surgical history before moving on to a gynecologic and obstetric history, followed by a comprehensive sexual history (1,2).
- details of pain
- where and when is the pain felt?
- “too tight” to allow penetration? may have associated with vaginismus
- if the pain is secondary, inquire about specific events, such as psychosocial trauma or exposure to infection, that might have triggered the pain
- is the pain positional? pelvic structural problems, such as uterine retroversion, may be present
- pain occurring each time she has intercourse?
- if not, is there a difference when she doesn’t have pain
- is she more relaxed and if so the possible reason?
- any relationship,life events, menstrual cycle
- sudden or chronic problem - an acute onset suggests an organic cause whilst a chronic problem is more suggestive of a psychosexual disorder
- other symptoms
- vaginal discharge - may indicate infection or other pathology
- is the patient depressed
- pruritus may indicate eczema or vulvar dystrophy
- regarding the pregnancy
- sex before the birth of the baby
- was intercourse previously free of pain, and did she enjoy sex?
- affects of pregnancy on sex?
- the delivery
- associated trauma during delivery?
- any tears or episiotomies? Does she feel confident that it healed well?
- feeling about becoming parents
- ask her what becoming parents has meant to them both
- did they plan the pregnancy or not?
- whether the baby sleeps with them? If so how do they feel about this?
- use of contraceptives and whether she trust it?
- still breastfeeding the baby?
- foreplay and non penetrative sexual behaviour
- is she becoming aroused and lubricating? (arousal causes lubrication and expansion of the upper vagina)
- does the patient reach orgasm?
- relationship with the partner
- has childbirth affected the relationship with the partner? If so how?
- do they find time to enjoy themselves as a couple? Are they affectionate?
- is the patient aware of effect dyspareunia has on their sexual relationship or is it just the husband who views it as a problem (3)
- physical examination may be deferred until the clinician establish a rapport with the patient
- observe the patient's demeanour e.g - if she is tense, nervous or reluctant to have an intimate examination.
- offer the patient an opportunity to participate during the pelvic examination e.g. – holding a mirror while the physician explain the findings
- stop the examination immediately if she asks you to do so (1,2)
- physical examination should include:
- abdominal examination
- to detect any masses or abdominal wall tenderness
- external genital examination – look for
- areas of erythema or discoloration –infection or dermatologic disease, e.g. - lichen sclerosus or lichen planus
- abrasions or other trauma - inadequate lubrication or forceful entry
- dryness of the vaginal mucosa - atrophy or chronic vaginal dryness
- abnormal discharge – infection
- use a cotton swab to identify any focal areas of tenderness
- internal examination
- gentle digital examination should be attempted initially
- look for muscular tightness, tenderness, or difficulty with voluntary contracting and relaxing - suggests pelvic floor muscle dysfunction
- palpate the urethra, bladder, and cervix for causes of dyspareunia
- a gentle bimanual examination
- carried out after the single-finger examination if it is not too uncomfortable for the patient
- check for pelvic and adnexal structures
- a small speculum may be used for visualization of internal structures
- examination may reveal no pain at all and everything may look normal.
- (1) Denman M. Investigating dyspareunia. GPonline 2012.
- (2) Seehusen DA, Baird DC, Bode DV. Dyspareunia in women. Am Fam Physician. 2014;90(7):465-70.
- (3) Ryan L, Hawton K. Female dyspareunia. BMJ. 2004;328(7452):1357
Last edited 03/2018