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Assessment of female dyspareunia

Last reviewed dd mmm yyyy. Last edited dd mmm yyyy

Authoring team

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).

History:

  • 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)

Examination:

  • 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.

Reference:


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