assessment of female dyspareunia

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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:

Last edited 03/2018

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