Clinical Review

Dyspareunia: 5 overlooked causes

OBG Manag. 2003 April;15(4):50-68

References

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3. Jalbuena JR. Atrophic vaginitis in Filipino women. Climacteric. 2001;4:75.-

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5. Anderson M, Kulzner S, Kaufman RH. Treatment of vulvovaginal lichen planus with vaginal hydrocortisone suppositories. Obstet Gynecol. 2002;100:359-362.

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7. Sobel JD, Faro SF, Force RW, et al. Vulvovaginal candidiasis: epidemiologic, diagnostic, and therapeutic considerations. Am J Obstet Gynecol. 1998;178:203-211.

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10. Meana M, Binik YM, Khalife S, Cohen DR. Biopsychosocial profile of women with dyspareunia. Obstet Gynecol. 1997;90(4 pt 1):583-589.

11. Bohm-Starke N, Hilliges M, Brodda-Jansen G, Rylander E, Torebjork E. Psychophysical evidence of nociceptor sensitization in vulvar vestibulitis syndrome. Pain. 2001;94:177-183.

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15. Bornstein J, Zarfati D, Abramovici H. Perineoplasty compared with vestibuloplasty for severe vulvar vestibulitis. Obstet Gynecol. 1997;89:695-698.

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Vaginismus is diagnosed by eliciting muscle spasms in the pelvic floor by depressing the levators. If a woman has primary vaginismus of psychogenic origin, there is no tenderness in the vestibule; note, however, that the exam may be so difficult for her to endure that evaluating the vestibule is not possible.

Pelvic-floor motor instability is treated with physical therapy and biofeedback. In secondary disease, vestibulitis must also be concomitantly addressed. Primary disease, meanwhile, is treated by desensitization techniques that help the patient control the relaxation of her musculature.

The fine points of examination

Asking the right questions. Before you begin the physical exam, it is crucial to get as much information as possible about the patient’s condition. The dyspareunia history includes the following:

a complete description of the pain problem and any concomitant sexual dysfunction
exploration of potential gynecologic causes
exploration of potential medical causes
psychosocial information¹⁸

In addition, a series of open-ended question asked in a nonjudgmental manner will help identify potential anatomic and medical sources of pain (TABLE), as well as psychosocial issues that may be a cause or result of dyspareunia (see “Discussing dyspareunia: Questions crucial to a thorough exam”).

The physical exam. Although guided by the history, the physical examination needs to be as comprehensive as possible. It should include:

systematic, meticulous inspection of every structure to confirm normal color, texture and architecture, and the presence or absence of lesions.
gentle palpation of all tissues for the source of the discomfort. This should include a Q-tip test of the vestibule for tender foci.
a speculum exam with inspection for mucosal integrity without fissure, erosion, or ulceration, as well as a check for the presence or absence of rugae and discharge. (Testing for pH is done with a reactive cardboard strip while the speculum is in place; then samples for wet mount and cultures are collected.)
gentle single-digit exam of the vestibule to confirm the Q-tip test, as well as single-digit palpation of the pelvic-floor musculature, anterior vaginal wall, urethra, and bladder to confirm superficial pain and avoid confusion with pelvic sources.
bimanual examination to evaluate for any nodularity or masses in the vagina, rectovaginal septum, or pelvis, as well as for mobility and tenderness of the pelvic organs.

Before attributing the dyspareunia to a lesion you encounter, it is important to reproduce pain at that lesion site. Whitened skin and some synechiae, for example, are painless; the source of the dyspareunia may be tenderness in the vestibule.

Note that with generalized dysesthesia (vulvodynia), there may be no physical findings.

Take steps to navigate the pain. Some women cannot tolerate a vulvar or vaginal examination; asking about previous experience will make it easier to tailor the exam appropriately. The following techniques also may be appropriate:

use of premedication
presence of a support person
an agreement to stop the exam if the patient so requests
use of a pediatric speculum

In rare cases, examination may need to be deferred until desensitization with a sexual therapist is achieved. Fortunately, most women tolerate the examination well and can identify the troubling areas.

It may not be possible to complete all components of an examination at a single visit. For example, a patient may have to return for a vaginal examination and wet mount if menses are present at the initial appointment.

Cultures for Candida and Trichomonas are important when microscopy is negative.

Essential laboratory studies.

Vaginal pH. A normal level (3.5 to 4.5) rules out bacterial infection and atrophy. Candida grows at any pH. Elevated pH is nonspecific and can represent recent intercourse or a small amount of blood. However, it also can suggest such causes of dyspareunia as atrophy, vaginal lichen planus, desquamative vaginitis, and Trichomonas.
Wet mount reveals 4 important features:
1. Epithelial cells. These should be superficial or intermediate. The presence of parabasal cells suggests atrophy regardless of the age group. It also may indicate inflammation from Candida, lichen planus, or desquamative inflammatory vaginitis.
2. Pathogens.Candida or Trichomonas may be identified. Microscopy for Candida lacks sensitivity; a negative examination in a symptomatic woman mandates a culture for Candida.¹⁹
3. Background flora. As mentioned earlier, lactobacillus dominates the normal vagina; when this predominance is seen on microscopy, there is no bacterial infection. A vaginal culture may grow Escherichia coli, group B streptococcus, Gardnerella, and a variety of normal commensals, but these are not the cause of dyspareunia when pH is normal and lactobacilli dominate the slide.
4. White blood cells. Large numbers suggest Candida, lichen planus, Trichomonas, gonorrhea, chlamydia, or desquamative inflammatory vaginitis.
Cultures for Candida and Trichomonas are important when microscopy is negative. Routine vaginal culture is not recommended. Cultures for herpes, gonorrhea, or chlamydia may be necessary.
Biopsy and blood tests offer data on hormonal levels or type-specific antibodies for herpes. Biopsy of the vulva or vagina is indicated whenever there is a visible lesion that needs identification.
Urine culture, colposcopy, or imaging such as ultrasonography and spine films may be indicated.
Specialty referrals may be helpful for evaluation of the gastrointestinal or genitourinary tract, or for diagnostic laparoscopy for endometriosis.