Dyspareunia resident survival guide

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Roghayeh Marandi

Overview

Dyspareunia is recurrent or persistent pain with sexual activity that causes marked distress or interpersonal conflict. It can affect men, but more common in women. It can due to psychological factors, physical factors, or combined factors. It may be classified into two types in women: superficial, which occurs in or around the vaginal entrance, and is characterized by initial discomfort in initial or attempted penetration of the vaginal introitus. Deep dyspareunia is a pain that occurs with deep vaginal penetration. which resulting from pelvic thrusting during intercourse. Causes are divided into three groups according to Onset, Frequency, or Location. According to dyspareunia's location, there are two types of dyspareunia in women: superficial, which occurs in or around the vaginal entrance, and is characterized by early discomfort in initial or attempted penetration of the vaginal introitus, and deep dyspareunia is pain that occurs with deep vaginal penetration, Which resulting from pelvic thrusting during intercourse. Determining whether dyspareunia is the entry or deep can point to specific causes. Based on the onset, dyspareunia can be divided into two groups: Primary (onset with first sexual experience) Often has psychological causes, such as sexual abuse in childhood, feeling of guilt or shame toward sex or fear of intercourse or painful first intercourse, and secondary dyspareunia that its beginning is after a previous sexual activity that was not painful. Dyspareunia can be Persistent, which occurs in all situations, possibly due to physical or psychological factors, or conditional dyspareunia that occurs in certain situations. Abdomino-pelvic disorders such as endometriosis, imperforate hymen, vaginal septum, or organic vulvodynia due to infection, lichen sclerosis, or vestibulitis, vaginal infections, prolapse, trauma, or vaginal dryness can cause Dyspareunia. It can also be due to gastrointestinal disorders such as chronic constipation, diverticular diseases, inflammatory bowel disease/proctitis. Scarring due to previous pelvic surgery, episiotomy, and perineorraphy, or urological causes such as cystitis, interstitial cystitis, or urethritis can cause dyspareunia as well.

Causes

Life Threatening Causes

Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated.

• Life threatening cause 1
• Life threatening cause 2
• Life threatening cause 3

Common Causes

• Vaginitis
• Hormonal changes perimenopause and menopause
• Vaginismus
• Pelvic inflammaatory disease
• Vulvodynia
• Endometriosis

Cardiovascular	Hemorrhoids, Renal nutcracker syndrome , Thrombosed piles
Dermatologic	Allergic contact dermatitis, Healed perineal lacerations, Irritant contact dermatitis, Kraurosis vulvae, Lichen planus, Lichen sclerosus, Obstetric perineal injury
Ear Nose Throat	Sjögren's syndrome
Endocrine	Menopause, Perimenopause, Prolactin secreting pituitary tumour, Prolactinoma, Reduced estrogen, Reduced libido
Gastroenterologic	Inflammatory bowel disease , Irritable bowel syndrome
Genetic	Congenital absence of lower part of vagina, Müllerian anomalies
Iatrogenic	Episiotomy, Gynecologic surgery, Obstetric surgery, Vaginal surgery
Infectious Disease	Atrophic vaginitis, Atrophic vulvitis, Atrophic vulvovaginitis, Autoimmune interstitial cystitis , Bartholin gland cyst, Bartholinitis, Candida albicans, Candidiasis, Chlamydia, Cystitis, Herpes simplex virus, Herpes virus 2, Pelvic infection, Trichomonas vaginalis, Trichomonas, Trichomoniasis , Urethritis, Urinary tract infection, Vaginitis, Vulva infection, Vulvovaginitis
Musculoskeletal/Orthopedic	Parkinson’s disease, Vaginismus, Vulval dystrophy
Neurologic	Parkinson’s disease, Peripheral neuropathies
Obstetric/Gynecologic	Atrophic vaginitis, Atrophic vulvitis, Atrophic vulvovaginitis, Autoimmune endometriosis , Autoimmune interstitial cystitis , Bartholin gland cyst, Bartholinitis, Chronic pain syndromes, Congenital absence of lower part of vagina, Endometrial conditions, Endometriosis, Episiotomy, Estrogen deficiency, Estrogen-based contraceptives, Female genital mutilation, Genital system cancer , Genital tract tumor, Genital ulcers, Gonorrhea, Gynaecological conditions , Gynecologic surgery, Healed perineal lacerations, Hemorrhoids, Imperforate hymen, Inflamed hymeneal orifice, Lactation, Myofascial pelvic pain syndrome, Narrow vagina, Obstetric perineal injury, Obstetric surgery, Ovarian tumour, Pelvic adhesions, Pelvic disorders, Pelvic infection, Pelvic inflammatory disease, Pelvic malignancy, Pelvic organ prolapse, Pelvic tumor, Perimenopause, Poor vaginal lubrication, Post-childbirth, Prolapsed tender ovaries with retroverted uterus, Provoked vulvar pain, Remnants of the hymen, Salpingo-oophoritis, Unruptured hymen, Vagina cancer, Vaginal abnormality, Vaginal dryness, Vaginal surgery, Vaginismus, Virilising ovarian tumour , Vulva infection, Vulval dystrophy, Vulval neoplasia, Vulvar vestibulitis syndrome , Vulvitis, Vulvodynia, Vulvovaginitis
Oncologic	Genital system cancer , Genital tract tumor, Ovarian tumour, Pelvic malignancy, Pelvic organ prolapse, Pelvic tumor, Prolactin secreting pituitary tumour, Prolactinoma, Uterine sarcoma , Uterine tumour, Vagina cancer, Virilising ovarian tumour , Vulval neoplasia, Yolk sack tumour
Psychiatric	Anxiety, Depression, Psychological disorders, Reduced libido, Relationship dysfunction
Renal/Electrolyte	Interstitial cystitis, Renal nutcracker syndrome
Rheumatology/Immunology/Allergy	Arthritis of the hips, Fibromyalgia, Kraurosis vulvae, Lichen planus, Menopause, Scleroderma, Sicca syndrome, Sjögren's syndrome
Sexual	Chlamydia, Estrogen-based contraceptives, Female genital mutilation, Genital ulcers, Gonorrhea, Herpes simplex virus, Herpes virus 2, Trichomonas vaginalis, Trichomonas, Trichomoniasis
Trauma	Allen-masters syndrome , Anal fissure, Cystitis, Trauma
Urologic	Interstitial cystitis, Peyronie's disease, Urethral caruncle, Urethritis, Urinary tract infection, Uterine sarcoma , Uterine tumour
Miscellaneous	Relationship dysfunction

Diagnosis

Shown below is an algorithm summarizing the diagnosis of dyspareunia

Assessment of Female dyspareunia

History and physical exam PAIN CHARACTERISTICS: Timing, duration, quality, location, provoked, or unprovoked MUSCULOSKELETAL HISTORY: Pelvic floor surgery, trauma, obstetrics BOWEL AND BLADDER HISTORY: Constipation, diarrhea, urgency, frequency SEXUAL HISTORY: Frequency, desire, arousal, satisfaction, relationship PSYCHOLOGICAL HISTORY: Mood disorder, anxiety, depression HISTORY OF ABUSE: Sexual, physical, neglect Physical exam: external musculoskeletal evaluation: complete lower back, abdomen, and pelvic inspection external visual and sensory examination, internal single digit palpation of the pelvic floor bimanual examination for evaluation of uterus, cul-de-sac, and adnexal regions the internal vaginal tissue, cervix Work up:vaginal secretions blood count Glucose Hormones: prolactin, TSH, FSH,LH, Testrstrone

Genital alterations Atrophic vaginitis Atrophic vulvitis Atrophic vulvovaginitis Autoimmune endometriosis Autoimmune interstitial cystitis Bartholin gland cyst Bartholinitis Chronic pain syndromes Congenital absence of lower part of vagina Endometrial conditions: Endometriosis Episiotomy Estrogen deficiency Estrogen-based contraceptives Female genital mutilation Genital system cancer Genital tract tumor Genital ulcers Gonorrhea Gynaecological conditions: Gynecologic surgery Healed perineal lacerations Hemorrhoids Imperforate hymen Inflamed hymeneal orifice Lactation Myofascial pelvic pain syndrome Narrow vagina Obstetric perineal injury Obstetric surgery Ovarian tumour Pelvic adhesions Pelvic disorders: Pelvic infection Pelvic inflammatory disease Pelvic malignancy Pelvic organ prolapse Pelvic tumor Perimenopause Poor vaginal lubrication Post-childbirth Prolapsed tender ovaries with retroverted uterus Provoked vulvar pain, Remnants of the hymen, Salpingo-oophoritis, Unruptured hymen, Vagina cancer, Vaginal abnormality, Vaginal dryness, Vaginal surgery, Vaginismus, Virilising ovarian tumour , Vulva infection, Vulval dystrophy Vulval neoplasia Vulvar vestibulitis syndrome Vulvitis Vulvodynia Vulvovaginitis

Hormonal changes Menopause Perimenopause Prolactin secreting pituitary tumour Prolactinoma Reduced estrogen Reduced libido

systemic disorders/drugs

Psychiatric problems

Anxiety, Depression, Psychological disorders, Reduced libido, Relationship dysfunction

Treatment

Shown below is an algorithm summarizing the treatment of [[disease name]] according the the [...] guidelines.

Do's

• The content in this section is in bullet points.

Don'ts

• The content in this section is in bullet points.

References

Template:WikiDoc Sources