Approach to the woman with sexual pain
- Elizabeth Gunther Stewart, MD
Elizabeth Gunther Stewart, MD
- Assistant Professor
- Harvard Medical School
Sexual problems are highly prevalent in women. In the United States, approximately 40 percent of women have sexual concerns and 12 percent report distressing sexual problems . Female sexual dysfunction takes different forms, including lack of sexual desire, impaired arousal, inability to achieve orgasm, or pain with sexual activity .
Sexual pain disorders may be primary (ie, pain present at first intercourse) or secondary (ie, pain developing after previously pain-free intercourse), and may be complete (with each sexual experience) or situational (with some experiences or partners, but not others). The etiologic spectrum ranges from simple anatomic problems to complex psychosocial/biologic issues. The intricate interaction of anatomical, physiological, and psychological factors that contribute to painful intercourse explains the etymology of "dyspareunia," which means "bad or difficult mating." (See "Differential diagnosis of sexual pain in women".)
A general approach to women with sexual pain disorders will be reviewed here. Etiologies of sexual pain disorders and treatment are discussed separately. (See "Differential diagnosis of sexual pain in women" and "Clinical manifestations and diagnosis of genitourinary syndrome of menopause (vulvovaginal atrophy)" and "Clinical manifestations and diagnosis of localized vulvar pain syndrome (formerly vulvodynia, vestibulodynia, vulvar vestibulitis, or focal vulvitis)" and "Treatment of myofascial pelvic pain syndrome in women".)
Anatomic and physiologic studies of the vaginal vestibule, vagina, bladder, and anus provide insight into possible neurologic pathways for transmission of genital pain in women who are otherwise healthy.
The vulvar vestibule, urethra, and bladder have a common embryologic origin, which may explain the concurrence of pain at two or more of these sites. As an example, interstitial cystitis is frequently accompanied by pain in the vestibule.
- Shifren JL, Monz BU, Russo PA, et al. Sexual problems and distress in United States women: prevalence and correlates. Obstet Gynecol 2008; 112:970.
- Sexual dysfunctions. In: Diagnostic and Statistical Manual of Mental Disorders, 5th ed., American Psychiatric Association, Arlington, Virginia 2013.
- Wesselmann U, Burnett AL, Heinberg LJ. The urogenital and rectal pain syndromes. Pain 1997; 73:269.
- Berkley KJ, Hubscher CH, Wall PD. Neuronal responses to stimulation of the cervix, uterus, colon, and skin in the rat spinal cord. J Neurophysiol 1993; 69:545.
- Steege JF, Zolnoun DA. Evaluation and treatment of dyspareunia. Obstet Gynecol 2009; 113:1124.
- Danby CS, Margesson LJ. Approach to the diagnosis and treatment of vulvar pain. Dermatol Ther 2010; 23:485.
- Cervero F. Sensory innervation of the viscera: peripheral basis of visceral pain. Physiol Rev 1994; 74:95.
- Hilliges M, Falconer C, Ekman-Ordeberg G, Johansson O. Innervation of the human vaginal mucosa as revealed by PGP 9.5 immunohistochemistry. Acta Anat (Basel) 1995; 153:119.
- Basson R, Berman J, Burnett A, et al. Report of the international consensus development conference on female sexual dysfunction: definitions and classifications. J Urol 2000; 163:888.
- Lahaie MA, Boyer SC, Amsel R, et al. Vaginismus: a review of the literature on the classification/diagnosis, etiology and treatment. Womens Health (Lond) 2010; 6:705.
- Moyal-Barracco M, Lynch PJ. 2003 ISSVD terminology and classification of vulvodynia: a historical perspective. J Reprod Med 2004; 49:772.
- Jamieson DJ, Steege JF. The prevalence of dysmenorrhea, dyspareunia, pelvic pain, and irritable bowel syndrome in primary care practices. Obstet Gynecol 1996; 87:55.
- FRANK RT. Dyspareunia; a problem for the general practitioner. J Am Med Assoc 1948; 136:361.
- Glatt AE, Zinner SH, McCormack WM. The prevalence of dyspareunia. Obstet Gynecol 1990; 75:433.
- Hansen A, Carr K, Jensen JT. Characteristics and initial diagnoses in women presenting to a referral center for vulvovaginal disorders in 1996-2000. J Reprod Med 2002; 47:854.
- Latthe P, Latthe M, Say L, et al. WHO systematic review of prevalence of chronic pelvic pain: a neglected reproductive health morbidity. BMC Public Health 2006; 6:177.
- Laumann EO, Paik A, Rosen RC. Sexual dysfunction in the United States: prevalence and predictors. JAMA 1999; 281:537.
- Pitts MK, Ferris JA, Smith AM, et al. Prevalence and correlates of three types of pelvic pain in a nationally representative sample of Australian women. Med J Aust 2008; 189:138.
- Christensen BS, Grønbaek M, Osler M, et al. Sexual dysfunctions and difficulties in denmark: prevalence and associated sociodemographic factors. Arch Sex Behav 2011; 40:121.
- Latthe P, Mignini L, Gray R, et al. Factors predisposing women to chronic pelvic pain: systematic review. BMJ 2006; 332:749.
- Meana M, Binik YM, Khalife S, Cohen DR. Biopsychosocial profile of women with dyspareunia. Obstet Gynecol 1997; 90:583.
- Danielsson I, Sjöberg I, Stenlund H, Wikman M. Prevalence and incidence of prolonged and severe dyspareunia in women: results from a population study. Scand J Public Health 2003; 31:113.
- Harlow BL, Stewart EG. A population-based assessment of chronic unexplained vulvar pain: have we underestimated the prevalence of vulvodynia? J Am Med Womens Assoc 2003; 58:82.
- Meana M, Binik YM. Painful coitus: a review of female dyspareunia. J Nerv Ment Dis 1994; 182:264.
- Butrick CW. Pathophysiology of pelvic floor hypertonic disorders. Obstet Gynecol Clin North Am 2009; 36:699.
- Blandon RE, Gebhart JB, Trabuco EC, Klingele CJ. Complications from vaginally placed mesh in pelvic reconstructive surgery. Int Urogynecol J Pelvic Floor Dysfunct 2009; 20:523.
- Bruheim K, Tveit KM, Skovlund E, et al. Sexual function in females after radiotherapy for rectal cancer. Acta Oncol 2010; 49:826.
- Lange MM, van de Velde CJ. Urinary and sexual dysfunction after rectal cancer treatment. Nat Rev Urol 2011; 8:51.
- Park SY, Bae DS, Nam JH, et al. Quality of life and sexual problems in disease-free survivors of cervical cancer compared with the general population. Cancer 2007; 110:2716.
- Jensen PT, Groenvold M, Klee MC, et al. Longitudinal study of sexual function and vaginal changes after radiotherapy for cervical cancer. Int J Radiat Oncol Biol Phys 2003; 56:937.
- Steege JF, Ling FW. Dyspareunia. A special type of chronic pelvic pain. Obstet Gynecol Clin North Am 1993; 20:779.
- Caruso S, Agnello C, Intelisano G, et al. Sexual behavior of women taking low-dose oral contraceptive containing 15 microg ethinylestradiol/60 microg gestodene. Contraception 2004; 69:237.
- McCoy NL, Matyas JR. Oral contraceptives and sexuality in university women. Arch Sex Behav 1996; 25:73.
- Ferrero S, Ragni N, Remorgida V. Deep dyspareunia: causes, treatments, and results. Curr Opin Obstet Gynecol 2008; 20:394.
- Coady D, Futterman S, Harris D, et al. The relationship between labrum tears of the hip and generalized unprovoked vulvodynia. XX World Conference, International Society for the Study of Vulvovaginal Disease. Edinburgh, Scotland 2009.
- Phillips NA. The clinical evaluation of dyspareunia. Int J Impot Res 1998; 10 Suppl 2:S117.
- Fisher BJ, Margesson LJ. Genital Skin Disorders, Mosby, St. Louis 1998. p.159.
- Ridley CM, Neill SM. The Vulva, Blackwell Science Ltd, London 1999. p.134.
- Paniel BJ. Surgical procedures in benign vulval disease. In: The Vulva, Ridley CM, Neill SM (Eds), Blackwell Science Ltd, London 1999. p.277.
- Rouzier R, Louis-Sylvestre C, Paniel BJ, Haddad B. Hypertrophy of labia minora: experience with 163 reductions. Am J Obstet Gynecol 2000; 182:35.
- Reissing ED, Brown C, Lord MJ, et al. Pelvic floor muscle functioning in women with vulvar vestibulitis syndrome. J Psychosom Obstet Gynaecol 2005; 26:107.
- NEUROANATOMIC PATHOPHYSIOLOGY
- Risk factors
- CLINICAL MANIFESTATIONS
- DIAGNOSIS AND EVALUATION
- - Sexual pain history
- - Additional medical history
- Physical examination
- - Patient comfort
- - Vulvar examination
- - Speculum examination
- - Bimanual and rectovaginal examination
- Diagnostic studies
- CAUSES AND TREATMENT
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS