Differential diagnosis of sexual pain in women
- Elizabeth Gunther Stewart, MD
Elizabeth Gunther Stewart, MD
- Assistant Professor
- Harvard Medical School
Individuals with sexual pain disorders experience genital pain just before, during, or after sexual intercourse. There are many possible etiologies of pain related to sex (table 1A-C). The leading cause in women under the age of 50 has been attributed to localized provoked vulvodynia . In women over the age of 50, urogenital atrophy is the leading cause .
Women often do not bring this complaint to the attention of their health care providers. A study from Sweden reported only 28 percent of women with a history of prolonged and severe pain with sex consulted a physician for their symptoms .
This topic will review the most common etiologies of sexual pain disorders in women and their treatment. The initial diagnostic approach to sexual pain is discussed separately. (See "Approach to the woman with sexual pain".) Male dyspareunia is reviewed separately. (See "Male dyspareunia".)
VULVAR PAIN SYNDROMES
Localized provoked vulvodynia (formerly, vestibulodynia) — Localized provoked vulvodynia refers to pain that is 'provoked' by touching the vestibule (figure 1). In its primary form, a woman has pain from her first experience with a tampon, speculum, or sexual relations. In its secondary form, the pain develops after a period of comfortable sexual relations. The diagnosis is clinical, based on characteristic history, a positive Q-tip test eliciting pain in the vestibule (figure 2), and exclusion of other pathology. It is important to recognize that the Q-tip test may be positive in the presence of inflammation, atrophy, infection and pelvic floor dysfunction.
Elimination of any vulvar pathology is essential. After treatment of any identified cause of pain, the pain itself needs treatment. Dyspareunia may be reduced or prevented with topical lidocaine ointment (5 percent in a neutral base) applied to the vestibule 10 minutes before intercourse and again after intercourse, if necessary. EMLA (lidocaine-prilocaine) cream is an alternative therapy. Physical therapy directed at the pelvic floor muscles can also be effective since these women have superficial pelvic floor muscles that are more tonic and more responsive to pressure than women without provoked vulvar pain . Additional long-term treatment protocols for vulvar pain syndromes are discussed separately. (See "Treatment of vulvodynia (vulvar pain of unknown cause)".)
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- VULVAR PAIN SYNDROMES
- Localized provoked vulvodynia (formerly, vestibulodynia)
- Generalized vulvodynia
- - Pudendal neuralgia
- GENITOURINARY SYNDROME OF MENOPAUSE
- INADEQUATE LUBRICATION UNRELATED TO HYPOESTROGENIC STATES
- URINARY TRACT DISEASE
- Painful bladder syndrome/interstitial cystitis
- Urethral diverticulum
- HYPERTONICITY OF LOCAL MUSCULATURE
- UTERINE RETROVERSION
- PELVIC ORGAN PROLAPSE
- POSTOPERATIVE DYSPAREUNIA
- ADNEXAL PATHOLOGY
- PELVIC ADHESIONS
- SEMINAL PLASMA ALLERGY
- PSYCHOGENIC DYSPAREUNIA
- LICHEN PLANUS
- LICHEN SCLEROSUS
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS