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".)
- Meana M, Binik YM, Khalife S, Cohen DR. Biopsychosocial profile of women with dyspareunia. Obstet Gynecol 1997; 90:583.
- Bachmann GA, Leiblum SR, Kemmann E, et al. Sexual expression and its determinants in the post-menopausal woman. Maturitas 1984; 6:19.
- 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.
- Bergeron S, Brown C, Lord MJ, et al. Physical therapy for vulvar vestibulitis syndrome: a retrospective study. J Sex Marital Ther 2002; 28:183.
- Stav K, Dwyer PL, Roberts L. Pudendal neuralgia. Fact or fiction? Obstet Gynecol Surv 2009; 64:190.
- Khoder W, Hale D. Pudendal neuralgia. Obstet Gynecol Clin North Am 2014; 41:443.
- Labat JJ, Riant T, Robert R, et al. Diagnostic criteria for pudendal neuralgia by pudendal nerve entrapment (Nantes criteria). Neurourol Urodyn 2008; 27:306.
- Pink L, Rancourt V, Gordon A. Persistent genital arousal in women with pelvic and genital pain. J Obstet Gynaecol Can 2014; 36:324.
- Schaffer J, Fantl JA. Urogenital effects of the menopause. Baillieres Clin Obstet Gynaecol 1996; 10:401.
- Kao A, Binik YM, Kapuscinski A, Khalife S. Dyspareunia in postmenopausal women: a critical review. Pain Res Manag 2008; 13:243.
- Mulherin DM, Sheeran TP, Kumararatne DS, et al. Sjögren's syndrome in women presenting with chronic dyspareunia. Br J Obstet Gynaecol 1997; 104:1019.
- Muniyappa R, Norton M, Dunn ME, Banerji MA. Diabetes and female sexual dysfunction: moving beyond "benign neglect". Curr Diab Rep 2005; 5:230.
- American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 5th, American Psychiatric Association, Arlington, VA 2013.
- Pacik PT. Understanding and treating vaginismus: a multimodal approach. Int Urogynecol J 2014; 25:1613.
- Oniz A, Keskinoglu P, Bezircioglu I. The prevalence and causes of sexual problems among premenopausal Turkish women. J Sex Med 2007; 4:1575.
- Nusbaum MR, Gamble G, Skinner B, Heiman J. The high prevalence of sexual concerns among women seeking routine gynecological care. J Fam Pract 2000; 49:229.
- Reissing ED, Binik YM, Khalifé S. Does vaginismus exist? A critical review of the literature. J Nerv Ment Dis 1999; 187:261.
- Binik YM. The DSM diagnostic criteria for vaginismus. Arch Sex Behav 2010; 39:278.
- Crowley T, Goldmeier D, Hiller J. Diagnosing and managing vaginismus. BMJ 2009; 338:b2284.
- 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.
- Reissing ED. Consultation and treatment history and causal attributions in an online sample of women with lifelong and acquired vaginismus. J Sex Med 2012; 9:251.
- Reissing ED, Binik YM, Khalifé S, et al. Vaginal spasm, pain, and behavior: an empirical investigation of the diagnosis of vaginismus. Arch Sex Behav 2004; 33:5.
- Ter Kuile MM, Van Lankveld JJ, Vlieland CV, et al. Vulvar vestibulitis syndrome: an important factor in the evaluation of lifelong vaginismus? J Psychosom Obstet Gynaecol 2005; 26:245.
- de Kruiff ME, ter Kuile MM, Weijenborg PT, van Lankveld JJ. Vaginismus and dyspareunia: is there a difference in clinical presentation? J Psychosom Obstet Gynaecol 2000; 21:149.
- Reissing ED, Binik YM, Khalifé S, et al. Etiological correlates of vaginismus: sexual and physical abuse, sexual knowledge, sexual self-schema, and relationship adjustment. J Sex Marital Ther 2003; 29:47.
- Shafik A, El-Sibai O. Vaginismus: results of treatment with botulin toxin. J Obstet Gynaecol 2000; 20:300.
- Ghazizadeh S, Nikzad M. Botulinum toxin in the treatment of refractory vaginismus. Obstet Gynecol 2004; 104:922.
- Brin MF, Vapnek JM. Treatment of vaginismus with botulinum toxin injections. Lancet 1997; 349:252.
- McGuire H, Hawton K. Interventions for vaginismus. Cochrane Database Syst Rev 2003; :CD001760.
- Ferreira JR, Souza RP. Botulinum toxin for vaginismus treatment. Pharmacology 2012; 89:256.
- Voorham-van der Zalm PJ, Lycklama A Nijeholt GA, Elzevier HW, et al. "Diagnostic investigation of the pelvic floor": a helpful tool in the approach in patients with complaints of micturition, defecation, and/or sexual dysfunction. J Sex Med 2008; 5:864.
- Butrick CW. Pathophysiology of pelvic floor hypertonic disorders. Obstet Gynecol Clin North Am 2009; 36:699.
- Dietz HP. Pelvic floor trauma following vaginal delivery. Curr Opin Obstet Gynecol 2006; 18:528.
- Hurtado EA, Appell RA. Management of complications arising from transvaginal mesh kit procedures: a tertiary referral center's experience. Int Urogynecol J Pelvic Floor Dysfunct 2009; 20:11.
- Peters KM, Carrico DJ. Frequency, urgency, and pelvic pain: treating the pelvic floor versus the epithelium. Curr Urol Rep 2006; 7:450.
- Paterson LQ, Davis SN, Khalifé S, et al. Persistent genital and pelvic pain after childbirth. J Sex Med 2009; 6:215.
- Ejegård H, Ryding EL, Sjogren B. Sexuality after delivery with episiotomy: a long-term follow-up. Gynecol Obstet Invest 2008; 66:1.
- Buhling KJ, Schmidt S, Robinson JN, et al. Rate of dyspareunia after delivery in primiparae according to mode of delivery. Eur J Obstet Gynecol Reprod Biol 2006; 124:42.
- Glazener CM. Sexual function after childbirth: women's experiences, persistent morbidity and lack of professional recognition. Br J Obstet Gynaecol 1997; 104:330.
- Steege JF, Zolnoun DA. Evaluation and treatment of dyspareunia. Obstet Gynecol 2009; 113:1124.
- McDonald E, Woolhouse H, Brown SJ. Consultation about Sexual Health Issues in the Year after Childbirth: A Cohort Study. Birth 2015; 42:354.
- Hay-Smith EJ. Therapeutic ultrasound for postpartum perineal pain and dyspareunia. Cochrane Database Syst Rev 2000; :CD000495.
- Fauconnier A, Chapron C, Dubuisson JB, et al. Relation between pain symptoms and the anatomic location of deep infiltrating endometriosis. Fertil Steril 2002; 78:719.
- Ferrero S, Esposito F, Abbamonte LH, et al. Quality of sex life in women with endometriosis and deep dyspareunia. Fertil Steril 2005; 83:573.
- Fauconnier A, Dubuisson JB, Foulot H, et al. Mobile uterine retroversion is associated with dyspareunia and dysmenorrhea in an unselected population of women. Eur J Obstet Gynecol Reprod Biol 2006; 127:252.
- Steege JF, Ling FW. Dyspareunia. A special type of chronic pelvic pain. Obstet Gynecol Clin North Am 1993; 20:779.
- Perry CP, Presthus J, Nieves A. Laparoscopic uterine suspension for pain relief: a multicenter study. J Reprod Med 2005; 50:567.
- Halperin R, Padoa A, Schneider D, et al. Long-term follow-up (5-20 years) after uterine ventrosuspension for chronic pelvic pain and deep dyspareunia. Gynecol Obstet Invest 2003; 55:216.
- Rhodes JC, Kjerulff KH, Langenberg PW, Guzinski GM. Hysterectomy and sexual functioning. JAMA 1999; 282:1934.
- Lamvu G, Robinson B, Zolnoun D, Steege JF. Vaginal apex resection: a treatment option for vaginal apex pain. Obstet Gynecol 2004; 104:1340.
- Brubaker L, Chiang S, Zyczynski H, et al. The impact of stress incontinence surgery on female sexual function. Am J Obstet Gynecol 2009; 200:562.e1.
- Ferrero S, Abbamonte LH, Giordano M, et al. Uterine myomas, dyspareunia, and sexual function. Fertil Steril 2006; 86:1504.
- Meana M, Binik YM. Painful coitus: a review of female dyspareunia. J Nerv Ment Dis 1994; 182:264.
- Binik YM, Reissing E, Pukall C, et al. The female sexual pain disorders: genital pain or sexual dysfunction? Arch Sex Behav 2002; 31:425.
- 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