A 28-year-old woman attends, complaining of pain on intercourse. She is in a new relationship and is taking the combined oral contraceptive pill.
Is this superficial or deep dyspareunia?
What are the possible causes?
How would you reach a diagnosis?
How would you approach the management of each condition?
Dyspareunia is recurrent or persistent genital pain associated with sexual intercourse. It may be classified as primary, when pain has always been present on sexual intercourse, or secondary, when intercourse has in the past been pain-free. It may also be classified as 'superficial' or 'deep', depending on the site of the pain.
Discomfort is usually introital and less commonly mid-vaginal. The cause may be poor arousal and/or lubrication, or topical irritants such as spermicides or latex. A number of vulval conditions may also cause discomfort.
Infection resulting in vulvitis/vulvovaginitis, such as Candida or genital herpes, can be a cause of superficial dyspareunia.
Vulvar vestibulitis (also known as focal vulvitis/vestibulitis) is a clinical diagnosis and the aetiology is unknown.1 It is characterized by pain at the introitus, on penetration during sexual intercourse or on the insertion of tampons. There is often a long history. On examination there is focal tenderness at the vestibule with variable erythema. General advice on vulval care should be given, including the avoidance of soap, shampoo and other potential irritants. Emollient creams and ointments may be used as a substitute. Tight-fitting garments may irritate the area and spermicidally lubricated condoms should be avoided.
Many specific treatments for vulvar vestibulitis exist; however, there is a lack of well-designed clinical trials. The natural history is that remission can occur in up to 50% of patients.1 Topical local anaesthetics may relieve pain during sexual intercourse. Pain modifiers, such as amitriptyline in small doses, have been used; other approaches include topical steroids, behavioural therapy and, as a last resort, surgery.2
Vulvodynia (dysaesthetic vulvodynia) is also of unknown aetiology and diagnosis is once again clinical.1 Pain is felt over a much broader area and can extend perianally or to the upper thighs. It is more prevalent in peri- or post-menopausal women and there is often a long history. The vulva appears normal, with tenderness to light touch over the labia.
General advice on vulval care should, once again, be given. Amitriptyline and gabapentin have been used with some success3 and selective serotonin reuptake inhibitors (SSRIs) may also be effective. Local anaesthetics are not generally helpful as they only provide short-term relief.
Vulval dermatitis may follow infection or be irritant, allergic, atopic or seborrhoeic. Itching and soreness are usually presenting features and there may be erythema, lichenification and fissuring of the vulval skin. Dermatological referral may be necessary, but most cases can be treated with ...