Evaluation and differential diagnosis of dyspareunia

Dyspareunia is genital pain associated with sexual intercourse. Although this condition has historically been defined by psychologic theories, the current treatment approach favors an integrated pain model. Identification of the initiating and promulgating factors is essential to reaching a successful diagnosis. The differential diagnoses include vaginismus, inadequate lubrication, atrophy and vulvodynia (vulvar vestibulitis). Less common etiologies are endometriosis, pelvic congestion, adhesions or infections, and adnexal pathology. Urethral disorders, cystitis and interstitial cystitis may also cause painful intercourse. The location of the pain may be described as entry or deep. Vulvodynia, atrophy, inadequate lubrication and vaginismus are associated with painful entry. Deep pain occurs with the other conditions previously noted. The physical examination may reproduce the pain, such as localized pain with vulvar vestibulitis, when the vagina is touched with a cotton swab. The involuntary spasm of vaginismus may be noted with insertion of an examining finger or speculum. Palpation of the lateral vaginal walls, uterus, adnexa and urethral structures helps identify the cause. An understanding of the present organic etiology must be integrated with an appreciation of the ongoing psychologic factors and negative expectations and attitudes that perpetuate the pain cycle.