Dyspareunia
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Direct answer
Dyspareunia — recurrent genital pain with intercourse — sorts first by depth: superficial (entry) pain points to the vulva, vestibule and vagina (vulvovaginal infection, vulval dermatitis, vestibulodynia, atrophic vaginitis, insufficient lubrication, post-episiotomy or perineal scar, vaginismus), while deep (pelvic) pain with thrusting points above the vault (endometriosis, chronic pelvic inflammatory disease, adenomyosis, fibroids, pelvic congestion, ovarian masses, or a fixed retroverted uterus). Management is cause-directed: treat the infection (candida with clotrimazole, bacterial vaginosis and trichomonas with metronidazole or clindamycin), local oestrogen for atrophy, excision of painful scars, and vaginismus with graded dilators, pelvic floor physiotherapy and psychosexual counselling rather than surgery. Deep dyspareunia unexplained on examination earns a transvaginal ultrasound and, if endometriosis is suspected, laparoscopy.
What you must remember
- The depth split is the diagnostic fork: entry pain — vulvar/vestibular/vaginal; deep pain — pelvic pathology; the exam stem almost always phrases the pain's location first.
- Superficial causes to list: vulvovaginal candidiasis (curdy discharge, itching), bacterial vaginosis and trichomoniasis, lichen sclerosus and dermatitis, vestibulodynia (severe pain to light touch at the vestibule — the cotton-swab test), atrophic vaginitis (postmenopausal or lactating, pale thin epithelium), inadequate lubrication and unaroused intercourse, perineal scar or episiotomy neuroma, congenital septa, and vaginismus.
- Vaginismus: involuntary spasm of the levator ani and pelvic floor preventing entry, usually with severe anticipatory fear; phobic avoidance follows; treatment is graduated dilators, pelvic floor desensitisation, and psychosexual therapy with the partner included — no operation.
- Deep causes to list: endometriosis (the classic cause, especially uterosacral and pouch of Douglas nodules), chronic pelvic inflammatory disease with adhesions, adenomyosis, fibroids, ovarian cysts, pelvic congestion syndrome and post-surgical adhesions; rarely, a fixed retroverted uterus.
- Examination sequence: inspect the vestibule (cotton-swab test), single-digit examination for spasm and scar, speculum for discharge, bimanual for uterosacral nodularity, fixed uterus or masses — the map is built before prescribing.
- Infections treated first: candida — topical azole (clotrimazole 500 mg stat or 200 mg five days) or oral fluconazole 150 mg; bacterial vaginosis — metronidazole 400 mg twice daily for seven days; trichomoniasis — metronidazole 2 g stat (treat partners); chlamydia/gonorrhoea per partner-treated protocols.
- Atrophy: local oestrogen — estriol or conjugated oestrogen cream or a 10 microgram ring — plus lubricants first in breast cancer survivors (with oncology consultation).
- The referral red flag: a firm vulval or vaginal lesion, a mass, or postcoital bleeding with an unhealthy cervix — biopsy and screening take priority over symptomatic treatment.
From complaint to cause, layer by layer
A 26-year-old newly married woman reports sharp pain "at entry" since marriage, with failed attempts at intercourse and tearing pain on pelvic examination. Inspection is normal, the cotton-swab test elicits sharp pain at the posterior vestibule, and single-digit examination triggers powerful levator spasm — vestibulodynia with secondary vaginismus. The plan runs in layers: treat any coexisting candida (two treated episodes), then lidocaine 4 per cent gel before attempts, graduated dilators from the smallest size under physiotherapy guidance, and couples psychosexual counselling to remove performance pressure. Over three months penetration becomes possible — the sequence matters because surgery has no role here.
The second case, a 32-year-old mother of two with deep pain before and during menses, dysmenorrhoea and dyschezia: bimanual examination finds tender uterosacral nodularity; transvaginal ultrasound shows a 4 cm endometrioma. This is endometriosis until laparoscopy says otherwise — hormonal suppression (continuous combined pill or progestins) and laparoscopic excision. The third, a 58-year-old five years post-menopause with entry pain and dryness: pale, friable vaginal epithelium, pH above 5.5 — genitourinary atrophy; local oestrogen cream twice weekly plus a lubricant reverses the surface.
How the exam frames it
Stems are engineered around the depth split and three named conditions: vaginismus (spasm, managed behaviourally), vestibulodynia (cotton-swab localisation), and endometriosis (deep pain plus dysmenorrhoea plus dyschezia). The "next step" answers reward examination before imaging, and counselling-plus-dilators when the stem describes spasm — choosing "hymenectomy" or "vaginoplasty" for vaginismus is the planted wrong option. Postmenopausal entry pain with dryness points to topical oestrogen; the partner-treatment rule for trichomonas is a small-print mark. When deep dyspareunia has a normal examination, the exam's next investigation is transvaginal ultrasound, then laparoscopy — in that order.
Frequently asked questions
What distinguishes superficial from deep dyspareunia?
Superficial or entry pain arises at penetration from vulval, vestibular or vaginal pathology, whereas deep pain occurs with thrusting and points to pelvic disease such as endometriosis, adhesions or fibroids.
How is vaginismus treated?
With graded vaginal dilators, pelvic floor physiotherapy and desensitisation with psychosexual counselling — a behavioural programme, since the spasm is involuntary and surgery has no role.
Which infection causes entry pain with curdy discharge?
Vulvovaginal candidiasis, treated with topical azoles such as clotrimazole or a single 150 mg fluconazole dose.
What is the cotton-swab test used for?
Localising provoked vestibulodynia — sharp pain on light swab touch at the vestibule, mapping the painful area and confirming a superficial pain generator.
Which management suits dyspareunia after menopause?
Local (vaginal) oestrogen — estriol or conjugated cream or a low-dose ring — with lubricants and moisturisers, after excluding infection and oncology consultation in breast cancer survivors.