Painful Intercourse
Differential Diagnosis
Common Diagnoses
- Pure Vaginismus: Psychogenic Spasm and Dryness
- Vulvovaginitis (Especially Infection, e.g. Bacterial or Fungal Vaginosis, Ulceration, Bartholinitis)
- Menopausal Vaginal Dryness (Atrophic Vaginitis)
- Endometriosis
- Cervicitis
- Pelvic Inflammatory Disease
Occasional Diagnoses
- Post-Partum Perineal Repair
- Pelvic Congestion (Pelvic Pain Syndrome)
- Fibroid and Retroverted Uterus, Ovaries in Pouch of Douglas
- Pelvic Adhesions (Post-Surgical or PID)
- Psychogenic/Relationship Issues
- Cystitis
- Urethritis
Rare Diagnoses
- Congenital Abnormality
- Large Ovarian Cyst or Tumour
- Vulval Dysplasia
- Urethral Caruncle
- Unruptured Hymen
- Anal Fissure, Thrombosed Piles, Perianal Abscess
Ready Reckoner
Key distinguishing features of the most common diagnoses
| Vaginismus | Vulvovaginitis | Atrophic Vaginitis | Endometriosis | PID | |
|---|---|---|---|---|---|
| Abnormal Discharge | No | Yes | Possible | No | Possible |
| Deep Dyspareunia | No | No | No | Yes | Yes |
| Heavy Painful Periods | No | No | No | Yes | Possible |
| Vaginal Dryness | Yes | No | Yes | No | No |
| Tight Introitus O/E | Yes | No | No | No | No |
Possible Investigations
Likely:High vaginal/cervical swabs.
Possible:Urinalysis, MSU, urethral swab, ultrasound, laparoscopy (in secondary care).
Small Print:FBC, ESR/CRP, CA-125, vulval biopsy (secondary care).
- Urinalysis for nitrite, pus cells and blood useful to rule out UTI.
- MSU will help guide treatment in UTI.
- If abnormal discharge, take high vaginal and cervical swabs to establish nature of pathogen. Urethral swab useful if possible urethritis (usually at genito-urinary medicine [GUM] clinic).
- FBC may show raised WCC in chronic PID.
- ESR/CRP elevated in PID.
- Pelvic ultrasound can define lie of the uterus and ovaries, presence of cysts and gross endometriosis.
- CA-125: If any suspicion of ovarian cancer.
- Investigations after referral may include laparoscopy (e.g. for endometriosis and PID) and vulval biopsy (for suspected dysplasia).
Top Tips
- Superficial dyspareunia (pain at the introitus) is usually caused by infection, vaginismus or atrophy; deep dyspareunia (deep pain) may be caused by pelvic pathology.
- If a sexually transmitted infection could be the cause, refer to a GUM clinic – these are best equipped for thorough screening, counselling and contact tracing.
- The patient complaining that her ‘vagina feels too small’ to accommodate her partner’s penis probably has vaginismus.
- Deep dyspareunia which is long-standing and positional is ‘collision’ dyspareunia and is very unlikely to be due to significant pathology.
- Deep dyspareunia usually resolves immediately on withdrawal; if it lasts a day or two after intercourse, it may well have a psychological basis.
Red Flags
- Relationship problems may cause dislike of intercourse which presents as pain. Disharmony may be the cause rather than result of the problem.
- Cyclical dyspareunia with generalised pelvic pain and heavy, painful periods suggest endometriosis or PID – refer for gynaecological opinion.
- Pelvic tumour is rare in this context, but consider this possibility in the older woman presenting with deep dyspareunia of recent onset.
- Examine the menopausal or perimenopausal woman complaining of persistent superficial dyspareunia – vulval dysplasia, rather than atrophic vaginitis, may be the cause.