Painful Intercourse

This term is taken to apply to women. It causes much misery and may be embarrassing for a woman to discuss with her doctor. As a result, it may be the ‘hidden agenda’, presenting as a nonexistent ‘discharge’ or vague ‘soreness down below’. Alternatively, it may be the underlying cause of a presentation of infertility or stress. Tact and sensitivity are the most valuable diagnostic and therapeutic tools in these situations.

Published: 2nd August 2022 | Updated: 15th August 2022

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
  • Pelvic Inflammatory Disease (PID) and Cervicitis

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)
  • Cystitis, Urethritis
  • Psychogenic/Relationship Issues

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

VaginismusVulvovaginitisAtrophic VaginitisEndometriosisPID
Abnormal DischargeNoYesPossibleNoPossible
Deep DyspareuniaNoNoNoYesYes
Heavy Painful PeriodsNoNoNoYesPossible
Vaginal DrynessYesNoYesNoNo
Tight Introitus O/EYesNoNoNoNo

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.
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Website disclaimer

Pulse Reference is based on the best-selling book Symptom Sorter.

The experts behind Pulse Reference are Dr Keith Hopcroft who is the co-author of Symptom Sorter, a GP in Essex and Pulse’s editorial advisor and Dr Poppy Freeman, a GP in Camden and also a clinical advisor to Pulse.

This website is for clinical guidance only and cannot give definitive diagnostic information. Practitioners should work within the limits of their individual professional practice, seek guidance when necessary and refer appropriately.