Painful Intercourse

Differential Diagnosis

Common Diagnoses

Occasional Diagnoses

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.

Published: 2nd August 2022 Updated: 10th April 2024

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