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Am Fam Physician. 2021;103(10):597-604

This clinical content conforms to AAFP criteria for CME.

Author disclosure: Dr. Hill does not have a formal relationship with any pharmaceutical company to disclose. A public database revealed a listing for Intrarosa, but this was not a direct payment or a violation of our conflict-of-interest policy. Dr. Taylor has no relevant financial affiliations to disclose.

Dyspareunia is recurrent or persistent pain with sexual intercourse that causes distress. It affects approximately 10% to 20% of U.S. women. Dyspareunia may be superficial, causing pain with attempted vaginal insertion, or deep. Women with sexual pain are at increased risk of sexual dysfunction, relationship distress, diminished quality of life, anxiety, and depression. Because discussing sexual issues may be uncomfortable, clinicians should create a safe and welcoming environment when taking a sexual history, where patients describe the characteristics of the pain (e.g., location, intensity, duration). Physical examination of the external genitalia includes visual inspection and sequential pressure with a cotton swab, assessing for focal erythema or pain. A single-digit vaginal examination may identify tender pelvic floor muscles, and a bimanual examination can assess for uterine retroversion and pelvic masses. Common diagnoses include vulvodynia, inadequate lubrication, vaginal atrophy, postpartum causes, pelvic floor dysfunction, endometriosis, and vaginismus. Treatment is focused on the cause and may include lubricants, pelvic floor physical therapy, topical analgesics, vaginal estrogen, cognitive behavior therapy, vaginal dilators, modified vestibulectomy, or onabotulinumtoxinA injections.

Dyspareunia, recurrent or persistent painful sexual intercourse, is common and can affect women's mental and physical health and relationships.1,2 The prevalence of dyspareunia in the United States is approximately 10% to 20% and varies by age and population.3 Women with sexual pain are at increased risk of sexual dysfunction, relationship distress, diminished quality of life, anxiety, and depression.2,4 Many women seeking medical care for sexual pain report believing that their concerns are invalidated and dismissed.5 Dyspareunia is a complex disorder often involving both psychosocial and physical conditions, requiring a detailed genitourinary examination and clinician knowledge of risk factors and the multifactorial nature of the disorder. Recommendations for treating dyspareunia are determined by the patient's current anatomy.

Risk Factors

Several risk factors should prompt clinicians to ask about painful sex.2,4,6,7 Demographic risk factors include younger age; White race; lower socioeconomic status; and being in the postpartum, perimenopausal, or postmenopausal period. Psychosocial risk factors include depression, anxiety, low sexual satisfaction, and a history of sexual abuse. Women who have had a vacuum-assisted or forceps vaginal delivery, are breastfeeding, or have had pelvic floor surgery are also at an increased risk. Sexual pain may occur with other conditions that cause pelvic pain, such as irritable bowel syndrome, musculoskeletal disorders, and fibromyalgia.1


Clinicians should create a safe and welcoming environment where patients feel comfortable discussing their sexuality. This includes avoiding moral or religious judgment, using neutral and inclusive terms that avoid assumptions about behavior or orientation, and recognizing that discussing sexual issues may be uncomfortable for the patient and clinician.8 A detailed history includes asking patients to describe the characteristics of the pain (e.g., location, intensity, duration); symptoms involving other organs, such as the bladder, bowel, or musculoskeletal system; sexual behaviors that cause pain; psychological history and symptoms; and current medical conditions. Additional history should include prior treatment for sexual dysfunction, whether the patient has recently given birth or is breastfeeding, and whether there is a history of intimate partner violence or sexual abuse.9

Determining which sexual activities are painful can suggest specific diagnoses. Patients who have pain with vaginal entry may have atrophy, inadequate lubrication, pelvic floor dysfunction, vaginitis, vulvodynia, or vaginismus, whereas patients who have deeper pain may have endometriosis or structural or anatomic abnormalities, such as uterine retroversion2,10 (Table 11,2,1019).

DiagnosisEntry or deepHistorical cluesExamination findingsAdditional testingTreatment options
Vulva and vagina
Dermatologic diseases (e.g., lichen sclerosus, lichen planus, contact dermatitis)11 EntryBurning, dryness, pruritusVisible skin changes (dependent on condition)Biopsy may be necessary to confirm diagnosisUsually topical steroids; depends on diagnosis
Inadequate lubrication1214 BothDryness; history of diabetes mellitus; history of chemotherapy or use of progestogens, aromatase inhibitors, tamoxifen, or gonadotropin-releasing hormone agonistsVulva may be normal or appear dryUsually unnecessaryDiscontinuation of causative medication if possible; use of vaginal moisturizers or lubricants
Pelvic floor dysfunction2,15,16 BothDifficulty evacuating stool or emptying bladder; aching after intercourse; pain in lower back, thighs, or groinPainful vaginal muscles just inside of the hymen during single-digit examinationUsually unnecessaryPelvic floor physical therapy, gabapentin (Neurontin), trigger point injections with local anesthetics or onabotulinumtoxinA (Botox), neuromodulation
Vaginal atrophy12 BothBurning, drynessTissue may appear pale and dry (although may appear normal in early menopause)Usually unnecessaryVaginal moisturizers or lubricants, topical estrogen, ospemifene (Osphena), prasterone (Intrarosa)
Vaginismus17 EntryDifficulty achieving penetration; possible history of anxiety, sexual abuse or trauma, or other causes of painful penetration; sometimes no prior risk factors are presentInvoluntary contraction of pelvic floor muscles with attempted insertion of finger or small speculumIdentify psychosocial factors, such as sexual abuse or anxietyMultidisciplinary approach includes cognitive behavior therapy, psychotherapy, relationship and sexual counseling, lubricants, sequential vaginal dilators, and onabotulinumtoxinA injection
Vaginitis2 BothDischarge, burning, or odorVaginal dischargepH testing, microscopy, polymerase chain reaction swab as indicatedAntibiotic or antifungal therapy according to diagnosis
Vulvodynia1,2,11,18 EntryChronic burning, tearing, aching, or stabbing vulvar pain of at least three months' durationVulva may be visually normal or may have focal areas of erythema around the vestibule and hymen that are painful, as elicited by a cotton swabAssess for comorbidities, such as depression, anxiety, a history of childhood sexual or physical abuse, fibromyalgia, irritable bowel syndrome, interstitial cystitis, musculoskeletal disorders, or pelvic floor muscle dysfunction; as indicated, rule out other etiologies (e.g., testing for vaginitis)Patient education about vulvar hygiene and using cotton underwear and pads, 2% lidocaine jelly or ointment applied by cotton ball placed on vulva at bedtime, amitriptyline, oral or compounded vaginal gabapentin, compounded vaginal muscle relaxants, estrogen, selective serotonin or norepinephrine reuptake inhibitors, pelvic floor physical therapy, cognitive behavior therapy, amitriptyline, surgical excision
Interstitial cystitis19 DeepUrinary urgency, frequency, and nocturiaPain with palpation of bladder baseInterstitial cystitis questionnaire; bladder instillation; cystoscopyDietary modification; antispasmodics; cimetidine (Tagamet); amitriptyline
Uterus and adnexa
Ovarian masses2 DeepLateralized pain with intercoursePain with adnexal palpationTransvaginal ultrasonographyObservation or laparoscopy as indicated
Uterine retroversion10 DeepPain may be related to sexual position; may be associated with endometriosisRetroverted uterus, may be painful when moved cephaladUsually unnecessary; transvaginal ultrasonography helpful to rule out myomasModify sexual positions; vaginal pessary; hysterectomy
Adhesions or chronic pelvic inflammatory disease2 DeepMay have lateralized, sharp pain; history of pelvic inflammatory disease or pelvic surgeryPossible fixation of pelvic organs on bimanual examinationPelvic imaging to rule out other diagnosesNonopioid analgesics; laparoscopic adhesiolysis
Endometriosis2 DeepFamily history; dysmenorrhea commonGeneralized pelvic tenderness; nodularity may be noted in cul-de-sac during rectovaginal examinationGenerally unnecessary; laparoscopy if diagnosis uncertain or patient desiresNonopioid analgesics, combined oral contraceptives, progestogens, levonorgestrel-releasing intrauterine system (Mirena), elagolix (Orilissa), laparoscopic excision

Physical Examination

Patients with dyspareunia may have anxiety about genital examinations. It can be helpful to explain to the patient why the examination is necessary and how it may help with diagnosis and treatment.9 Offering the patient a mirror to follow along during the examination may help with patient education about normal anatomy and aid in pinpointing painful areas. Clinicians should visually inspect the external genitals, evaluating for atrophy, discoloration, erythema, lesions, or trauma (Figure 120). For patients reporting focal pain, clinicians should localize the pain by using a small cotton swab to systematically press on the external genital tissue, including the hymen.

Next, the clinician should palpate the vagina beginning with a lubricated single digit, assessing for a narrow introitus or pain with palpation of the pelvic floor 16 (Figure 220). Palpating slowly through 360 degrees will allow the clinician to evaluate the pelvic floor muscles (levator ani, obturator internus, and piriformis) to determine whether tension or pain occurs (unilaterally or bilaterally) and to assess for pain from the urethra, bladder base, and cervix.2

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