| Vulva and vagina | | | | | |
| Dermatologic diseases (e.g., lichen sclerosus, lichen planus, contact dermatitis)11 | Entry | Burning, dryness, pruritus | Visible skin changes (dependent on condition) | Biopsy may be necessary to confirm diagnosis | Usually topical steroids; depends on diagnosis |
| Inadequate lubrication12–14 | Both | Dryness; history of diabetes mellitus; history of chemotherapy or use of progestogens, aromatase inhibitors, tamoxifen, or gonadotropin-releasing hormone agonists | Vulva may be normal or appear dry | Usually unnecessary | Discontinuation of causative medication if possible; use of vaginal moisturizers or lubricants |
| Pelvic floor dysfunction2,15,16 | Both | Difficulty evacuating stool or emptying bladder; aching after intercourse; pain in lower back, thighs, or groin | Painful vaginal muscles just inside of the hymen during single-digit examination | Usually unnecessary | Pelvic floor physical therapy, gabapentin (Neurontin), trigger point injections with local anesthetics or onabotulinumtoxinA (Botox), neuromodulation |
| Vaginal atrophy12 | Both | Burning, dryness | Tissue may appear pale and dry (although may appear normal in early menopause) | Usually unnecessary | Vaginal moisturizers or lubricants, topical estrogen, ospemifene (Osphena), prasterone (Intrarosa) |
| Vaginismus17 | Entry | Difficulty achieving penetration; possible history of anxiety, sexual abuse or trauma, or other causes of painful penetration; sometimes no prior risk factors are present | Involuntary contraction of pelvic floor muscles with attempted insertion of finger or small speculum | Identify psychosocial factors, such as sexual abuse or anxiety | Multidisciplinary approach includes cognitive behavior therapy, psychotherapy, relationship and sexual counseling, lubricants, sequential vaginal dilators, and onabotulinumtoxinA injection |
| Vaginitis2 | Both | Discharge, burning, or odor | Vaginal discharge | pH testing, microscopy, polymerase chain reaction swab as indicated | Antibiotic or antifungal therapy according to diagnosis |
| Vulvodynia1,2,11,18 | Entry | Chronic burning, tearing, aching, or stabbing vulvar pain of at least three months' duration | Vulva may be visually normal or may have focal areas of erythema around the vestibule and hymen that are painful, as elicited by a cotton swab | Assess 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 |
| Bladder | | | | | |
| Interstitial cystitis19 | Deep | Urinary urgency, frequency, and nocturia | Pain with palpation of bladder base | Interstitial cystitis questionnaire; bladder instillation; cystoscopy | Dietary modification; antispasmodics; cimetidine (Tagamet); amitriptyline |
| Uterus and adnexa | | | | | |
| Ovarian masses2 | Deep | Lateralized pain with intercourse | Pain with adnexal palpation | Transvaginal ultrasonography | Observation or laparoscopy as indicated |
| Uterine retroversion10 | Deep | Pain may be related to sexual position; may be associated with endometriosis | Retroverted uterus, may be painful when moved cephalad | Usually unnecessary; transvaginal ultrasonography helpful to rule out myomas | Modify sexual positions; vaginal pessary; hysterectomy |
| Pelvis | | | | | |
| Adhesions or chronic pelvic inflammatory disease2 | Deep | May have lateralized, sharp pain; history of pelvic inflammatory disease or pelvic surgery | Possible fixation of pelvic organs on bimanual examination | Pelvic imaging to rule out other diagnoses | Nonopioid analgesics; laparoscopic adhesiolysis |
| Endometriosis2 | Deep | Family history; dysmenorrhea common | Generalized pelvic tenderness; nodularity may be noted in cul-de-sac during rectovaginal examination | Generally unnecessary; laparoscopy if diagnosis uncertain or patient desires | Nonopioid analgesics, combined oral contraceptives, progestogens, levonorgestrel-releasing intrauterine system (Mirena), elagolix (Orilissa), laparoscopic excision |
