Painful sexual intercourse

Specialties > General practice

Differential Diagnosis Schema 🧠

Gynecological Causes

Vaginitis: Often presents with itching, discharge, and superficial dyspareunia; common causes include Candida, bacterial vaginosis, and trichomoniasis.
Endometriosis: Deep dyspareunia, dysmenorrhea, and chronic pelvic pain; often associated with infertility.
Pelvic inflammatory disease (PID): Presents with pelvic pain, abnormal discharge, and fever; can lead to chronic pain and infertility.
Vaginismus: Involuntary spasm of the vaginal muscles leading to difficulty with penetration and significant pain.
Vulvodynia: Chronic pain or discomfort in the vulva, often described as burning or stinging.

Urological Causes

Urinary tract infection (UTI): Dysuria, frequency, urgency, and suprapubic pain; pain during intercourse may be due to inflammation.
Interstitial cystitis: Chronic bladder pain, often exacerbated by bladder filling or intercourse; associated with urinary frequency and urgency.

Musculoskeletal Causes

Pelvic floor dysfunction: Pain due to hypertonic or dysfunctional pelvic floor muscles; often associated with chronic pelvic pain.
Coccydynia: Pain in the coccyx area, exacerbated by sitting or during sexual intercourse.

Psychological Causes

Sexual trauma history: Past experiences of sexual abuse or trauma can lead to significant psychological distress and dyspareunia.
Anxiety or depression: Psychological distress can manifest as physical symptoms, including dyspareunia.
Relationship issues: Discord within a sexual relationship can contribute to discomfort or pain during intercourse.

Dermatological Causes

Lichen sclerosus: Chronic inflammatory skin condition that causes white patches and thinning of the vulvar skin, leading to pain during intercourse.
Eczema or psoriasis: Skin conditions affecting the vulva or perineum can lead to discomfort or pain during sexual activity.

Key Points in History 🥼

Onset and Duration

Acute onset: May suggest infection (e.g., UTI, PID) or trauma.
Chronic or recurrent pain: More likely associated with conditions like endometriosis, interstitial cystitis, or psychological factors.
Pain with initial sexual activity: May indicate vaginismus or psychological causes.

Location of Pain

Superficial pain: Typically associated with vaginitis, vulvodynia, or dermatological conditions.
Deep pelvic pain: Suggests conditions like endometriosis, PID, or pelvic floor dysfunction.
Unilateral pain: May point towards ovarian cysts or adnexal pathology.

Associated Symptoms

Abnormal discharge: Commonly seen in infections such as vaginitis or PID.
Menstrual irregularities: Suggests endometriosis or hormonal imbalances.
Dysuria or urinary frequency: Points towards UTI or interstitial cystitis.
Fatigue or low mood: May indicate psychological causes or systemic conditions like chronic fatigue syndrome.

Background

Obstetric and gynecological history: Previous surgeries, childbirth, or use of contraception can influence the diagnosis.
Sexual history: Assess for risk factors of sexually transmitted infections, history of sexual trauma, and sexual practices.
Psychiatric history: Important for assessing underlying psychological causes or coexisting mental health conditions.
Medication use: Certain medications, such as SSRIs, may contribute to sexual dysfunction.
Family history: Can be relevant in conditions like endometriosis, which may have a genetic component.

Possible Investigations 🌡️

Pelvic Examination

Inspection: Identifies dermatological conditions, signs of infection, or anatomical abnormalities.
Speculum examination: Allows for visualizing the vagina and cervix to assess for infections or masses.
Bimanual examination: Helps identify masses, tenderness, or pelvic organ prolapse.

Laboratory Tests

Swabs and cultures: For diagnosing infections such as bacterial vaginosis, Candida, or STIs.
Urinalysis: Assesses for urinary tract infection or hematuria.
Hormonal assays: May be indicated in cases of menstrual irregularities or suspected hormonal imbalances.

Imaging

Pelvic ultrasound: First-line imaging to assess for uterine, ovarian, or adnexal pathology.
MRI pelvis: Useful in cases where deep endometriosis or adenomyosis is suspected.
Cystoscopy: Considered in cases of suspected interstitial cystitis or bladder pathology.

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