Introduction

Questions related to sexual functioning should be asked as part of the reproductive history. Two helpful questions are, “Are you sexually active?” and “Are you having any sexual difficulties at this time?”

During the pelvic examination, the patient should be placed in a half-sitting position and given a hand-held mirror and then asked to point out the site of pain and describe the type of pain.

Etiology

A. Vulvovaginitis
Vulvovaginitis is inflammation or infection of the vagina. Areas of marked tenderness in the vulvar vestibule without visible inflammation occasionally show lesions resembling small condylomas on colposcopy.

B. Vaginismus
Vaginismus is voluntary or involuntary contraction of muscles around the introitus. It results from fear, pain, sexual trauma, or having learned negative attitudes toward sex during childhood.

C. Remnants of the Hymen
The hymen is usually adequately stretched during initial intercourse, so that pain does not occur subsequently. In some women, the pain of initial intercourse may produce vaginismus. In others, a thin or thickened rim or partial rim of hymen remains after several episodes of intercourse, causing pain.

D. Insufficient Lubrication of the Vagina
See vaginal atrophy in the section on Menopausal Syndrome.

E. Infection, Endometriosis, Tumors, or Other Pathologic Conditions
Pain occurring with deep thrusting during coitus is usually due to acute or chronic infection of the cervix, uterus, or adnexa; endometriosis; adnexal tumors; or adhesions resulting from prior pelvic disease or operation. Careful history taking and a pelvic examination will generally help in the differential diagnosis.

F. Vulvodynia
This is the most frequent cause of dyspareunia in premenopausal women. It is characterized by a sensation of burning along with other symptoms including pain, itching, stinging, irritation, and rawness. The discomfort may be constant or intermittent, focal or diffuse, and experienced as either deep or superficial. There are generally no physical findings except minimal erythema that may be associated with a subset of vulvodynia, vulvar vestibulitis. Vulvar vestibulitis is normally asymptomatic, but the pain is associated with touching or pressure on the vestibule such as with vaginal entry or insertion of a tampon.

Treatment

A. Vulvovaginitis
Lesions resembling warts on colposcopy or biopsy should be treated in the appropriate way (see Vaginitis). Irritation from spermicides may be a factor. The couple may be helped by a discussion of noncoital techniques to achieve orgasm until the infection subsides.

B. Vaginismus
Sexual counseling and education on anatomy and sexual functioning may be appropriate. The patient can be instructed in self-dilation, using a lubricated finger or test tubes of graduated sizes. Before coitus (with adequate lubrication) is attempted, the patient - and then her partner - should be able to easily and painlessly introduce two fingers into the vagina. Penetration should never be forced, and the woman should always be the one to control the depth of insertion during dilation or intercourse.

C. Remnants of the Hymen
In rare situations, manual dilation of a remaining hymen under general anesthesia is necessary. Surgery should be avoided.

D. Insufficient Lubrication of the Vagina
If inadequate sexual arousal is the cause, sexual counseling is helpful. Lubricants may be used during sexual foreplay. For women with low plasma estrogen levels, use of a lubricant during coitus is sometimes sufficient. If not, systemic hormone replacement therapy (see Menopausal Syndrome) or estrogen vaginal cream may be used. An alternative is the estradiol vaginal ring. The ring may be worn continuously and replaced every 3 months. Concomitant progestin therapy is not needed with the ring.

E. Infection, Endometriosis, Tumors, or Other Pathologic Conditions
Medical treatment of acute cervicitis, endometritis, or salpingitis and temporary abstention from coitus usually relieve pain. Hormonal or surgical treatment of endometriosis may be helpful. Dyspareunia resulting from chronic pelvic inflammatory disease or any condition causing extensive adhesions or fixation of pelvic organs is difficult to treat without extirpative surgery. Couples can be advised to try coital positions that limit deep thrusting and to use manual and oral sexual techniques.

F. Vulvodynia
Since the cause of vulvodynia is unknown, management is difficult. Few treatment approaches have been subjected to methodologically rigorous trials. A variety of specific (antiviral, antifungal, or estrogen cream) and nonspecific (corticosteroid or anesthetic) agents have been tried with varying degrees of success. Pain control through behavioral therapy, biofeedback, or acupuncture has also been tried. No single approach has been consistently shown to be effective. Patients with continuous genital burning or pain may benefit from treatment with a tricyclic antidepressant such as amitriptyline in gradually increasing doses from 10 mg/d to 75-100 mg/d. For vulvar vestibulitis, surgery - usually consisting of vestibulectomy - has reportedly been the most consistently successful approach.

Preferences:
Mariani L: Vulvar vestibulitis syndrome: an overview of non-surgical treatment. Eur J Obstet Gynecol Reprod Biol 2002;101:109.