This document discusses dyspareunia (recurring pain during sexual intercourse) and vulvodynia (chronic genital pain). It describes the causes, symptoms, diagnosis, and treatment options. Dyspareunia and vulvodynia can have physical and psychological causes, and treatment may involve medications, physical therapy, cognitive behavioral therapy, and sometimes surgery. A multidisciplinary approach is often needed to properly diagnose and address the underlying causes of genital pain.

1. DYSPAREUNIA & VULVODYNIA
DR ALKA MUKHERJEE
DR APURVA MUKHERJEE
NAGPUR M.S. INDIA

2. DR ALKA MUKHERJEE
MBBS DGO FICOG FICMCH PGDCR PGDMLS MA(PSY)
Director & Consultant At Mukherjee Multispecialty Hospital
MMC ACCREDITATED SPEAKER
MMC OBSERVER MMC MAO – 01017 / 2016
Present Position
 Director of Mukherjee Multispecialty Hospital
 Hon.Secretary INTERNATIONAL COUNCIL FOR HUMAN RIGHTS
 Hon.Secretary NARCHI NAGPUR CHAPTER (2018-2020)
 Hon.Secretary AMWN (2018-2021)
 Hon.Secretary ISOPARB (2019-2021)
 Life member, IMA, NOGS, NARCHI, AMWN & Menopause
Society, India, Indian medico-legal & ethics association(IMLEA),
ISOPRB, HUMAN RIGHTS
 Founder Member of South Rapid Action Group, Nagpur.
 On Board of Super Specialty, GMC, IGGMC, AIIMS Nagpur,
NKPSIMS, ESIS and Treasury, Nagpur for “ WOMEN SEXUAL
HARASSMENT COMMITTEE.”
mukherjeehospital@yahoo.com
www.mukherjeehospital.com
https://www.facebook.com/
Mukherjee Multispeciality
https://www.instagram.com/
Achievement
 Winner of NOGS GOLD MEDAL – 2017-18
 Winner of BEST COUPLE AWARD in Social
Work - 2014
 APPRECIATION Award IMA - MS
 Past Position
 Organizing joint secretary ENDO-GYN
2019
 Vice President IMA Nagpur (2017-2018)
Vice President of NOGS(2016-2017)
Organizing joint secretary ENDO-GYN
Organizing secretary AMWICON – 2019

3. Dyspareunia
• Dyspareunia is the term for recurring pain in the genital area or
within the pelvis during sexual intercourse.
• The pain can be sharp or intense. It can occur before, during, or
after sexual intercourse.
• Dyspareunia is more common in women than men.
• It has many possible causes, but it can be treated.
• Complex disorder:
1. Superficial - superficial dyspareunia is pain localized to the vulva
or vaginal entrance
2. Deep - deep dyspareunia is pain perceived inside the vagina or
lower pelvis, which is often associated with deep penetration
3. Primary - primary dyspareunia occurs at initial intercourse, and
4. Secondary dyspareunia occurs after some time of pain-free
intercourse.

4. Vulvodynia
• Vulvodynia is a chronic pain that is defined as genital pain with no
known etiology that lasts more than three months and may or may not
be associated with sexual intercourse .
• The International Society for the Study of Vulvovaginal Diseases (ISSVD),
the International Society for the Study of Women’s Sexual Health
(ISSWSH), and the International Pelvic Pain Society (IPPS) further
describe vulvodynia
• by the site of pain (localized, generalized, or mixed);
• if it is provoked, spontaneous, or mixed; or
• if the pain is intermittent, persistent, constant, immediate, or delayed
• Localized vulvodynia refers to pain limited to the vulvar vestibule around
the hymeneal ring at the entrance to the vagina, and
• generalized vulvodynia is defined as pain affecting the entire vulvar
region
• Vulvodynia has no clear etiology.

5. ISSVD, ISSWSH, and IPPS potential associated
Factors:
• Other pain syndromes,
• Genetics,
• Hormonal factors,
• Inflammation,
• Musculoskeletal or neurologic mechanisms,
• Psychosocial factors, and
• Structural defects

6. Difference between
Dyspareunia
• Descriptive term for the symptom of
pelvic or vaginal pain associated with
intercourse (i.E., It describes pain that
always occurs with provoking touch
such as intercourse).
• Dyspareunia can occur at the entrance
of the vagina, deep in the vaginal
canal, or in the pelvis.
• Dyspareunia may be acute or chronic,
• Can be used to describe pain that
coexists with other comorbidities such
as endometriosis, interstitial cystitis,
pelvic floor myalgias, and vulvar
dermatoses.
vulvodynia
• Vulvodynia may occur with or
without provocation
(i.E.,Spontaneously).
• Vulvodynia is localized to the vulva
and vaginal introitus.
• Vulvodynia is a term used
specifically for the classification of
chronic pain (i.E., Pain lasting
longer than three months).
• Can be used to describe pain that
coexists with other comorbidities
such as endometriosis, interstitial
cystitis, pelvic floor myalgias, and
vulvar dermatoses.

7. Causes
• vaginal
dryness from menopause,
childbirth, breastfeeding,
medications, or too little arousal
before intercourse
• skin disorders that
cause ulcers, cracks, itching, or
burning
• infections, such
as yeast or urinary tract
infections (UTIs)
• injury or trauma from childbirth,
an accident, an episiotomy,
a hysterectomy or pelvic surgery
•vulvodynia, or pain centered in the
vulva area
•vaginitis, or inflammation of the
vagina
•vaginismus, or a spontaneous
tightening of the muscles of the
vaginal wall
•endometriosis
•cystitis
•pelvic inflammatory disease (PID)
•uterine fibroids
•irritable bowel syndrome (IBS)
•Radiation and chemotherapy

8. Factors that reduce sexual desire or affect a person’s
ability to become aroused can also cause dyspareunia.
• Stress, which can result in tightened muscles of the pelvic
floor
• Fear, guilt, or shame related to sex
• Self-image or body issues
• Medications such as birth control pills
• Relationship problems
• Conditions such as cancer, arthritis, diabetes, and thyroid
disease
• History of sexual abuse or rape

9. Symptoms
• Dyspareunia pain can vary. Pain may occur:
• In the vagina, urethra, or bladder
• During penetration
• During or after intercourse
• Deep in the pelvis during intercourse
• After pain-free intercourse
• Only with specific partners or circumstances
• With tampon use
• Along with burning, itching, or aching
• With a feeling of stabbing pain, similar to menstrual cramps

10. Who’s at risk for dyspareunia?
• Both women and men can experience dyspareunia, but the
condition is more common in women. Dyspareunia is one of
the most common problems of postmenopausal women.
• Around 75 percent of women have painful intercourse at
some time, according to the American College of
Obstetricians and Gynecologists (ACOG), a woman is at an
increased risk if she:
• Take medications that cause vaginal dryness
• Have a viral or bacterial infection
• Are postmenopausal

11. Diagnosis
• A complete medical and sexual history.
• Possible questions a doctor may ask:
• When and where do she feel pain?
• Which partners or positions cause pain?
• Do any other activities cause pain?
• Does her partner want to help?
• Are there other conditions that may be contributing to her
pain?

12. Vulvar anatomy
Physical examination of patients with genital pain should include an external
musculoskeletal evaluation, followed by external visual and sensory examination,
as well as internal single digit palpation of the pelvic floor muscles. If tolerated by
the patient, the provider may proceed to a bimanual examination and a speculum
exam.

13. • The internal musculoskeletal and vaginal single-digit exam - most reliable
method for evaluating pelvic muscle tenderness
• Using the index finger, the examiner can palpate the lateral, anterior, and
posterior walls of the vagina, the urethra, and pelvic floor muscles
(levator ani, coccygeus, piriformis, and obturator internus).
• Access the specific areas for tone, tenderness, or involuntary spasms of
the muscles of the introitus and pelvic floor
• Tenderness during minimal or moderate palpation is considered
abnormal; pelvic and vaginal structures can tolerate approximately 2 kg
of pressure without pain.
• The patient is then asked to squeeze or contract around the single digit
to assess their muscle strength. An effort should also be made to identify
any scars from previous surgeries, episiotomy, or trauma.

14. Pelvic floor muscles

15. Vaginal sensory innervation

16. Vaginal cotton swab examination

17. Important elements to discuss during clinical
evaluation of female sexual pain
• Medical History Questions
a) PAIN CHARACTERISTICS - Timing, duration, quality, location, provoked,
or unprovoked
b) MUSCULOSKELETAL HISTORY Pelvic floor surgery, trauma, obstetrics
c) BOWEL AND BLADDER HISTORY Constipation, diarrhea, urgency,
frequency
d) SEXUAL HISTORY Frequency, desire, arousal, satisfaction, relationship
e) PSYCHOLOGICAL HISTORY Mood disorder, anxiety, depression
f) HISTORY OF ABUSE Sexual, physical, neglect

18. • A pelvic examination is also
common in diagnosis. A
look at the external and
internal pelvic area for
signs of:
• dryness
• inflammation or infection
• anatomical problems
• genital warts
• scarring
• abnormal masses
• endometriosis
• tenderness
• Pap test
• pelvic ultrasound
• culture test to check for
bacteria or yeast infection
• urine test
• allergy test
• counseling to determine
the presence of emotional
causes

19. Treatment
• Antibiotics
• Antifungal medicines
• Topical or injectable corticosteroids
• Trying alternative medications may restore natural
lubrication and reduce pain.
• Low estrogen levels cause dyspareunia in some women. A
prescription tablet, cream, or flexible ring can deliver a
small, regular dose of estrogen to the vagina.

20. Local Anesthetics
• Sensitization of peripheral vestibular nerves has been
suggested as a possible mechanism of pain in vulvodynia
• topical anesthetics, such as lidocaine, can be used to
relieve pain during intercourse
• useful for short-term therapy and in combination with
other therapies (e.g., physical therapy and botulinum
toxin).
• Local anesthetics are theorized to desensitize peripheral
vulvar and vaginal nerves and achieve pain relief.
Typically, topical 5% lidocaine is used once or twice daily
with reevaluation after six to eight weeks of use

21. Hormonal Treatment
• Vulvovaginal atrophy caused by decreased levels of estrogen is a common
problem in aging women.
• In patients who present with the main symptoms of atrophy, dryness, and
dyspareunia, the first line of therapy consists of topical estrogen to restore
normal vaginal ph levels and thicken and increase cell numbers leading to the
revascularization of the epithelium
• low-dose conjugated estrogens available in the forms of vaginal inserts (e.G.,
Cream, tablet, and ring) can be applied periodically from a few times a week to
every three months.
• Topical estrogen should be considered to avoid the systemic effect of oral
estrogen
• Patients using estrogen supplementation in any form should be followed
clinically and estrogen supplementation is contraindicated in patients with
certain comorbidities such as breast cancer and uncontrolled cardiovascular
disease.
• Topical vaginal estrogen therapy may take up to four weeks before patients
notice an effect.

22. Anti-Inflammatory Agents
• Tissue levels of interleukin-B, an inflammatory mediator
cytokine, have been reported to be higher in the hymenal
region of the vestibule of women with vulvodynia
• Injectable anti-inflammatory agents such as corticosteroids,
interferons, and mast cell stabilizers have been used to treat
vulvodynia with some improvement

23. Botulinum Type A
• Injection of botulinum toxin A into the pelvic floor muscles
has been shown in some studies to decrease dyspareunia
and vulvodynia caused by pelvic floor myalgia and
contracture .
• Botulinum toxin A is hypothesized to inhibit nociceptors
leading to a decrease in peripheral and central sensitization
associated with vulvodynia .
• A long-term assessment of the effectiveness of botulinum
injections after 24 months revealed that patients could have
sexual intercourse and had improved quality of life
• Not recommended as a first-line therapy as further clinical
trials of botulinum type A are needed, but it is used as an
adjunct to other therapies

24. Systemic Medications
• Tricyclic antidepressants and anticonvulsants Tricyclic
antidepressants – amitriptyline reduces peripheral nerve
sensitization and have been used in the management of
neuropathic pain - take up to three weeks to achieve pain
control

25. Physical Therapy and Behavioral Therapy
• Pelvic floor physical therapy - it allows the pelvic floor
muscles to relax and retrains pain receptors.
• Cognitive behavioral therapy effective in reducing the
anxiety and fear related to dyspareunia
• Cognitive behavioral therapy focuses on patterns of thinking
and helps identify behaviors associated with negative
thoughts and feelings
• Non-invasive and safe therapeutic option

26. Home care
• These home remedies can also reduce dyspareunia
symptoms:
• Use water-soluble lubricants.
• Have sex when patient and partner are relaxed.
• Communicate openly with partner about pain.
• Empty the bladder before sex.
• Take a warm bath before sex.
• Take an over-the-counter pain reliever before sex.
• Apply an ice pack to the vulva to calm burning after sex

27. Surgical Therapy
• Last resort when all conservative and medical management options have failed
or when surgery is indicated to determine and/or treat pelvic adhesions,
endometriosis, or pelvic organ prolapse.
• The surgical options are specific to the disorder:
1. Vulvar vestibulectomy,
2. Lysis of pelvic adhesions, or
3. Excision of endometriosis
• Thorough counseling is necessary prior to pursuing surgical treatment.
• Patients must understand that surgery may improve their pain, and their pain
may sometimes return or worsen.
• Vestibulectomy can be an effective treatment only for localized, provoked
vestibulodynia - significant pain relief in 60% to 90% of patients
• Generally, surgical techniques include a complete vulvar vestibulectomy, which
involves excision of the mucosa of the entire vulvar vestibule and the mucosa
adjacent to the urethra, or a modified vestibulectomy, which limits the excision
of mucosa to the posterior vestibule .

28. Preventing dyspareunia
• To reduce the risk of pain during intercourse:
• After childbirth, wait at least six weeks before
resuming sexual intercourse.
• Use a water-soluble lubricant when vaginal dryness is an
issue.
• Use proper hygiene.
• Get proper routine medical care.
• Prevent sexually transmitted diseases (stds) by using
condoms or other barriers.
• Encourage natural vaginal lubrication with enough time for
foreplay and stimulation.

29. SUM-UP
• Despite the prevalence and impact of dyspareunia, many
women do not seek care.
• Women with dyspareunia often suffer in silence and feel
that their pain has not been assessed or validated by
providers.
• Dyspareunia and vulvodynia can be challenging to
diagnose and may require a multidisciplinary approach;
therefore, a comprehensive and systematic exam is
required to understand the specific causes of genital pain.
• Treatments often involve multimodal approaches that
include education, medication, cognitive behavioral
therapy, physical therapy, and possibly surgery.