1. Approach dyspareunia
Pawin Puapornpong

2. Approach dyspareunia Location: Entry vs Deep
Onset: During or after intercourse
Pruritic pain: vaginitis
Aching: pelvic congestion
Single site or multiple sites which site came first: expectation of pain
Situational or generalized: psychologic
Positional: pain minimized with women superior position

3. Approach dyspareunia Other sexual dysfunction: arousal disorders
Vaginal symptoms: discharge,odor>>vaginitis
History of STD: PID
Obsteric history; postpartum dyspareunia
Surgery or radiation: vaginal stricture
Contraception method: risk of PID,trauma/irritation

4. Approach dyspareunia Medical causes: DM,IBS,skin disorder
Psychological causes: Depression,anxiety

5. Superficial dyspareunia
Vaginismus
Vaginal infection
Episiotomy scars & narrow vagina
Insufficient vaginal lubrication
Atrophic vagina due to menopause

6. Vaginismus
Recurrent or persistent involuntary spasm of the musculature of the outer third of the vagina that interferes with intercourse
Etiology: Unknown
PE: Palpable spasm of vaginal musculature, difficult inserting speculum

7. Insufficient vaginal lubrication
Well-delineated entry pain, vaginal pain, vaginal dryness,friction,irritation,difficulty and pain with penetration
Etiology: Estrogen deficiency,arousal-phase difficulty
PE:inspection of pubic hair,labia fullness, vaginal mucosa,vaginal depth

8. Deep dyspareunia
PID
Endometriosis
Ectopic pregnancy
Pelvic congestion

9. Pelvic inflammatory disease
Deep pain
Etiology: Infection
PE: discharge,uterine tenderness or cervical motion tenderness

10. Endometriosis and pelvic adhesion
Deep pain, cyclic pain with menses complaint of “Something being bumped into”
Etiology: unknown
PE:Nodules,Fixed uterus or adnexa

11. Pelvic congestion Postcoital ache, deep pelvic pain Etiology: unknown
PE: Unremarkable

12. Management
Aimed at identifying & properly treating the underlying cause
Adequate lubrication
Topical oestrogen for atrophic vagina
Surgery : vaginal prolapse or pelvic pathology

13. Differential diagnosis
Dyspareunia
Vulvodynia
Vaginismus
Atrophic tissue or impaired lubrication
Endometriosis&pelvic adhesion
Adnexal pathology
R/V uterus,uterine fibroid
Chronic cervicitis:PID,Endometritis
Pelvic congestion
Urethral disorders:cystitis

14. Thank you