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268: DYSPAREUNIA

Cynthia E. Neville, DPT, PT, WCS

CONDITION/DISORDER SYNONYMS

  • Painful intercourse

  • Urogenital pain disorders

  • Sexual pain disorder

  • Levator ani syndrome

  • Vaginismus

ICD-9-CM CODES

  • 625.0 Dyspareunia

  • Associated Diagnoses

    • 617 Endometriosis

    • 625.1 Vaginismus

    • 625.7 Vulvodynia

    • 625.71 Vulvar vestibulitis

    • 724.7 Disorders of coccyx

    • 728.2 Muscular wasting and disuse atrophy

    • 728.85 Spasm of muscle

    • 729.1 Myalgia

ICD-10-CM CODES

  • M62.83 Muscle spasm

  • M79.1 Myalgia

  • N94.1 Dyspareunia

  • N94.2 Vaginismus

PREFERRED PRACTICE PATTERN

  • 4C: Impaired Muscle Performance1

PATIENT PRESENTATION

A 28-year-old woman delivered her first baby vaginally 12 weeks ago. She sustained a Grade 2 perineal wound during the delivery. The wound became infected. The wound was surgically repaired and revised during a subsequent surgery. The obstetrician (OB) told the patient that some of the perineal scar tissue had to be removed. She was cleared by her OB/gynecologist (Gyn) to have intercourse but experienced severe pain during initial penetration and also with deep penetration during the first attempt at intercourse with her husband.

KEY FEATURES

Description

  • Pain during initial or deep penetration during sexual intercourse

Essentials of Diagnosis

  • Rule out gynecological pathology

  • Pain with vaginal penetration during gynecological examination, insertion of tampon, or during and after sexual intercourse

  • Pain to palpation of the superficial genital muscles and/or deep levator ani pelvic floor muscles (PFMs)

FIGURE 268-1

Diagnostic approach: Vaginitis. PID, pelvic inflammatory disease; TSS, toxic shock syndrome. (From Henderson MC, Tierney LM, Smetana GW. The Patient History: An Evidence-Based Approach to Differential Diagnosis. www.accessmedicine.com. Copyright © The McGraw-Hill Companies, Inc. All rights reserved.)

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General Considerations

  • Female only

  • May be a side effect of vaginal delivery associated with perineal trauma or pelvic joint injury

  • Vaginal stenosis and atrophy causing painful intercourse may be secondary to radiation of the pelvis for treatment of cancers

  • Urogenital pain disorders are frequently associated with pain in nearby body areas; especially back, pelvic, hip, groin regions

Demographics

  • Severe perineal trauma occurs in 0.5% to 10% of vaginal births2

  • Exact prevalence of pelvic pain is not known, estimates vary in the literature from 3.8% to 24%3

  • Many patients with pelvic pain will go on to develop chronic pain syndrome with depression, pain out of proportion to pathology, and changing roles in marriage, family, and career4

CLINICAL FINDINGS

SIGNS AND SYMPTOMS

  • Report of vaginal pain during penetration

  • Perceived reduction in size of vaginal opening attributed to muscle spasm

  • May complain of lower quadrant abdominal pain during sexual intercourse

  • Symptoms may worsen or decrease during and after sexual intercourse

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