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Female sexual pain: Differential diagnosis

Female sexual pain: Differential diagnosis
Literature review current through: Jan 2024.
This topic last updated: Feb 15, 2023.

INTRODUCTION — Female sexual pain (FSP) can be a significant cause of distress and is often associated with other disorders of female sexual function (decreased desire, arousal, orgasm, satisfaction). While FSP may occur in the context of sexual activity, the pain can also occur as genital pain with or without the presence of a partner. Pain can occur in isolation or may be a manifestation of regional pathology or chronic medical conditions.

This topic will review the differential diagnosis of FSP. Related content on the evaluation of sexual pain, evaluation and treatment of vulvodynia, and the overview of sexual dysfunction in females is presented separately.

(See "Female sexual pain: Evaluation".)

(See "Vulvar pain of unknown cause (vulvodynia): Clinical manifestations and diagnosis".)

(See "Vulvar pain of unknown cause (vulvodynia): Treatment".)

(See "Overview of sexual dysfunction in females: Management".)

In this topic, when discussing study results, we will use the terms "woman/en" or "patient(s)" as they are used in the studies presented. However, we encourage the reader to consider the specific counseling and treatment needs of transgender and gender-expansive individuals.

DEFINITION AND TERMINOLOGY

Definition – FSP is vulvovaginal or pelvic pain that is provoked by or exacerbated during sexual contact [1,2]. Individuals with sexual pain disorders experience genital pain just before, during, or after sexual intercourse or other sexual activities that involve the clitoris, vulva, vagina, and/or perineum. The pain can be mild to severe, generalized or localized, lifelong or acquired, and idiopathic or secondary [3].

Nomenclature – Terms that are commonly used when discussing FSP include:

Apareunia – Inability to achieve vaginal insertion [4].

Dyspareunia – Recurrent or persistent pain with sexual intercourse that causes distress. It affects approximately 10 to 20 percent of American women [4].

Superficial dyspareunia – Dyspareunia limited to the vulva or vaginal entrance [5].

Deep dyspareunia – Dyspareunia associated with deep penetration that manifests in the deeper parts of the vagina or lower pelvis [5].

Primary dyspareunia – Pain with vaginal insertion has occurred since onset of coitarche [5].

Secondary dyspareunia – Pain begins after some time of pain-free sexual activity [5].

Genitopelvic pain/penetration disorder (GPPD) – An all-encompassing term for FSP as defined by the American Psychiatric Association [6].

Pelvic anatomy terminology – The Society of Gynecologic Surgeons has released recommendations for standardized terminology for the female pelvis [7-9].

APPROACH TO DIAGNOSIS — FSP pain has many etiologies; causes can be single or a combination (table 1). A detailed discussion of the stepwise evaluation of individuals with FSP is presented separately. (See "Female sexual pain: Evaluation".)

Briefly, issues to consider when forming a differential diagnosis include:

Superficial (distal) versus deep (proximal) symptoms – Causes of FSP can be from anatomically distal (inferior [eg, vulvar, lower vagina]) to anatomically proximal (superior [eg, upper vagina]) pelvic locations. Distal etiologies typically result in superficial dyspareunia or apareunia while proximal etiologies more commonly cause deep dyspareunia (eg, deeply infiltrating endometriosis).

Identifiable versus idiopathic FSP – Similar to the classification system for vulvar pain [10], patients with FSP can be grouped into those with an identifiable cause of their symptoms and those with idiopathic FSP. For individuals with FSP related to a specific cause, the pathogenesis of pain is related to that diagnosis. Those with FSP and no identifiable cause appear to have a type of chronic pain syndrome. Both identified and idiopathic FSP can occur in the same individual.

Nongynecologic causes of FSP – FSP can be caused by gynecologic, gastrointestinal, urologic, infectious, and neurologic pathology. Nongynecologic etiologies are discussed below. (See 'Other conditions contributing to increased pain' below.)

Overlap with chronic pain syndromes and central sensitization FSP can be a clinical feature of other chronic pain processes or syndromes, including bladder pain syndrome (BPS), myofascial pelvic pain, and fibromyalgia (table 2). Chronic pain syndromes can be characterized by central sensitization of pain.

SUPERFICIAL DYSPAREUNIA (DISTAL SEXUAL PAIN) — Distal FSP refers to pain with vulvar contact or vaginal insertion that involves the vulva and/or or distal vagina. Common causes of distal FSP include reduced estrogen levels, decreased lubrication, myofascial pelvic pain syndrome (MPPS), vulvar pain of unknown cause (vulvodynia), alterations of vaginal anatomy (congenital anomalies, skin diseases, and postprocedure changes), and persistent genital arousal disorder (PGAD) (table 1).

Decreased serum estrogen — Decreases in circulating levels of estrogen (particularly estradiol) can result from physiologic, pharmacologic, or iatrogenic causes. Decreased estrogen levels contribute to both tissue changes and reduced lubrication, both of which can contribute to FSP.

Hormonal contraception – Separate from the possible impact on lubrication (see 'Decreased lubrication' below), hormonal contraception use may be associated with hormone-mediated provoked vestibulodynia. Specifically, combined oral contraceptives are associated with decreased serum estradiol hormone levels, decreased serum-free testosterone levels, increased sex hormone binding globulin (SHBG) levels, and decreased thickness of the labia minora and epithelium of the vaginal orifice [11,12]. Despite these observations, the exact mechanism of altered circulating sex hormones in causing sexual pain has not yet been elucidated.

Postpartum/lactation – The postpartum and lactating periods are known to be hypoestrogenic hormonal states [13]. Breastfeeding, particularly exclusive breastfeeding, is associated with increased risk of dyspareunia [14,15]. Clinicians should evaluate for evidence of hypoestrogenism although clinical findings of atrophy have not been clearly shown to be the cause of dyspareunia [16]. If topical estrogen therapy does not relieve symptoms, other etiologies should be sought.

Genitourinary syndrome of menopause (formerly atrophic vaginitis) – Genitourinary syndrome of menopause (GSM) is defined as "a collection of symptoms and signs associated with a decrease in estrogen and other sex steroids involving changes to the labia majora/minora, clitoris, vestibule/introitus, vagina, urethra, and bladder." The syndrome may include, but is not limited to, genital symptoms of "dryness, burning, and irritation; sexual symptoms of lack of lubrication, discomfort or pain, and impaired function; and urinary symptoms of urgency, dysuria, and recurrent urinary tract infections" [17]. Vaginal dryness, a common symptom of GSM, can begin early in the menopausal transition; increased duration of menopause is associated with increased risk of on vaginal dryness [18].

(See "Genitourinary syndrome of menopause (vulvovaginal atrophy): Clinical manifestations and diagnosis".)

(See "Genitourinary syndrome of menopause (vulvovaginal atrophy): Treatment".)

Reduced ovarian function – Ovarian function can be inadequate (eg, premature ovarian insufficiency, radiation therapy) or absent (eg, bilateral oophorectomy) and resultant low-serum estrogen levels can lead to FSP. Survey data suggest that vaginal dryness is worse among individuals who are surgically menopausal (underwent bilateral oophorectomy) compared with those who are naturally menopausal [19].

Antiestrogen therapy – Antiestrogen therapies (eg, selective estrogen receptor modulators and aromatase inhibitors) can result in vulvovaginal atrophy, including vaginal epithelial thinning, decreased elasticity, and decreased lubrication. Ensuing vaginal dryness and dyspareunia can occur in 57 percent of patients on aromatase inhibitors and 31 percent on tamoxifen. Patients on antiestrogen therapy can additionally experience low sexual desire, decreased orgasmic function, and decreased sexual satisfaction [20].

Decreased lubrication — Physiologic vaginal lubrication is a result of vaginal epithelial transudation and cervical secretion. Sex steroids, predominantly estradiol, as well as testosterone and progesterone, affect the structure and blood flow of the genital tissues [21]. Specifically, they impact neurotransmitters, smooth muscle contractility in blood vessels and tissues, epithelial mucus production, and growth factors [21]. Reductions in circulating estrogen can decrease vaginal lubrication and reductions in lubrication that contribute to FSP can occur in other settings as well.

Hormonal contraception – There are limited high-quality data regarding the impact of combined oral contraception on vaginal lubrication. Combined oral contraceptives (estradiol and progestin-containing) are associated with increased self-report of vaginal dryness [22]. Non-oral hormonal contraceptives such as the vaginal ring, implant, and levonorgestrel IUD do not appear to be associated with a decrease in vaginal lubrication [23].

Decreased physiologic arousal – Physiologic arousal normally increases genital lubrication and blood flow [24]. Medical and psychological conditions, and/or their pharmacotherapeutic agents, have been associated with decreased physiologic genital arousal and/or lubrication, including hypothyroidism [25], diabetes mellitus [26], hypertension [27], depression, heart disease [28], Sjögren's disease [29], Sicca syndrome [30], Behcet syndrome [31], and medications with neurologic, hormonal, and vascular effects that ultimately decrease sexual function, including arousal and lubrication [32].

(See "Overview of sexual dysfunction in females: Epidemiology, risk factors, and evaluation".)

Surgery – The available data on impact of most types of pelvic surgery on lubrication are limited. Hysterectomy with or without oophorectomy has been associated with vaginal dryness [33]. Radical hysterectomy generally results in worsened sexual pain compared with total hysterectomy for benign indications. Patients undergoing nerve-sparing laparoscopic radical hysterectomy have reported less of a decrease in vaginal lubrication compared with patients undergoing conventional laparoscopic radical hysterectomy [34].

(See "Overview of sexual dysfunction in female cancer survivors".)

(See "Myofascial pelvic pain syndrome in females: Clinical manifestations and diagnosis".)

(See "Vulvar pain of unknown cause (vulvodynia): Clinical manifestations and diagnosis".)

Constriction or obstruction of vaginal orifice — Any process that limits the introital aperture or elasticity can result in FSP.

Obstructive gynecologic conditions — Patients who have never been able to achieve vaginal intercourse or pain-free intercourse are evaluated for congenital anomalies, pelvic organ prolapse, myofascial pelvic pain syndrome (MPPS), and vulvar pain of unknown etiology. Pelvic organ prolapse is more common in older and/or postpartum individuals. Findings of prolapse, MPPS, and vulvar pain can be primary or secondary causes of FSP.

Congenital anomalies – Individuals who have never been able to achieve pain-free vaginal insertion are evaluated for hymenal variants (eg, imperforate, microperforate, cribriform, or septate conformations) and vaginal septae (transverse or longitudinal) [35,36].

(See "Congenital anomalies of the hymen and vagina".)

(See "Congenital uterine anomalies: Clinical manifestations and diagnosis".)

Pelvic organ prolapse – Symptomatic pelvic organ prolapse is associated with dyspareunia [37]. Surgical repair of prolapse can improve dyspareunia related to the prolapse; new-onset postoperative dyspareunia is possible but less common [38].

(See "Pelvic organ prolapse in females: Epidemiology, risk factors, clinical manifestations, and management".)

(See "Pelvic organ prolapse in women: Diagnostic evaluation".)

(See "Sexual function in females with pelvic floor and lower urinary tract disorders", section on 'Pelvic organ prolapse'.)

Vaginismus and myofascial pelvic pain syndrome (MPPS) — Vaginismus and MPPS are thought to be musculoskeletal pain disorders that negatively impact the patient's well-being.

Vaginismus – Vaginismus has historically referred to involuntary muscle spasm with vaginal penetration. The definition and inclusion criteria have evolved to include a range of symptoms. In the absence of identifiable etiology, patients often require multimodal therapy.

Definitions and criteria – The terminology and diagnostic criteria from both the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) and the Fourth International Consultation on Sexual Medicine (ICSM) are acceptable. Both include vaginismus as one component of FSP. While the wording is similar, patients may identify more with one description than the other.

-Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) – In the DSM-5, "vaginismus" is a symptom within the umbrella category "genito-pelvic pain/penetration disorder" (GPPPD) [39]. This is an evolution from the prior definitions of vaginismus that included "involuntary (pelvic) muscle spasm" [40], "pain and fear of vaginal penetration" [40], and "recurrent or persistent involuntary spasm of the musculature of the outer third of the vagina that interferes with sexual intercourse" [41]. In the DSM-5, GPPPD is characterized by marked difficulty with at least one of the following: (a) vaginal intercourse/penetration, (b) genitopelvic pain, (c) fear of vaginal intercourse/penetration/pain, or (d) heightened pelvic floor muscle tension during attempted penetration [39].

-International Consultation on Sexual Medicine (ICSM) – In 2016, the Fourth International Consultation on Sexual Medicine (ICSM) further elaborated on specific components of the disorder and incorporated them under the umbrella term "female genital-pelvic pain dysfunction." The ICSM defined female genital-pelvic pain dysfunction as "persistent or recurrent difficulties while performing or caused by at least one of the following action/symptoms" [2]: (a) vaginal penetration during intercourse, (b) marked vulvovaginal pain during genital contact, (c) marked fear or anxiety about vulvovaginal or pelvic pain in anticipation of, during, or as a result of genital contact, or (d) marked hypertonicity or overactivity of pelvic floor muscles with or without genital contact.

Evaluation – Patients are evaluated for identifiable causes of their symptoms; diagnosed etiologies are treated accordingly (eg, pain related to GSM). Whether or not a direct cause is identified, patients may need additional therapy for symptoms of fear or anxiety that result from either anticipated pain or from relationship distress.

Treatment – There is no single treatment for vaginismus and these patients often benefit from a multimodal approach that includes myofascial pelvic physical therapy, medications, and other interventions (eg, trigger point injections), and mental health support (eg, pain psychiatry or cognitive behavioral therapy). Examples of treatment approaches are presented in the related content below:

-(See "Vulvar pain of unknown cause (vulvodynia): Treatment".)

-(See "Myofascial pelvic pain syndrome in females: Treatment".)

-(See "Myofascial pelvic pain syndrome in females: Pelvic floor physical therapy for management".)

-(See "Chronic pelvic pain in adult females: Treatment".)

Myofascial pelvic pain syndrome (MPPS) – MPPS, also known as overactive pelvic floor muscles, pelvic floor myalgia, high-tone pelvic floor muscles, or pelvic floor muscle spasm, is a subset of chronic pelvic pain that can result in dyspareunia in addition to other pelvic organ dysfunction [42]. MPPS can be associated with several extrapelvic musculoskeletal conditions, including arthritis, tendonitis, and abdominal, hip, and lumbosacral joint dysfunction [43]. The condition is characterized by short, tight, tender pelvic floor muscles that can be localized or diffuse (figure 1).

(See "Myofascial pelvic pain syndrome in females: Clinical manifestations and diagnosis".)

(See "Myofascial pelvic pain syndrome in females: Treatment".)

(See "Myofascial pelvic pain syndrome in females: Pelvic floor physical therapy for management".)

(See "Surgical female urogenital anatomy", section on 'Pelvic muscles'.)

Vulvar dystrophies and dermatoses — Any dermatologic process that causes vulvovaginal irritation, pain, or scarring can contribute to FSP. Commonly encountered dermatologic processes include:

Vulvar dystrophies and dermatoses – These include contact dermatitis, lichen sclerosus, lichen simplex chronicus, and lichen planus, all of which can cause dyspareunia secondary to anatomic changes [44].

Vulvar dermatitis and vulvar lesions – Vulvar dermatitis, including irritant contact dermatitis (exogenous) and atopic dermatitis (eczema, or endogenous), represents numerous vulvar conditions that present with chronic irritation and/or pruritus [45]. The resultant rubbing and scratching can cause irritation and/or burning, which in turn can contribute to FSP. (See "Vulvar dermatitis".)

The diagnostic process and presentation of various vulvar lesions are discussed in greater detail separately:

-(See "Vulvar lesions: Diagnostic evaluation".)

-(See "Vulvar lesions: Differential diagnosis of red lesions".)

-(See "Vulvar lesions: Differential diagnosis of white lesions".)

-(See "Vulvar lesions: Differential diagnosis of pigmented (black, brown, blue) lesions".)

-(See "Vulvar lesions: Differential diagnosis of pigmented (black, brown, blue) lesions".)

-(See "Vulvar lesions: Differential diagnosis of vesicles, bullae, erosions, and ulcers".)

Lichen sclerosus – Lichen sclerosus is a benign, chronic, progressive dermatologic condition identified by marked inflammation, epithelial thinning, and distinctive dermal changes that are often accompanied by symptoms of pruritus and pain. The characteristic white, atrophic papules and plaques most frequently affect the labia minora and/or labia majora (picture 1), although the whitening may extend over the perineum and around the anus in a keyhole fashion (picture 2A-B). Dyspareunia is often a late symptom of lichen sclerosus. (See "Vulvar lichen sclerosus: Clinical manifestations and diagnosis".)

Lichen planus – Lichen planus is a less common inflammatory dermatologic condition, but when it occurs, the desquamative, erosive, chronic dermatitis can involve the vulva and/or vagina (picture 3A-B). Scarring can cause significant anatomic change, including severe stenosis of the vaginal opening and urethral obstruction. Dyspareunia and difficulty with urination/dysuria are the major symptoms of severe progressive disease. (See "Vulvar lichen planus".)

Vulvar granuloma fissuratum – Vulvar granuloma fissuratum refers to recurrent mechanical fissure formation of the posterior fourchette and can occur premenopausally or postmenopausally [46,47]. It is characterized by recurrent fissuring or bleeding at posterior fourchette on vaginal insertion or exam and can be present as part of other vulvar dermatoses, particularly vulvar lichen sclerosus.

Postprocedure anatomic change — Any vulvovaginal surgery or procedure (eg, repair of obstetric perineal laceration) can place the patient at risk for superficial dyspareunia. Etiologies include the reduced elasticity of scar tissue (eg, after radiation therapy), stenosis, formation of granulation tissue, and nerve injury or functional change [48-50].

Pregnancy and birth can result in FSP

Vaginal or cesarean birth – Postpartum FSP has been reported by patients following both cesarean and vaginal birth at eight months postpartum [51]. (See "Postpartum perineal care and management of complications", section on 'Perineal pain or dyspareunia'.)

Assisted vaginal birth – Compared with nonoperative vaginal birth, operative vaginal delivery is associated with increased sexual pain through at least 12 months postpartum [52]. (See "Assisted (operative) vaginal birth".)

Perineal laceration, episiotomy, and/or perineal repair – Patients with second-, third-, or fourth-degree perineal lacerations (ie, obstetric anal sphincter injury) are at higher risk for dyspareunia compared with those with no perineal lacerations or those with labial or first-degree vaginal and/or perineal lacerations [53,54]. (See "Postpartum perineal care and management of complications".)

Pelvic floor reconstructive surgery – Pelvic floor reconstructive surgeries involving the vaginal orifice (such as posterior colpoperineorrhaphy) can reduce or worsen dyspareunia [55]. Possible etiologies include postoperative development of vaginal stenosis or MPPS. Posterior colporrhaphy with levator myorrhaphy (levator muscle plication) is associated with higher risk of dyspareunia than posterior colporrhaphy without levator myorrhaphy [56]. (See "Sexual function in females with pelvic floor and lower urinary tract disorders".)

In addition, transvaginally-placed synthetic mesh for pelvic organ prolapse has been associated with dyspareunia [57,58]. (See "Transvaginal synthetic mesh: Complications and risk factors", section on 'Pelvic pain or dyspareunia'.)

Other vulvovaginal procedures – Any surgery, procedure, or injury that can cause scar formation, granulation tissue, or nerve injury can contribute to FSP. These can include, but are not limited to, Bartholin gland surgery, vulvar or vaginal laser treatment, and labiaplasty [59-61].

Cancer surgery and/or therapy Surgery, traditional chemotherapy, radiation, and antiestrogen medications can reduce the skin elasticity or vaginal aperture and result in FSP [62,63].

Female genital cutting – Also known as female circumcision, female genital cutting involves the partial or total removal of external female genitalia or other injury to the female genital organs for nonmedical reasons (picture 4 and picture 5) [64], and is highly associated with dyspareunia [65]. (See "Female genital cutting".)

DEEP DYSPAREUNIA (PROXIMAL SEXUAL PAIN) — Proximal FSP refers to deep vaginal, uterine, or pelvic pain related to sexual activity. Gynecologic conditions as well as their treatments may be associated with deep dyspareunia. These include, but are not limited to (table 1):

Endometriosis – Endometriosis can contribute to proximal FSP through multiple mechanisms including dysmenorrhea, deep infiltration of surrounding organs (eg, bowel, bladder), endometriomas, and vascular changes [66-69]. (See "Endometriosis: Clinical features, evaluation, and diagnosis", section on 'Clinical features'.)

Adnexal masses – Individuals with adnexal masses, both benign and malignant, can present with proximal FSP. (See "Approach to the patient with an adnexal mass", section on 'Clinical presentation'.)

Pelvic inflammatory disease or other abdominopelvic infections (eg, appendicitis, rectovaginal abscess) – Infections can contribute to FSP from active inflammation and vascular change or following infection as a result of adhesion formation [70].

(See "Pelvic inflammatory disease: Clinical manifestations and diagnosis", section on 'Symptoms'.)

(See "Postoperative peritoneal adhesions in adults and their prevention", section on 'Clinical presentations and diagnosis'.)

Uterine fibroids (leiomyomas) – While uterine fibroids are not typically painful, they can cause FSP if they degenerate or distort anatomy. (See "Uterine fibroids (leiomyomas): Epidemiology, clinical features, diagnosis, and natural history", section on 'Painful intercourse'.)

Myofascial pelvic pain syndrome (MPPS) – MPPS is a source of chronic pelvic pain that can result in dyspareunia as well as other pelvic floor dysfunction [42]. (See 'Vaginismus and myofascial pelvic pain syndrome (MPPS)' above.)

Malignancy – Gynecologic cancers can cause FSP as can their treatments, including surgery, radiation therapy, traditional chemotherapy, and hormone-blocking therapies. (See "Treatment-related toxicity from the use of radiation therapy for gynecologic malignancies", section on 'Vagina'.)

Surgery for the above conditions – Hysterectomy for any indication can cause proximal FSP. Mechanisms include shortened vagina [71], neuropathic pain [72], granulation tissue, or pelvic or vaginal adhesions.

OTHER CONDITIONS CONTRIBUTING TO INCREASED PAIN — FSP can be a symptom of both distal and proximal pelvic pain syndromes, including (table 1):

Chronic female pelvic pain – Chronic pelvic pain can result from pathology of a specific organ system, a chronic pain syndrome that involves central sensitization of pain, or both. Regardless of etiology, individuals with chronic pelvic pain can experience FSP as well.

(See "Chronic pelvic pain in nonpregnant adult females: Causes", section on 'Neurologic'.)

(See "Chronic pelvic pain in adult females: Evaluation".)

(See "Chronic pelvic pain in adult females: Treatment".)

Vulvar pain of unknown cause (vulvodynia or vestibulodynia) – Vulvar pain of unknown cause describes vulvar pain of at least three months' duration that has no identifiable etiology and may have associated factors [10]. This diagnosis contrasts with vulvar pain caused by a specific disorder (eg, lichen sclerosus) (table 3). The pain may be localized to a specific area (such as vestibulodynia or clitorodynia) or diffuse and the symptoms may be provoked, spontaneous, or both. The diagnosis is idiopathic and one of exclusion [73].

(See "Vulvar pain of unknown cause (vulvodynia): Clinical manifestations and diagnosis".)

(See "Vulvar pain of unknown cause (vulvodynia): Treatment".)

Interstitial cystitis/bladder pain syndrome (IC/BPS) – IC/BPS is generally characterized by urinary urgency, urinary frequency, and bladder pain in the absence of infection or other identifiable etiologies [74,75]. Pain may extend throughout the pelvis. Individuals with IC/BPS can present with superficial FSP, including vulvodynia, as well as deep pain [76]. (See "Interstitial cystitis/bladder pain syndrome: Clinical features and diagnosis".)

Pudendal neuralgia – Pudendal neuralgia is pain that occurs in the distribution of the pudendal nerve and is typically caused by nerve entrapment, compression, or inflammation [77]. Contributing events include childbirth, surgery, bicycle riding, and musculoskeletal or age-related changes [78]. Diagnosis is based on the Nantes criteria and include pain in the anatomic trajectory of the pudendal nerve that is worsened by sitting but does not wake the patient at night and occurs without objective sensory loss [77]. Pudendal block can be both diagnostic and therapeutic.

Pelvic congestion syndrome – Pelvic congestion syndrome is a vascular cause of pelvic pain, of which FSP can be one symptom [79]. (See "Vulvovaginal varicosities and pelvic congestion syndrome", section on 'Pelvic congestion syndrome'.)

Persistent genital arousal disorder (PGAD) Persistent genital arousal disorder is characterized by "persistent or recurrent, unwanted or intrusive, distressing sensations of genital arousal (eg, feelings of being on the verge of orgasm and of lubrication and swelling, tingling, throbbing, contractions) that persist for ≥3 months and may include other types of genitopelvic dysesthesia (GPD; eg, buzzing, burning, twitching, itch, pain)" [80]. The most common site of distressing sensation is the clitoris, but it can also occur in other genitopelvic regions. PGAD has been broadened to include GPD. As many etiologies can contribute to PGAD/GPD, patients benefit from a biopsychosocial diagnostic and treatment approaches.

PSYCHOSOCIAL CONTRIBUTORS — While the following entities might not directly cause sexual pain, their presence can exacerbate pelvic or sexual pain of any etiology (table 1).

Intimate partner violence — Physical intimate partner violence (IPV), sexual assault, and resultant posttraumatic stress disorder (PTSD) have all been associated with sexual pain [81,82]. Thus, patients presenting with sexual pain should also be screened for remote or current IPV, assault, and PTSD.

(See "Intimate partner violence: Diagnosis and screening".)

(See "Evaluation and management of adult and adolescent sexual assault victims in the emergency department".)

(See "Posttraumatic stress disorder in adults: Epidemiology, pathophysiology, clinical features, assessment, and diagnosis".)

Impact of mental health — The relationship between mental health and chronic pain, including sexual pain, is complex and intertwined. Psychiatric disease is an established risk factor for female sexual dysfunction, including pain [83-86]. It is important to distinguish individuals with primary psychiatric comorbidity from those who are developing secondary mood disorders, including anxiety, depression, or other expressions of psychopathology, in reaction to their sexual pain. (See "Female sexual pain: Evaluation".)

(See "Chronic pelvic pain in adult females: Evaluation".)

(See "Chronic pelvic pain in adult females: Treatment".)

RESOURCES FOR PATIENTS AND CLINICIANS — A membership fee may be required to access the full information from these organizations.

American College of Obstetricians and Gynecologists (ACOG)

The Menopause Society – Provides free information for patients in addition to specialty information for clinicians

International Society For The Study of Vulvovaginal Disease (ISVVD)

National Vulvodynia Association

International Pelvic Pain Society – Provides free patient handouts in additional to specialty information for clinicians

International Urogynecological Association (IUGA) – Provides free patient pamphlets in multiple languages

International Society for the Study of Women's Sexual Health

International Society for Sexual Medicine

American Physical Therapy Association

Society for Sex Therapy and Research

American Association of Sexuality Educators, Counselors and Therapists

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Female sexual dysfunction".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

Basics topics (see "Patient education: Vaginismus (The Basics)" and "Patient education: Dyspareunia (painful sex) (The Basics)")

SUMMARY AND RECOMMENDATIONS

Definition – Female sexual pain (FSP) is vulvovaginal or pelvic pain that is provoked by or exacerbated during sexual contact. Individuals with sexual pain disorders experience genital pain just before, during, or after sexual intercourse or other sexual activities that involve the clitoris, vulva, vagina, and/or perineum. The pain can be mild to severe, generalized or localized, lifelong or acquired, and idiopathic or secondary. Superficial pain is described as anatomically distal while deep pain is anatomically proximal. (See 'Definition and terminology' above.)

Approach to diagnosis – FSP pain has many etiologies; causes can be single or a combined (table 1). The evaluation of individuals with FSP is presented in detail separately. (See "Female sexual pain: Evaluation".)

Briefly, factors for consideration include (see 'Approach to diagnosis' above):

Anatomic location – The pain can be distal, proximal, or both.

Identifiable versus idiopathic FSP – Patients with FSP can be grouped into those with an identifiable cause of their symptoms versus those with idiopathic FSP.

Nongynecologic causes of FSP – FSP can be caused by gastrointestinal, urologic, infectious, and neurologic pathology in addition to gynecologic sources.

Overlap with chronic pain syndromes FSP can be a clinical feature of other chronic pain processes or syndromes, including myofascial pelvic pain, bladder pain syndrome (BPS), and fibromyalgia.

Superficial (ie, distal) FSP – Superficial FSP refers to pain limited to the vulva or vaginal entrance that generally occurs with vaginal insertion or may prevent vaginal insertion. Common causes of distal sexual pain include reduced estrogen levels, decreased lubrication, vulvar pain of unknown etiology, alterations of vaginal anatomy (congenital anomalies, skin diseases, and postprocedure changes), and myofascial pelvic pain syndrome (MPPS). (See 'Superficial dyspareunia (distal sexual pain)' above.)

-(See 'Decreased serum estrogen' above.)

-(See 'Decreased lubrication' above.)

-(See 'Constriction or obstruction of vaginal orifice' above.)

Deep (ie, proximal) FSP – Deep FSP refers to deep vaginal, uterine, or pelvic pain related to sexual activity (during or after penetration and/or deep thrusting). Both gynecologic conditions and their treatments may be associated with deep dyspareunia. These include, but are not limited to, endometriosis, adnexal masses, pelvic inflammatory disease-related changes, fibroids (leiomyomas), malignancy, and procedures or treatments for these processes. (See 'Deep dyspareunia (proximal sexual pain)' above.)

Syndromes of increased pain sensitivity – FSP can be a symptom of both distal and proximal pelvic pain syndromes, including vulvar pain of unknown cause (vulvodynia), MPPS, and persistent genital arousal disorder (PGAD). (See 'Other conditions contributing to increased pain' above.)

Nongynecologic causes of FSP – FSP can have gynecologic and nongynecologic causes, and these can overlap in some patients. In general, causes of chronic pelvic pain (urologic, gastrointestinal, neurologic, musculoskeletal, vascular) can also contribute to FSP (table 2).

Contributors to FSP – The presence of intimate partner violence (IPV) and psychiatric illness may cause or exacerbate sexual pain of any etiology, either directly or indirectly. (See 'Psychosocial contributors' above.)

ACKNOWLEDGMENT — The UpToDate editorial staff acknowledges Robert Barbieri, MD, and Fred Howard, MD, who contributed to an earlier version of this topic review.

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Topic 5409 Version 27.0

References

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