Guidelines for the physical exam
Before the exam, ensure the patient has not used any topical genital treatment in the past 2 weeks that may interfere with sensitivity to the exam.4 To decrease patients’ anxiety about the exam, remind them that they can stop the exam at any time.7 Also consider offering the use of a mirror to better pinpoint the location of pain, and to possibly help the patient learn more about her anatomy.2,7
Begin the exam by palpating surrounding areas that may be involved in pain, including the abdomen and musculoskeletal features.3,6,19 Next visually inspect the external genitalia for lesions, abrasions, discoloration, erythema, or other abnormal findings.2,3,6 Ask the patient for permission before contacting the genitals. Because the labia may be a site of pain, apply gentle pressure in retracting it to fully examine the vestibule.6,7 Contraction of the pelvic floor muscles during approach or initial palpation could signal possible vaginismus.4
After visual inspection of external genitalia, use a cotton swab to map the vulva and vestibule in a clockwise fashion to precisely identify any painful locations.2-4,6 If the patient’s history of pain has been intermittent, it’s possible that the cotton swab will not elicit pain on the day of the initial exam, but it may on other days.4
Begin the internal exam by inserting a single finger into the first inch of the vagina and have the patient squeeze and release to assess tenderness, muscle tightness, and control.2,6 Advance the finger further into the vagina and palpate clockwise, examining the levator muscles, obturator muscles, rectum, urethra, and bladder for abnormal tightness or reproduction of pain.2,4,6 Complete a bimanual exam to evaluate the pelvic organs and adnexa.2,4 If indicated, a more thorough evaluation of pelvic floor musculature can be performed by a physical therapist or gynecologist who specializes in pelvic pain.2-4
If the patient consents to further evaluation, consider using a small speculum, advanced slowly, for further internal examination, noting any lesions, abrasions, discharge, ectropion, or tenderness.2-4,7 A rectal exam may also be needed in cases of deep dyspareunia.6 Initial work-up may include a potassium hydroxide wet prep, sexually transmitted infection testing, and pelvic ultrasound.2,4 In some cases, laparoscopy or biopsy may be needed.2,4
Treatments for common causes
Treatment often begins with education about anatomy, to help patients communicate about symptoms and engage more fully in their care.3 Additional education may be needed on genital functioning and the necessity of adequate stimulation and lubrication prior to penetration.1,2,9-11 A discussion of treatments for the wide range of possible causes of dyspareunia is outside the scope of this article. However, some basic behavioral changes may help patients address some of the more common contributing factors.
For example, if vaginal infection is suspected, advise patients to discontinue the use of harsh soaps, known vaginal irritants (eg, perfumed products, bath additives), and douches.3 Recommend using only preservative- and alcohol-free lubricants for sexual contact, and avoiding lubricants with added functions (eg, warming).3 It’s worth noting that avoidance of tight clothing and thong underwear due to possible risk for infections may not be necessary. A recent study found that women who frequently wore thong underwear (more than half of the time) were no more likely to develop urinary tract infections, yeast vaginitis, or bacterial vaginosis than those who avoid such items.30 However, noncotton underwear fabric, rather than tightness, was associated with yeast vaginitis30; therefore, patients may want to consider using only breathable underwear.3
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