Assessment And Diagnosis

Once treatable causes for the pain of dyspareunia (e.g., infections, dermatological conditions, sexually transmitted diseases) are ruled out, the pain needs to be carefully characterized. Questions about the location, quality, and temporal characteristics (e.g., When did the pain start? When does the pain occur? How long does it last?) of the pain are crucial to obtain a solid understanding of the pain experienced and may also help in diagnosis. In terms of pain history, many women link the pain onset to their first intercourse experience, but it may actually have long preceded this. Similarly, women with vulvar vestibulitis have been found to describe their pain in a consistent manner (14). Some patients, however, may have limited knowledge of their pelvic/genital anatomy, in which case a diagram is often helpful. It is also important for the physician to try and locate the affected region by attempting to replicate the pain through palpation and/or pelvic examination. This, however, can be a very painful and upsetting experience for the patient, therefore, it is vital to adequately prepare the patient and inquire about the intensity of the pain prior to the examination. If upon examination, pain is experienced, the physician should then determine whether this is the same pain experienced during intercourse. This can be assessed by inquiring about pain location, quality, and intensity during both intercourse and examination. In the case that the gynecologist fails to replicate the pain, it is important to clarify to the patient that the gynecological examination is not the same scenario as the bedroom and that there are many factors that could produce variability in the pain experienced. For example, emotional reactions to the pain may vary; some women may react very strongly by vocalizing and moving away from the painful stimulation, whereas others may "grin and bear it." It is therefore necessary to distinguish between the intensity of the pain and the unpleasantness associated with it, as these two components form separate dimensions of the pain experience. A further assessment of these factors includes inquiring about activities that produce the pain (e.g., different sexual positions, certain kinds of exercise) and assessing the temporal characteristics of the pain (e.g., does the pain vary with menstrual cycle) to name a few. To this end, keeping a pain diary can be extremely informative for both the physician and the patient.

Asking questions about the pain not only provides useful diagnostic information, but is also of therapeutic benefit to the patient by validating her experience, since many times, the pain is the last thing that medical professionals may inquire about, if at all. Asking about past treatments, previous diagnoses, and remedies that helped/worsened the pain are also key in obtaining a complete picture of the problem. Furthermore, careful questioning about how the pain has affected the patient's relationships, sexuality, psychological well-being, and overall quality of life will provide a more thorough understanding of the pain and clarify potential treatment options (e.g., physical therapy, psychological treatment for the pain and/or couple problems).

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