Abstract
Dyspareunia is defined as pain on sexual intercourse. It can affect both sexes, but is more common in females. It is difficult to estimate the number of patients suffering from dyspareunia as the condition is vastly under-reported, but research suggests the point prevalence to be up to 20% of women and 2% of men. It is an important condition requiring prompt assessment, as it can be the cause of emotional distress and relationship disharmony. A range of conditions, many of which are treatable, cause dyspareunia. This article aims to highlight the important causes and their initial management in primary care. An approach to completing an assessment of a patient presenting with dyspareunia is also discussed.
The GP curriculum and dyspareunia
There are three GP curriculum examples relevant to the management of patients with dyspareunia:
Demonstrate knowledge of women’s health problems, conditions and diseases Communicate sensitively with women about sexuality and intimate issues
Manage primary contact with patients who have a male genito-urinary problem Know that men may be both more reticent and less articulate about their health than women, and describe strategies to compensate for this during the consultation Demonstrate a non-judgemental, caring and professional consulting style to minimise embarrassing male patients
Appreciate the definition of sexual health as being about the ‘enjoyment of the sexual activity you want without causing yourself or anyone else suffering or physical or mental harm’ Manage primary contact with patients who have sexual health concerns and problems Manage common as well as rare but important presenting signs and symptoms which will require subsequent examination, investigation, treatment and/or referral, as appropriate (e.g. genital skin/mucosal conditions, abnormal genital smell, discharge, presentations of pain and vaginal bleeding) Perform a sexual health examination including digital and speculum examination, and assessment of the size, position and mobility of the uterus and be able to recognise any abnormality of the pelvic organs Co-ordinate care and make timely, appropriate referrals to specialist services, especially to gynaecologists, sexual and reproductive health specialists, genito-urinary specialists, urologists, specialists in infectious diseases and specialists in sexual dysfunction – knowing the boundaries of what is reasonable and practicable in general practice Understand that sexual health problems have physical, psychological and social effects
The impact of dyspareunia
Dyspareunia can have a devastating effect on patients and their sexual relationships. Painful intercourse can cause poor libido, reduced sexual satisfaction, and avoidance of intimacy and sexual activity. Some patients may feel obliged to partake in painful intercourse, with the aim of maintaining their relationship. It has also been linked to a reduced quality of life and poor emotional wellbeing; patients with dyspareunia have higher levels of anxiety and depression than those without, although it is difficult to prove if these are a cause or an effect of the condition.
Patients often find it difficult to discuss dyspareunia, as it is such a sensitive topic, which might explain why it is under-reported in primary care. Being open and asking patients about it directly if they disclose information about related symptoms (e.g. pelvic or testicular pain) might give them the confidence to confide further. This article discusses an approach to the assessment, management and differential diagnoses of dyspareunia for both female and male patients.
Assessment of women with dyspareunia
History
Characteristics of dyspareunia
Sexual history
Gynaecological and obstetric history
A general enquiry about the patient’s past medical history and medication use should be made. Dermatological conditions such as lichen sclerosus, eczema and psoriasis can affect the vulva as well as other sites. Diabetes mellitus, irritable bowel syndrome (IBS) and Crohn’s disease are all associated with higher rates of dyspareunia. Medications including progestogen-only and combined hormonal contraceptives, aromatase inhibitors, and tamoxifen can cause reduced vaginal lubrication and dyspareunia.
Examination
Before commencing an examination it is important to discuss what it will involve. Reassure the patient that the examination will be stopped immediately if it causes pain. A chaperone should always be offered. Try to ascertain how the patient feels about undergoing examination; if they appear anxious and tense it may be more appropriate to postpone it to a second consultation.
Begin by palpating the abdomen. This may help to put the patient at ease and will allow assessment for suprapubic tenderness and abdominal masses. Move on to inspection of the external genitalia. Look at the vulval skin for signs of ulcers, scars or erythema. Attempt to perform a speculum examination to assess the vagina for loss of rugation or evidence of prolapse. A woman who is unable to tolerate insertion of the speculum may have vaginismus (see below). Finally, gently perform a bimanual examination to assess for: uterine retroversion, enlargement or tenderness; immobility of the pelvic organs; thickening of uterosacral ligaments; cervical excitation; or tenderness on posterior palpation of the rectum - the latter is commonly found in IBS.
Investigations
It is helpful to request a mid-stream urine (MSU) test in all patients to exclude urinary tract infection (UTI). High vaginal and endo-cervical swabs should be performed to look for evidence of STIs in at-risk patients. Transvaginal ultrasound should also be considered in patients with deep dyspareunia, especially if an enlarged uterus or adnexal tenderness is found on examination, as an underlying gynaecological cause is more likely to be causative.
Causes of superficial dyspareunia
Common and important causes of superficial dyspareunia are discussed below. Other conditions that should be considered in the differential diagnosis include diabetes mellitus, Sjögren’s syndrome, use of hormonal medications and pelvic radiotherapy or chemotherapy.
The cause of superficial dyspareunia is identifiable in most patients. Unfortunately, resolution is not always easily achieved. GPs should aim to educate all patients about the condition and offer reassurance that dyspareunia is a common complaint which can be improved in many cases. General advice about wearing cotton underwear and avoiding perfumed products, soaps, panty liners and tight-fitting clothes should be given. The benefit of using vaginal lubricants prior to attempting intercourse should also be discussed.
Lichen sclerosus
Lichen sclerosus is a chronic skin disorder that can affect the anogenital region. It is most commonly seen around the time of the menopause, but can occur in any age group. It causes vulval pruritis (often worse at night), vulval pain and dyspareunia. Examination reveals white thickened plaques, subepithelial haemorrhages, excoriation, or fissuring of the area secondary to intercourse. In more advanced cases there can be distortion of the vulval architecture (Figure 1).
Advanced lichen sclerosus
Treatment is with a highly potent topical steroid (e.g. clobetasol propionate ointment), which patients should be advised to apply once daily for 4 weeks, alternate days for 4 weeks and then twice weekly for 4 weeks (Neill et al., 2010). It is vital to regularly review treatment response; any woman who has unresponsive disease, or in whom there is doubt about the diagnosis, should be referred to secondary care for a biopsy, as in a small number of women the condition can progress to vulval carcinoma.
Lichen planus
Lichen planus is a mucocutaneous condition. It typically affects women who are in their 30 s or older and presents similarly to lichen sclerosus, although it is less prevalent. The appearance of lichen planus varies depending on the site affected. Cutaneous lesions are polygonal mauve papules, whereas mild mucosal involvement shows a white lace-like pattern. With more severe mucosal disease shiny, erythematous erosions may be seen. These bleed easily on contact. Distortion of the vulva can occur, causing narrowing of the vagina and severe dyspareunia.
Milder forms of the disease often do not require treatment, especially if asymptomatic, but symptomatic disease should be managed with potent topical steroids. Referral to secondary care allows confirmation of the diagnosis by biopsy.
Contact dermatitis
Contact dermatitis of the vulva is a common condition. Signs and symptoms include pruritis, burning-type pain, fissuring and superficial dyspareunia. It is typically caused by soaps, sanitary pads, toilet paper, condoms and mucosal irritation with urine or faeces. Examination reveals erythema of the vulval region and lichenification caused by repeated scratching. Treatment involves removing the causative factor and the use of topical steroids or sedative antihistamines.
Genital ulceration
Genital herpes is the most common cause of genital ulceration. It is caused by herpes simplex virus, which in most cases is sexually transmitted. Pruritis and severe burning pain around the genitals are classic presenting symptoms, and there may be systemic symptoms including myalgia and fever on first presentation. The severity of pain may prevent sexual intercourse entirely. The condition is characterised by erythematous papules, vesicles or ulcers on the genitals or upper thighs (Figure 2).
Genital herpes.
Genital herpes requires treatment with an antiviral agent (e.g. aciclovir 200 mg, five times daily) to reduce the severity of a first attack or, if given during prodromal symptoms (tingling, pruritis or pain in lumbo-sacral dermatome), to abort recurrent attacks. If pain is severe, 5% lidocaine ointment can be applied to the affected areas. All suspected first cases of genital herpes should be referred to genitourinary medicine (GUM) on the same day to confirm the diagnosis by viral swab. This will also provide an opportunity to test for other STIs.
Vulval aphthous ulcers can also occur, although these are less common than genital herpes. They present with vulval pain and are caused by viral infection or in response to stress. The ulcers are deep and yellow-based with surrounding erythema. Aphthous ulcers usually self-resolve, but refer to GUM to exclude herpes infection.
Trichomonas vaginalis
Trichomonas vaginalis is a flagellated protozoan that is sexually transmitted. It causes a frothy, yellow, offensive vaginal discharge, dysuria, vulval pruritis and soreness. A high vaginal swab should be taken to test for the organism. Treatment is with metronidazole 400 mg twice daily for 5 to 7 days.
Vulvovaginal candidiasis
Vulvovaginal candidiasis is an infection most commonly caused by Candida albicans. Seventy five percent of women are likely to be infected at least once during their reproductive years (Sobel, 1993); risk factors include diabetes, pregnancy, and the use of antibiotics, hormone replacement therapy (HRT), or the combined oral contraceptive pill (COCP). Symptoms of candidiasis include pruritis vulvae, dysuria, non-offensive vaginal discharge and dyspareunia. It can also be asymptomatic. On examination the vulva may look swollen and erythematous. A white, thick, curd-like vaginal discharge is usually evident (Figure 3). Candidiasis can be treated with topical antifungals, such as clotrimazole cream and pessaries, or systemically with oral fluconazole 150 mg given as a single dose.
Vulvovaginal candidiasis.
Bartholin’s gland abscess
The Bartholin’s glands are situated bilaterally at the base of the labia minora (4 o’clock and 8 o’clock positions) and produce secretions to lubricate the vagina. Infection of the glands can lead to a Bartholin’s abscess (Figure 4). Presentation is typically with vulval pain and swelling, fever and severe dyspareunia. Examination reveals a tender, vulval swelling at the site of the Bartholin’s gland.
Bartholin’s abscess.
Most small abscesses can be managed in primary care with a course of broad-spectrum oral antibiotics and advice about symptomatic relief with warm baths and simple analgesia. Larger abscesses, or those that do not respond to oral antibiotics, require a same-day referral to gynaecology for marsupilisation of the abscess or balloon catheter insertion. Bartholin’s gland abscesses usually affect young women in their 20 s. They are rare in older women; unexplained vulval lumps in this age group should be urgently referred to gynaecology to exclude malignancy.
Atrophic vaginitis
Atrophic vaginitis is the term given to changes to the vulvovaginal region in response to low oestradiol levels. This most commonly occurs around the time of and following the menopause, but similar effects are seen in the postpartum period, breastfeeding, hyperprolactinaemia or during use of anti-oestrogen therapy. Most menopausal women are mildly affected, but up to 47% of this age group develop debilitating symptoms (Stika, 2010). It usually presents with vulvovaginal dryness, dyspareunia, pruritis vulvae and urinary symptoms. Pain may persist following intercourse and there may be bleeding from trauma to the fragile tissues. The vulval and vaginal epithelium usually appears thin, smooth, pale and shiny, and is accompanied by a loss of vaginal volume and lubrication. Fissuring can sometimes be seen secondary to trauma.
Treatment involves the use of vaginal lubricants when the main complaint is dyspareunia, applied before intercourse to combat friction. Vaginal moisturisers can also be used; these need to be applied regularly to provide continuous moisture to the vaginal walls. Topical HRT is another useful option, as it delivers hormones directly to the tissue that is in need. It is administered intravaginally in the form of a cream, pessary, tablet or ring and, as it is topical, can be used relatively safely for long periods. If the woman is also suffering from other menopausal symptoms (e.g. hot flushes or night sweats) it may be more appropriate to consider systemic HRT.
Vaginismus
Vaginismus describes a condition in which there are persistent problems in allowing vaginal penetration with a penis or other object. It is caused by involuntary contraction of the muscles of the lower third of the vagina. There is a large amount of overlap between vaginismus and vulvodynia (see below). Vaginismus may be primary (present from first sexual experience) or secondary, arising after a period of normal sexual activity (e.g. subsequent to sexual abuse or relationship difficulties). Patients often avoid penetrative intercourse completely and usually experience difficulty using tampons or tolerating speculum examination.
Treatment of vaginismus should be adapted according to what the patient would like to achieve. Strategies include muscle relaxation techniques and desensitisation by using vaginal dilators. Depending on local availability it may be possible to refer patients for psychosexual counselling on the NHS, usually through sexual health or mental health services. The charity Relate also offers psychosexual therapy, charging a small fee per session.
Postpartum dyspareunia
Dyspareunia in the weeks following childbirth is common. Signorello et al. (2001) found that 58% of women with mild perineal trauma and 74% of those with a high degree perineal tear complained of dyspareunia shortly after delivery. The rate was still high at 3 months postpartum, but in many cases it had resolved by 6 months. Other risk factors include episiotomy, ventouse or forceps delivery, breastfeeding, primiparity and low mood.
Vulvodynia
Vulvodynia is vulval pain without a clinically obvious dermatological, anatomical, infectious or neurological cause. The pain, which can be severe, is most often of a burning type, but has been described as a sharp, stinging or raw sensation. It is most commonly provoked by intercourse, but use of tampons, tight clothing and activities such as cycling can trigger symptoms, sometimes for days afterwards.
There are two main types of vulvodynia: generalised and localised. Localised vulvodynia affects the vestibule only. In the generalised form the pain can also affect the top of the thighs and labia majora. The diagnosis of vulvodynia is clinical and is one of exclusion. The vulval area may be erythematous on examination, but there should be no other dermatological changes. A referral to gynaecology is usually needed to confirm the diagnosis. As part of the secondary care assessment process sensory mapping may be performed. This involves using a cotton bud to elicit areas of point tenderness of the vulva. The most commonly affected area is the posterior introitus and in many cases abnormally severe pain is provoked in response to gentle stimulation (allodynia).
A trial of local anaesthetic (e.g. 5% lidocaine ointment) before sexual intercourse may be beneficial. If there is no apparent trigger a tricyclic antidepressant can be considered, as these are effective in treating neuropathic-type pain and hypersensitivity (Reed et al., 2007). Non-pharmacological treatments include cognitive behavioural therapy (CBT), vaginal desensitisation with dilators and psychosexual counselling.
Female genital mutilation/cutting
Female genital mutilation (FGM) is defined by the World Health Organisation (WHO) as the ‘partial or total removal of the external female genitalia or injury to female genital organs’ (WHO, 2012). There are four types, ranging from clitoral damage to cutting and repositioning the labia to create a cover over the vaginal opening, leaving only a small space for urination (infibulation). It is illegal in the UK, yet is increasingly seen due to population movement from areas in which it is more commonly practised, such as Somalia, Egypt, Sudan, India and Indonesia.
Superficial dyspareunia arising from tenderness of scar tissue and formation of lacerations during intercourse is a common complaint. Complications of more severe forms of FGM can be managed by carrying out defibulation, a surgical procedure to reopen the fused labia.
Causes of deep dyspareunia
Deep dyspareunia is more likely to have an underlying gynaecological aetiology. The most important causes are discussed below. However, uterine retroversion, uterine leiomyomas, pelvic organ prolapse, IBS, Crohn’s disease and constipation should also be considered as potential causes.
Pelvic inflammatory disease
Pelvic inflammatory disease is infection arising from the lower genital tract that has ascended to cause endometritis, salpingitis, oophoritis, pelvic abscesses or pelvic peritonitis. Simms et al. (1999) estimated the prevalence of PID in reproductive age women in the UK to be 1.7%. The infection is caused by a variety of organisms including Chlamydia trachomatis, Neisseria gonorrhoeae and Escherichia coli. Risk factors include young age, multiple sexual partners and, less commonly, insertion of an intrauterine device or surgical termination of pregnancy.
PID typically presents with dyspareunia, lower abdominal pain, abnormal vaginal discharge, intermenstrual bleeding, postcoital bleeding and, in acute cases, fever. Examination findings include mucopurulent vaginal discharge, cervical excitation, adnexal tenderness and sometimes a tender pelvic mass representing a tuboovarian abscess. A pregnancy test should always be performed to rule out the important differential diagnosis of ectopic pregnancy. Endocervical swabs should be taken to assess for STIs; those with positive results should be referred to GUM to undergo full STI screening. Blood tests including full blood count and inflammatory markers can be useful to support the diagnosis.
Criteria for admission to secondary care for PID
Endometriosis
Endometriosis is estimated to affect between 5 and 15% of women of reproductive age. It is characterised by the presence of endometrial tissue outside the uterine cavity. Dyspareunia occurs in around 79% of affected women, especially if they have uterosacral ligament involvement (Fauconnier et al., 2002). It is usually most severe before menstruation. The pain is thought to arise from direct pressure on the endometriotic tissue during intercourse and pelvic organ immobilisation. Other symptoms of endometriosis include pelvic pain, dysmenorrhoea, infertility, dyschezia and dysuria. Examination often reveals a fixed retroverted uterus and tenderness of uterosacral ligaments. Although transvaginal ultrasound may show adnexal masses suggestive of endometriosis the gold standard diagnostic investigation is laparoscopy, which allows endometriotic lesions to be visualised and biopsies taken. However, if a patient presents with a convincing history of endometriosis it is not essential to refer for laparoscopy.
Medical treatments such as non-steroidal anti-inflammatory drugs (NSAIDS), COCP, medroxyprogesterone acetate or the levonorgestrel-releasing intrauterine system (IUS) can improve symptoms in many cases. Patients that do not respond to these therapies should be referred to secondary care to confirm the diagnosis. These patients can be offered gonadotrophin-releasing hormone (GnRH) agonists, which induce a state of artificial menopause. GnRH agonists can be used short term to improve symptoms but can cause troublesome menopausal symptoms and osteoporosis, thus low-dose HRT should be offered simultaneously. If medical therapies fail, patients can be treated surgically by ablation of individual lesions or by hysterectomy and bilateral salpingo-oophorectomy. The latter should be reserved for those with debilitating symptoms and/or when the woman has completed her family. For a more detailed overview of endometriosis, please see a previous InnovAiT article (Mackintosh et al. 2012).
Adenomyosis
Adenomyosis is estimated to affect approximately 1% of women (Farquhar and Brosens, 2006), predominantly those who are multiparous and in their 30 s or 40 s. It is characterised by the presence of endometrial glands and stroma in the uterine myometrium. Symptoms of adenomyosis include secondary dysmenorrhoea, menorrhagia, dyspareunia, pelvic pain and infertility. Examination sometimes reveals an enlarged, tender uterus. Diagnosis of the condition is difficult and largely clinical, as the sensitivity of transvaginal ultrasound is poor.
Patients may undergo a trial of treatment in primary care for symptomatic relief (e.g. IUS). However, this often fails and thus a referral to gynaecology will be needed for further management (e.g. GnRH agonists). Hysterectomy is usually the only definitive treatment and in most cases the diagnosis is only confirmed post-hysterectomy.
Interstitial cystitis
Interstitial cystitis is a chronic problem affecting the bladder. It is thought to be due to an abnormality of the bladder mucosa and most commonly affects women in their 40 s. It typically presents with pelvic pain relieved by voiding and symptoms of UTI. Dyspareunia is likely to be caused by pressure effects on the bladder; however, intercourse can also trigger flare-ups of urinary symptoms after the event.
Patients should be asked to keep a voiding diary, and testing for genital and urinary infections is recommended. It is also important to consider a referral for cystoscopy to rule out the differential diagnosis of bladder carcinoma. Management is difficult and includes avoidance of bladder irritants such as coffee, alcohol, spices, fizzy drinks and citrus fruits. NSAIDS, antihistamines and tricyclic antidepressants can be helpful, as can pelvic floor exercises, CBT and bladder retraining.
Pelvic congestion syndrome
This is an uncommon cause of dyspareunia associated with postcoital discomfort and pelvic pain, exacerbated by long periods of standing. It is caused by enlargement and slow emptying of pelvic veins. There may be evidence of lower limb or perineal varicosities. Patients should be referred to gynaecology for further investigation.
Assessment of men with dyspareunia
History
A full enquiry covering the characteristics of the dyspareunia is vital in eliciting the cause and gaining an understanding of the impact it is having, both on the individual and their sexual relationships (Box 1). A sexual history (Box 2) will allow assessment of STI risk, and should include discussion about urinary symptoms, which are commonly found in patients with prostatitis. It is important to ask about medications the patient is taking, especially with regards to antidepressants (e.g. venlafaxine), which can cause erectile pain.
Examination
Prior to commencing an examination a full discussion about what it will involve should occur and a chaperone should be offered. Begin with an abdominal examination to assess for tenderness or a palpable bladder. Move on to look at the external genitalia for evidence of ulcers and dermatological conditions (e.g. lichen sclerosus). The penis should be examined for phimosis, Peyronie’s disease and urethral discharge. The scrotum, testes and spermatic cord should be palpated to look for evidence of testicular masses, varicocele, orchitis, hydrocoele, epididymal cyst or inguinal hernia. The examination should be completed with a rectal examination to assess for prostatic enlargement or tenderness.
Investigations
As a minimum, a urinalysis and MSU should be checked to assess for UTI or haematuria. A first-void urine sample or urethral swab should be considered if the patient is thought to be at risk of STIs. An ultrasound of the scrotum and testes may be required if an abnormality is found on examination, although patients who have suspicious testicular masses should be referred to urology as a 2-week wait.
Male causes of dyspareunia
Some of the more common causes of male dyspareunia are discussed below. Other causes include seminal vesicle calculi, pelvic arteriovenous malformation and the use of some antidepressants.
Peyronie’s disease
This is an acquired penile deformity thought to be caused by recurrent trauma to the penis, leading to inflammation and fibrous plaque formation within the tunica albuginae that covers the corpora cavernosa. This process causes deformity of the erect penis. In severe cases a band of fibrotic tissue occurs around the circumference of the penis, causing an hour-glass formation with the distal end of the penis remaining flaccid on erection. Patients complain of pain on erection and intercourse. If deformity is severe intercourse may be impossible. Examination often reveals a palpable fibrous plaque at the site of deformity, most commonly on the dorsal aspect of the penis. Even with no treatment pain often improves after 6 months, so management should be conservative whenever possible. If symptoms are persistent or troublesome a urology referral may be required.
Phimosis
Patients with phimosis have an inability to retract the prepuce over the glans penis. Phimosis is caused by scarring from recurrent balanitis, traumatic retraction of the prepuce, or balanitis xerotica obliterans (BXO). Affected patients usually present with erectile pain and dyspareunia, recurrent UTIs or poor urinary stream. Adhesions can be seen connecting the inner surface of the prepuce with the glans penis. If BXO is causative, a ring of hardened white tissue is usually seen at the penile tip (Figure 5). There may be narrowing of the urethral meatus. Affected patients should be referred to urology for circumcision.
Balanitis xerotica obliterans.
Short frenulum
This condition can be congenital, or secondary to recurrent trauma or infection. There is downward curvature of the erect penis and painful intercourse due to abnormal positioning of the glans. There may also be recurrent tears or thickening of the frenulum secondary to tension and restriction; these may be evident on examination. Affected patients should be referred to urology for circumcision.
Post vasectomy pain syndrome
This is an uncommon condition of unknown aetiology that occurs in less than 10% of patients who undergo a vasectomy. Symptoms may start several years after the procedure. Patients typically complain of orchalgia and dyspareunia, which may be complicated by ejaculatory pain. They may also suffer testicular pain on exertion. Referral for vasectomy reversal, nerve blocks and psychosexual counselling may improve symptoms.
Genital herpes
Male patients can also contract genital herpes. The condition is investigated and managed in the same way as for female patients.
Prostatitis and chronic pelvic pain syndrome
The causative organisms in both acute and chronic bacterial prostatitis are most commonly Escherichia coli, enterococci and Proteus spp, with the infection usually ascending from the distal urethra. Both conditions present with urinary symptoms, including dysuria, frequency, poor urinary stream and, sometimes, retention. There is usually a degree of pain in the perineum, penis or suprapubic region and pain on ejaculation. In acute bacterial prostatitis the patient is generally unwell with fever, myalgia and lethargy; these features are absent in chronic bacterial prostatitis. On rectal examination a tender, warm, enlarged prostate is characteristic, and an MSU usually reveals the presence of white blood cells. Those with chronic bacterial and less severe forms of acute bacterial prostatitis can be managed in primary care with antibiotics. Ciprofloxacin 500 mg twice daily for 4 weeks can be used first line (RCGP Sex, Drugs and HIV Task Group and British Association for Sexual Health and HIV, 2006), although antibiotic choice should be guided by local policies. Patients who are systemically unwell with high fever or tachycardia should be admitted on the same day to urology for intravenous antibiotics.
Chronic pelvic pain syndrome is a type of prostatitis when no evidence of infection can be found. It is thought to have a multifactorial aetiology and is a diagnosis of exclusion. Symptoms are as for chronic bacterial prostatitis but should be present for a minimum of 3 months. Affected patients are generally diagnosed in secondary care and can be treated with antibiotics, alpha-blockers, NSAIDs or tricyclic antidepressants.
Chronic orchalgia
Chronic orchalgia is usually defined as testicular pain present for 3 months or longer. It has many potential causes, including epididymal cyst, hydrocoele, inguinal hernia, orchitis, prostatitis, varicocele and interstitial cystitis. Pain may interfere with daily activities and can occur on ejaculation and/or intercourse. An MSU is needed to rule out UTI. If a testicular abnormality is found on examination further investigation with ultrasound or a urology referral may be required.
If a definite cause is found for the pain it should be treated appropriately. However, in many cases no cause is found and these patients may benefit from a trial of NSAIDs or the application of cool packs to the scrotum. Elevating the scrotum by wearing supportive underwear or placing a folded towel under the scrotum when sitting or lying is useful. Empirical treatment with antibiotics, tricyclic antidepressants or gabapentin can improve symptoms.
Key points
Dyspareunia is a common but under-reported symptom in primary care. It is seen more often in females A thorough assessment is vital to determine the cause of dyspareunia Dyspareunia should be dealt with promptly as it can be the cause of great emotional distress and relationship difficulties Many of the causes of dyspareunia can be managed in primary care, without requiring referral to specialists. Important investigations to consider are genital swabs and MSU
Footnotes
Acknowledgement
We would like to thank Dr Alexa Slade for her help with the writing of this article under the InnovAiT ‘buddy’ scheme.