Causes and Treatment of Introital Dyspareunia in Sexually Active Women: A Prospective Cohort Study

<jats:p>Background. Dyspareunia is persistent or recurrent pain or discomfort before, during, or after sexual intercourse. Most studies identify provoked localized vulvodynia (PLV) as a principal cause. In this prospective study, however, central introital dyspareunia (CID) was the most frequent cause of introital dyspareunia. Moreover, 70% of cases had multiple concomitant causes, indicating that appropriate management requires a thorough, systematic diagnostic evaluation. Methods. We conducted a descriptive analysis of the differential diagnoses among women presenting with painful intercourse over a 1-year period. All new patients presenting with dyspareunia between October 2019 and November 2020 to clinics for lower genital tract pathology at Femicare and the Regional Hospital of Tienen (Tienen, Belgium) or University Hospital Antwerp (Antwerp, Belgium) were invited to participate. For consenting patients, the physician completed a questionnaire covering demographic characteristics, obstetric history, and the type and severity of pain. A systematic clinical examination, including office microscopy of vaginal fluid, was performed and yielded one or more diagnoses. Six months after a tailored treatment was proposed, participants were invited to complete an online questionnaire about treatment satisfaction. Results. During the 1-year study period, 210 new patients presenting with dyspareunia were included. Participants were 15-73 years old (mean, 37.2 years) and had experienced dyspareunia for a mean of 3.2 years before referral (range, 1 month-20 years). Two-thirds (68.1%) had secondary dyspareunia. Pain was reported most frequently during initial penetration (89.3%), after sexual intercourse (e.g., during urination; 68.9%), or during coital movement (59.7%). Identified causes included severe lateral vulvodynia (29.5%), severe central pain (65.7%), increased pelvic floor muscle tone (37.6%), vulvovaginal infections (28.2%), vaginal atrophy (29.0%), dermatoses (9.5%), scar-related problems (4.3%), and less frequent conditions (rectocele, vaginal septum, or fecal soiling). A single disorder was identified in 24.8% of participants, whereas 70.0% had at least two contributing disorders. At 6 months after treatment, 67 of 78 women (85.9%) reported improved quality of life, and 15 of 78 (19.2%) reported complete resolution of dyspareunia. Conclusions. Dyspareunia is a common medical complaint. Although localized provoked vulvodynia is often presumed to be the principal cause, our findings indicate that central introital dyspareunia is more frequent, affecting approximately two-thirds of patients. Furthermore, the condition was multifactorial in up to 70% of cases. A comprehensive examination is therefore needed to identify the potentially diverse causes before treatment is proposed.</jats:p>