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    Chronic sexual pain: a layered guide to evaluation



    The musculoskeletal structures of the lumbopelvic area intimately affect the PF and may cause pain with sexual activity. Intra-articular hip disorders such as femoroacetabular impingement are common in women and hip evaluation via history and exam is needed.23 Observe gait and routinely perform a provocative test for hip impingement, such as the FABER (flexion, abduction, external rotation) test. The obturator internus, part of the PF along which the PN runs, is a main hip rotator; pain on palpation of this muscle, and at the greater trochanter of the hip, is suggestive of hip dysfunction contributing to painful sex. Also assess for tenderness at the pubic symphysis, coccyx, and sacroiliac joint. Lumbar disc disease and osteoarthritis are common with age, and older women may report pain during sexual activity in positions that stress these conditions. Further evaluation by an orthopedist and PT may be needed.


    It has been recognized for years that deep dyspareunia suggests endometriosis, but clinicians should remember to evaluate for painful PF responses that usually coexist, adding to sexual pain. After endometriosis surgeries, ongoing painful sex is an often-overlooked concern, and hormonal therapies routinely used postoperatively may cause the additional painful consequence of atrophy of genital tissues.

    We now appreciate that sexual pain is a usual component of the 3 main CPP disorders that are often comorbid: endometriosis, interstitial cystitis/painful bladder syndrome (IC/PBS), and irritable bowel syndrome (IBS). IC/PBS causes significant introital pain, as LPV often coexists, as well as urethrodynia. Penetration may also induce severe long-lasting pain flares, as the base of the bladder and the often hypertonic PF are compressed. Include gentle specific assessment for tenderness of the urethra and bladder base in your single digit exam. Similarly, IBS sufferers frequently have PF hypertonicity, as well as defecatory dysfunction and anal fissures.

    A complete evaluation must attend to the possibility of one or more of these overlapping disorders. Further evaluation of complicated pain in several layers includes imaging of the pelvic organs, PF, and lumbopelvic region.


    Body-wide disorders may underlie the development of sexual pain. Three interconnected systems control tissue healing: the endocrine system, the immune system, and the nervous system. Even borderline diabetes can affect sensory nerves in the vulva, just as it causes burning pain in peripheral nerves elsewhere in the body. Consider the possibility of autoimmune disorders, which are common in women, when inflammatory surface changes do not respond quickly to treatment. Conditions such as Sjogren’s, lupus, and connective tissue disorders may affect mucosa, fascia, and small nerve fibers.

    Menopause, whether it occurs naturally or is medically or surgically induced, affects all layers in most women to some degree. We now understand more about how declines in estrogen and androgen may disrupt vulvar and pelvic tissues, due to sex hormone receptors in mucosa, myofascia, and sensory neurons. In some women, menopause triggers LPV, resulting in severe sexual pain and vestibular exam findings similar to those in younger patients.24,25 Topical hormone therapy usually benefits menopausal dyspareunia, and testing baseline and follow-up blood hormone levels is not necessary. But for women who do not respond quickly, re-evaluation for LPV and disorders in other layers is key to a complete diagnosis in menopause, too.

    Centralized pain may occasionally be present as a component of chronic sexual pain.26 Findings suggesting this condition include systemic allodynia, hyperesthesia, and lowered pain thresholds, and comorbidities such as fibromyalgia and chronic headaches. Assembling a team of specialists in neurology and rheumatology for further evaluation of systemic conditions is crucial. Research and experience continue to show the benefits of integrating complementary mind-body therapies into care of complex and systemic pain disorders.27


    Deborah Coady, MD, FACOG
    Dr Coady is Clinical Assistant Professor of Obstetrics and Gynecology at NYU Langone Medical Center, New York.


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