A 24-year-old woman comes to the office due to intimacy issues with her husband. They have been married for a year and have been unable to have sexual intercourse. The husband has had erectile dysfunction for the past 3 months; he says that it is due to his wife experiencing dyspareunia and his fear of causing her more pain. They now attempt intercourse only once or twice a month due to lack of interest. The patient reports no dysuria, urinary frequency, vaginal pruritus, or pain in the perineum. She has no medical problems or previous surgeries. She has regular menses, lasting 4-5 days, with painful cramping on the first day. The patient has been unable to use tampons due to vaginal pain. She has had no previous sexual partners. The patient takes no medications and does not use tobacco, alcohol, or illicit drugs. Examination of the external genitalia shows no lesions and no pain on external touch. An internal pelvic examination is attempted but not completed due to the patient's intolerance. Which of the following is the most likely diagnosis?

Question

A 24-year-old woman comes to the office due to intimacy issues with her husband.  They have been married for a year and have been unable to have sexual intercourse.  The husband has had erectile dysfunction for the past 3 months; he says that it is due to his wife experiencing dyspareunia and his fear of causing her more pain.  They now attempt intercourse only once or twice a month due to lack of interest.  The patient reports no dysuria, urinary frequency, vaginal pruritus, or pain in the perineum.  She has no medical problems or previous surgeries.  She has regular menses, lasting 4-5 days, with painful cramping on the first day.  The patient has been unable to use tampons due to vaginal pain.  She has had no previous sexual partners.  The patient takes no medications and does not use tobacco, alcohol, or illicit drugs.  Examination of the external genitalia shows no lesions and no pain on external touch.  An internal pelvic examination is attempted but not completed due to the patient's intolerance.  Which of the following is the most likely diagnosis?

Quizplus · Accepted Answer

11ec25c8_d9b7_efec_bc81_d749fb78d8c6_MD0003_00 This patient has genito-pelvic pain/penetration disorder, previously known as vaginismus, characterized by pain on and an aversion to attempted vaginal penetration. Genito-pelvic pain/penetration disorder may be limited to primarily a sexual context or include pain with tampon insertion and gynecologic examinations. This condition causes psychological distress and may have an identifiable cause, such as a history of vaginal trauma. The condition is underreported due to significant patient anxiety and avoidance of examinations. Examination differentiates it from other pathologies (eg, infectious vaginitis, vulvodynia) but may be limited as patients often cannot tolerate speculum insertion. Patients have no tenderness on external examination. Treatment is aimed at relaxing the vaginal muscles and includes desensitization therapy and Kegel exercises. (Choice A) Atrophic vaginitis may present with entry dyspareunia, thinning mucosa, and a narrowed vaginal introitus; this is unlikely in a premenopausal patient. (Choice B) Endometriosis may cause deep dyspareunia (eg, internal pelvic pain on penetration), but not insertional vaginal discomfort. (Choice C) Female sexual interest/arousal disorder describes a lack of interest in sexual activity. Although this couple is avoiding intercourse, it is likely due to aversion from anticipated pain rather than a lack of interest. (Choice E) Localized provoked vulvodynia, formerly termed vestibulodynia, is pain to superficial touch on the vestibule. Typically, there is an area of tenderness to touch on external examination. This patient has a normal external examination, making this diagnosis unlikely. (Choice F) Pudendal neuralgia presents as superficial pain located at the vulva, perineum, and rectum (eg, pudendal nerve distribution). This patient has no pain on external examination, making this diagnosis unlikely. Educational objective: Genito-pelvic pain/penetration disorder is characterized by pain on attempted vaginal penetration that precludes sexual intercourse. References: Vaginismus: review of current concepts and treatment using Botox injections, bupivacaine injections, and progressive dilation with the patient under anesthesia. (http://www.ncbi.nlm.nih.gov/pubmed/21556985)

A 24-Year-Old Woman Comes to the Office Due to Intimacy