01Principles and purposeThe professional or clinical skill and the decisions it supports.
Dyspareunia means recurrent or persistent pain associated with sexual activity, but location and timing matter more than the label. Superficial pain at the vulva or introitus can arise from infection, dermatosis, vulvodynia, genitourinary syndrome of menopause, scarring, inadequate arousal or pelvic-floor overactivity. Deep pain can reflect endometriosis, pelvic inflammatory disease, ovarian or uterine disease, bladder pain, bowel disease, adhesions or musculoskeletal pain.
Vaginismus is better understood as involuntary tightening, fear and avoidance around attempted vaginal penetration. The difficulty can affect tampons, examinations or sexual activity differently. It is not deliberate refusal and cannot be diagnosed solely because an examination is difficult. Pain, prior procedures, trauma, beliefs and anticipatory fear can reinforce a cycle of guarding and further pain.
Begin with the patient’s aim and language. Ask whether symptoms occur with touch, insertion or deep movement; whether they are lifelong or acquired, generalised or situational; and whether lubrication, arousal, position or cycle changes them. Include vulval skin, discharge, bleeding, urinary, bowel and pelvic symptoms, medicines, menopause and childbirth. Speak alone when assault or coercion is possible.
A trauma-informed examination starts with an explanation and shared plan. The patient chooses whether to proceed and may inspect the equipment, self-position, use a mirror or stop at any point. Inspection may identify dermatosis, fissure, ulcer, scar or discharge. Cotton-swab mapping, pelvic-floor assessment, speculum or bimanual examination is selected only when its result will change care; no examination should be forced to prove vaginismus.
Investigations follow the differential. Pregnancy testing and early-pregnancy assessment may be time critical. Site-specific STI tests support infection assessment, but negative lower-tract tests do not exclude PID. An unexplained vulval lump, ulceration or bleeding needs suspected-cancer pathway referral; tissue diagnosis is determined in specialist care. Offer transvaginal ultrasound for suspected endometriosis when suitable, but do not exclude endometriosis because examination or ultrasound is normal.
Treatment is layered. Treat infection or dermatosis accurately, address hormonal atrophy where appropriate, and use analgesia for defined pain. Pelvic-floor physiotherapy can teach relaxation, desensitisation and movement. Psychosexual therapy can address fear, communication and trauma responses. Graded dilator work is optional, collaborative and never rushed; penetrative intercourse is not the sole measure of recovery.
Key points
- Ask where pain occurs: introital or superficial pain suggests vulval, dermatological, pelvic-floor or lubrication causes, while deep pain suggests pelvic pathology.
- Vaginismus describes involuntary pelvic-floor tightening and fear or difficulty with attempted penetration; never overcome resistance by force or repeated examination.
- Take a private, inclusive history covering onset, provocation, menstrual and menopausal context, discharge, urinary or bowel symptoms, trauma, consent and pregnancy possibility.
- Offer inspection and examination only when clinically useful and freely consented; a patient may defer, limit or stop any component.
- Treat infection, dermatosis, endometriosis, atrophy or another identified cause and combine pelvic-floor physiotherapy or psychosexual therapy when appropriate.
- Use lubrication, pacing, non-penetrative intimacy and graded self-directed work as options, not requirements imposed by a partner.
- Review unresolved or worsening symptoms and refer for vulval, gynaecological, urological, colorectal, pelvic-health or pain expertise according to the pattern.
02Situations and prioritiesThe context, relevant information and actions that matter most.
Burning, tearing or pain at touch and entry directs assessment towards vulval skin, lubrication, vestibular and pelvic-floor causes.
Pain with deeper penetration, cycle association or pelvic symptoms increases suspicion of endometriosis, infection or structural pelvic disease.
Pregnancy with pain, bleeding, collapse or shoulder-tip pain requires urgent ectopic assessment regardless of a chronic pain history.
Fever, discharge and marked pelvic tenderness supports urgent infection assessment and empirical treatment when criteria are met.
Anticipatory fear and involuntary pelvic-floor contraction can prevent penetration, and force predictably worsens the pain-fear cycle.
An unexplained vulval lump, ulceration or bleeding warrants suspected-cancer pathway assessment rather than repeated empirical treatment.
03Assessment and interpretationHow to gather information, assess the situation and recognise uncertainty.
Consider the information, its meaning and its limitations before deciding what follows.
- 01
Trauma-informed history and pain map - Why
- Localise superficial, deep, provoked and contextual features while identifying consent and safety concerns.
- Interpretation and limitations
- The pattern narrows causes but mixed pelvic, skin and psychological contributors frequently coexist.
- 02
Pregnancy test - Why
- Identify pregnancy when pelvic pain or bleeding could represent an obstetric emergency.
- Interpretation and limitations
- A positive result changes urgency; a very early negative urine test may require serum testing or repeat assessment.
- 03
Vulval and pelvic examination with consent - Why
- Identify dermatosis, fissure, focal tenderness, pelvic-floor overactivity, mass or cervical and adnexal signs.
- Interpretation and limitations
- Use the least invasive useful step; inability or refusal to tolerate examination does not invalidate symptoms.
- 04
Site-specific infection testing - Why
- Detect STI, candidiasis, bacterial vaginosis or urinary infection when symptoms and exposure support testing.
- Interpretation and limitations
- Treat detected disease in context; colonisation or a negative lower-tract test may not explain or exclude upper-tract pain.
- 05
Pelvic ultrasound or specialist imaging - Why
- Assess ovarian, uterine and selected deep pelvic causes when history or examination indicates.
- Interpretation and limitations
- A normal ultrasound does not exclude endometriosis, vulvodynia, pelvic-floor dysfunction or trauma-related pain.
04Worked approachesCases with ordered reasoning, an action and a check of the outcome.
01Worked caseSeparate pain from penetration fearAn adult has burning at the introitus and involuntary closure during attempted examination.+
- 1Ask about location, triggers, skin and discharge symptoms, bladder and bowel features, trauma, consent and what the patient wants from care.
- 2Offer inspection and limited examination under the patient’s control, stopping immediately if consent is withdrawn or guarding increases.
- 3Treat any identified skin, infection or hormonal cause and explain how pain and anticipatory pelvic-floor contraction can reinforce each other.
- 4Offer pelvic-floor and psychosexual support with optional graded self-directed work, then review function and distress without requiring penetration.
02Acute branchExclude urgent pelvic diseaseSevere new deep pain occurs with bleeding, fever, collapse or possible pregnancy.+
- 1Assess observations, pregnancy status, abdominal and pelvic signs and immediate analgesia needs.
- 2Use the ectopic, torsion, pelvic infection or acute abdominal pathway according to findings.
- 3Do not delay urgent referral while attempting a complete psychosexual assessment.
03Persistent symptomsCoordinate multidisciplinary carePain persists after an initial cause has been treated or routine tests are unrevealing.+
- 1Revisit location, dermatology, pelvic floor, bladder, bowel, endometriosis and safety rather than repeating the same tests.
- 2Refer to the discipline matching the dominant unresolved feature and share the patient’s examination preferences.
- 3Set goals around comfort, autonomy and chosen sexual activity, with planned review for new red flags.
05Feedback, follow-up and evidenceReview outcomes, seek feedback and identify what to improve.
- Track pain location, provocation and effect on chosen activities using the patient’s own goals.
- Review response and adverse effects after treating infection, dermatosis or genitourinary syndrome.
- Check that pelvic-floor exercises or dilator work remain voluntary and do not reproduce escalating pain.
- Reassess pregnancy, bleeding, fever, bowel, urinary and vulval red flags when the pattern changes.
- Coordinate referrals so the patient is not subjected to repeated unnecessary intimate examinations.
06Special situationsVariants, exceptions and circumstances that change the usual approach.
Location changes the differential
Entry pain and deep pelvic pain overlap, but they start with different anatomical questions and examination choices.
Guarding is involuntary
Pelvic-floor closure is a protective response that becomes stronger when pain, fear or forced examination is repeated.
Normal imaging has limits
Ultrasound cannot exclude several important pain mechanisms, including superficial vulval and pelvic-floor disorders.
Recovery need not mean penetration
Comfort, agency and desired intimacy are valid outcomes even when penetrative sex is not a current goal.
07Common pitfallsFrequent interpretation and management errors.
- 01
Forcing a speculum examination to confirm vaginismus.
- 02
Assuming all sexual pain is psychological after one normal scan.
- 03
Treating recurrent discharge empirically without confirming the diagnosis.
- 04
Using partner attendance when private assessment for coercion is needed.
- 05
Making penetration or dilator progression the only measure of success.