Synopsis
Distinguish superficial from deep sexual pain and involuntary penetration difficulty, exclude urgent and treatable disease, use trauma-informed examination, and coordinate pelvic, psychosexual and specialist care.
- 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.
Key red flags
Pregnancy with unilateral pelvic pain, syncope, shoulder-tip pain or bleeding needs urgent ectopic-pregnancy assessment.
Fever, purulent discharge, cervical excitation or severe pelvic tenderness can indicate pelvic inflammatory disease or another infection requiring prompt treatment.
An unexplained vulval lump, ulceration or bleeding needs suspected-cancer pathway assessment rather than repeated empirical treatment.
New deep pain with abdominal distension, weight loss, altered bowel habit or postmenopausal bleeding requires investigation for pelvic pathology.
Pain associated with assault, coercion or fear demands private safety assessment and must not be managed as a couple communication problem.
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.
An unexplained vulval lump, ulceration or bleeding warrants suspected-cancer pathway assessment rather than repeated empirical treatment.
Reasoning priorities
Localise superficial, deep, provoked and contextual features while identifying consent and safety concerns.
The pattern narrows causes but mixed pelvic, skin and psychological contributors frequently coexist.
Worked reasoning
An adult has burning at the introitus and involuntary closure during attempted examination.
- Ask about location, triggers, skin and discharge symptoms, bladder and bowel features, trauma, consent and what the patient wants from care.
- Offer inspection and limited examination under the patient’s control, stopping immediately if consent is withdrawn or guarding increases.
- Treat any identified skin, infection or hormonal cause and explain how pain and anticipatory pelvic-floor contraction can reinforce each other.
- Offer pelvic-floor and psychosexual support with optional graded self-directed work, then review function and distress without requiring penetration.
Pain persists after an initial cause has been treated or routine tests are unrevealing.