EpistemisIntroital dyspareunia
Specialty: Gynecology and breast.
Why it occurs
- Acute infectious vulvovaginitis (especially candidiasis or trichomoniasis with erythema of the introitus)
- Vulvovaginal atrophy due to hypoestrogenism (menopause or lactation)
- Provoked vestibulodynia (inflammation of the vaginal vestibule of neuropathic or local inflammatory basis)
- Painful episiotomy or stiff scars from previous births
- Hypertrophic imperforate or semilunar hymen
- Vulvar contact dermatitis
Initial workup
Comprehensive vulvovaginal physical examination under colposcope (vulvoscopy) with selective mapping using the "swab test" to delimit areas of exquisite pain in the vaginal vestibule (Bartholin's and Skene's glands). Vaginal smear and culture to rule out candidiasis, bacterial vaginosis and trichomoniasis. Assessment of the stiffness of previous perineal scars.
red flags
Presence of painful ulcers or vesicular lesions suspicious of active genital herpes, chronic fissures that bleed repeatedly in the posterior commissure of the vulva, suspicion of vulvar neoplasia (persistent nodular or verrucous lesion), severe vaginismus that completely prevents physical examination.
Standard management
- Clotrimazole 2% cream applied to the vaginal introitus every 12 hours for 7 days if mycosis is confirmed
- Topical estradiol cream or low-dose vaginal tablets if mucosal atrophy is present
- 2% Amitriptyline cream combined with 2% Baclofen for application in the vaginal vestibule in provoked vestibulodynia
- Local vestibular infiltration with lidocaine and methylprednisolone in specific painful points (note: the systematic use of water-based lubricants should be recommended and soaps that destroy the vulvar lipid mantle should be avoided).
Educational guidance for study. It is NOT a prescription recommendation. The actual choice depends on the cause, the patient, and current guidelines.
- Area
- Gynecology and breast
- Listed causes
- 6
- Treatment options
- 4