Deep dyspareunia

Specialty: Gynecology and breast.

• Internal pelvic pain during intercourse
• painful deep penetration
• internal painful intercourse

Why it occurs

• Deep infiltrating endometriosis (located in the uterosacral ligaments, rectovaginal septum or pouch of Douglas)
• Acute or chronic Pelvic Inflammatory Disease (PID) with adhesion formation
• Severe diffuse adenomyosis
• Fixed and painful uterine retroversion
• Persistent adnexal mass (such as giant endometrioma or ovarian tension cyst)

Initial workup

Detailed bimanual gynecological examination to evaluate uterine mobility (a fixed and painful uterus suggests adhesions or endometriosis) and look for selective pain on palpation of the vaginal fornices or uterosacral ligaments. High-resolution transvaginal ultrasound to assess uterine (adenomyosis, fibroids) and adnexal status. Magnetic resonance imaging of the pelvis to detect deep foci of endometriosis.

Standard management

• Ibuprofen 600 mg or Naproxen 500 mg orally administered prophylactically 1 or 2 hours before planned sexual relations — if the pain is mild and positional
• Continuous oral contraceptives to reduce local inflammation if it is associated with endometriosis
• If active Pelvic Inflammatory Disease is confirmed: Ceftriaxone 500 mg intramuscularly in a single dose associated with Doxycycline 100 mg orally every 12 hours for 14 days (note: re-educate in the use of coital positions that limit the depth of penetration to relieve immediate mechanical symptoms).