Assessment of dyspareunia

The normal vaginal pH in women of childbearing age is 4.5. In postmenopausal women, the vaginal pH is generally in the 6.0 to 7.0 range. Elevated pH is seen in bacterial infections, including trichomoniasis, and in atrophic vaginitis. Generally, Candidainfections will present with a normal range pH.

The presence of volatile amines (fishy odour) is not encountered in normal vaginal fluids. The presence of a fishy odour following addition of 10% potassium hydroxide (KOH) to the vaginal sample is suggestive of bacterial vaginosis when accompanied by at least two other Amsel criteria.[26]Amsel R, Totten PA, Spiegel CA, et al. Nonspecific vaginitis. Diagnostic criteria and microbial and epidemiologic associations. Am J Med. 1983 Jan;74(1):14-22. http://www.ncbi.nlm.nih.gov/pubmed/6600371?tool=bestpractice.com [27]Workowski KA, Bachmann LH, Chan PA, et al. Sexually transmitted infections treatment guidelines, 2021. MMWR Recomm Rep. 2021 Jul 23;70(4):1-187. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8344968 http://www.ncbi.nlm.nih.gov/pubmed/34292926?tool=bestpractice.com

Scored in accordance to Nugent classification, which involves counting the bacterial morphotypes.

Would consider if refractory to therapy and no other cause is elucidated.

NAATs are the most sensitive confirmatory test. Amplicons should be typed to determine whether HSV-1 or HSV-2 is responsible for the infection.[15]Centers for Disease Control and Prevention. Genital herpes. Sep 2022 [internet publication]. https://www.cdc.gov/std/treatment-guidelines/herpes.htm

Considered if NAATs are not available. If viral culture is the only available virological test, culture isolates should be typed to determine whether HSV-1 or HSV-2 is responsible for the infection.[15]Centers for Disease Control and Prevention. Genital herpes. Sep 2022 [internet publication]. https://www.cdc.gov/std/treatment-guidelines/herpes.htm

Patients should have tests to exclude vulvovaginitis.

Considered when refractory to therapy and no other cause elucidated.

Confirmatory for endometriomas.[17]National Institute for Health and Care Excellence. Endometriosis: diagnosis and management. Nov 2024 [internet publication]. https://www.nice.org.uk/guidance/ng73 [Figure caption and citation for the preceding image starts]: Ultrasound of ovarian endometriomaFrom the collection of Dr Jonathon Solnik; used with permission [Citation ends].

Direct visualisation of implants at time of surgery and histopathology do not always correlate, since there is no standardised method used by all pathologists, and atypical lesions may be difficult to assess without biopsy.[Figure caption and citation for the preceding image starts]: Laparoscopic image of ovarian endometriomaFrom the collection of Dr Jonathon Solnik; used with permission [Citation ends].

Endometrial biopsies can often be helpful to distinguish adenomyosis from chronic endometritis.

Useful for detecting smaller leiomyomas than ultrasound can identify.

Most important diagnostic test. Should be ordered initially in all patients with a suspected diagnosis.

All patients with irritative voiding symptoms should have urine microscopy and culture to rule out infection.

Patients at high risk of bladder cancer (smokers, exposure to aniline dyes) should have urine cytology.

May guide further antibiotic therapy if presumptive antibiotics are ineffective; best sent prior to administration of antibiotics.

If symptoms resolve with the avoidance of the proposed allergen (seminal fluid), then further testing may not be indicated.

A referral should be made to an allergist. Patients demonstrate positive skin prick testing and/or serum-specific immunoglobulin E to whole seminal fluid or fractionated seminal plasma proteins.[29]Bernstein JA. Human seminal plasma hypersensitivity: an under-recognized women's health issue. Postgrad Med. 2011 Jan;123(1):120-5. http://www.ncbi.nlm.nih.gov/pubmed/21293092?tool=bestpractice.com [30]Sublett JW, Bernstein JA. Seminal plasma hypersensitivity reactions: an updated review. Mt Sinai J Med. 2011 Sep-Oct;78(5):803-9. http://www.ncbi.nlm.nih.gov/pubmed/21913207?tool=bestpractice.com

If symptoms resolve with the avoidance of the proposed allergen, (latex, spermicide), then further testing may not be indicated.

A referral should be made to an allergist for patch testing.

If symptoms resolve with the avoidance of the potential allergens and irritants, then further testing may not be indicated. Included in the trial should be minimisation of drying activities such as excessive cleaning and bathing, and decreasing use of soap, which has a drying effect.

A referral should be made to an allergist for patch testing.

A thin to moderately thick membrane at the opening of the vagina, with or without small perforations, points towards imperforate hymen (potentially with accumulation of menstrual blood in the vagina [haematocolpos]).[Figure caption and citation for the preceding image starts]: Bulging, bluish imperforate hymen with haematocolposBMJ Case Reports 2009 [doi:10.1136/bcr.08.2008.0722] Copyright © 2009 by the BMJ Publishing Group Ltd. [Citation ends].

Any suspicious dermatological abnormality of the vulva should be investigated with histological examination. Pre-cancerous changes and cancer of the vulva must be excluded prior to initiating any treatment for a presumptive dystrophy.

An open consultation style may help to identify psychological causes; the 'LOFTI' (listening, observing, feelings, thinking, interpreting) psychosexual assessment can be a useful guide.[9]Lee NMW, Jakes AD, Lloyd J, et al. Dyspareunia. BMJ. 2018 Jun 19;361:k2341. https://www.bmj.com/content/361/bmj.k2341.long http://www.ncbi.nlm.nih.gov/pubmed/29921565?tool=bestpractice.com [11]Cowan F, Frodsham L. Management of common disorders in psychosexual medicine. The Obstetrician & Gynaecologist. 2015 Jan;17(1):47-53 

Wet prep is diagnostic in 50% to 60% of cases that are confirmed by trichomonal culture.[32]Kelly KG. Tests on vaginal discharge. In: Walker HK, Hall WD, Hurst JW, editors. Clinical methods: the history, physical, and laboratory examinations. 3rd ed. Boston, MA: Butterworths; 1990. https://www.ncbi.nlm.nih.gov/books/NBK288 http://www.ncbi.nlm.nih.gov/pubmed/21250131?tool=bestpractice.com

Cervical cultures for gonorrhoea and chlamydia should be taken when there is a clinical suspicion for cervicitis (e.g., history of deep thrust dyspareunia and vaginal discharge) or PID (e.g., history of deep thrust dyspareunia, fever, diffuse lower abdominal pain).

Consider at first consultation. Non-specific test for infection of medium predictive value that on its own is unlikely to alter management. However, combined with wet mount PMNs and serum erythrocyte sedimentation rate, normal results for all three tests effectively exclude pelvic inflammatory disease (PID).

Consider at first consultation. Non-specific test for inflammatory process that on its own is unlikely to alter management. However, combined with serum WBC count and wet mount PMNs, normal results for all three tests effectively exclude PID.

Consider at first consultation. Presence of vaginal PMNs confirms vaginal infection but test is not specific for pathogens most likely to cause PID. Combined with serum WBC count and erythrocyte sedimentation rate, normal results for all three tests effectively exclude PID.

Nucleic acid amplification testing (NAAT) of genital samples for gonorrhoea and chlamydia is more sensitive than culture and recommended as first-line method of testing in suspected PID. Mycoplasma genitalium is associated with PID and cervicitis; guidelines recommend NAAT of genital samples.[13]Jensen JS, Cusini M, Gomberg M, et al. 2021 European guideline on the management of Mycoplasma genitalium infections. J Eur Acad Dermatol Venereol. 2022 May;36(5):641-50. https://onlinelibrary.wiley.com/doi/10.1111/jdv.17972 http://www.ncbi.nlm.nih.gov/pubmed/35182080?tool=bestpractice.com [14]Centers for Disease Control and Prevention. Mycoplasma genitalium. Jul 2021 [internet publication]. https://www.cdc.gov/std/treatment-guidelines/mycoplasmagenitalium.htm#:~:text=Initial%20empiric%20therapy%20for%20PID,effective%20in%20eradicating%20the%20organism [33]British Association for Sexual Health and HIV. 2018 United Kingdom national guideline for the management of pelvic inflammatory disease. 2018 [internet publication]. https://www.bashhguidelines.org/current-guidelines/systemic-presentation-and-complications/pid-2019

Ultrasound is helpful when the clinical examination suggests presence of an abscess.

Nucleic acid amplification testing (NAAT) of genital samples for gonorrhoea and chlamydia is more sensitive than culture and recommended as first-line method of testing in suspected PID. Culture of Mycoplasma genitalium can take up to 6 months, and is limited to research settings.[14]Centers for Disease Control and Prevention. Mycoplasma genitalium. Jul 2021 [internet publication]. https://www.cdc.gov/std/treatment-guidelines/mycoplasmagenitalium.htm#:~:text=Initial%20empiric%20therapy%20for%20PID,effective%20in%20eradicating%20the%20organism