Women's Sexual Function and Dysfunction. Irwin Goldstein MD

Physical examination in female sexual dysfunction

Elizabeth Gunther Stewart

Introduction

When a woman has found the courage to speak up about sexual dysfunction, the problem is unlikely to be a new one. Women vainly await spontaneous regression, and try available modalities to achieve resolution. Reassurance for them at this point will come only from adequate history and examination. Scheduling time for thorough investigation or referring to an experienced colleague will address their concern. The physical examination is key in identifying physical abnormality underlying female sexual dysfunction.

History factors that influence physical examination

General influences on the physical examination

The physical examination should be tailored to the chief complaint, to rule out a physical reason for dysfunction in desire, arousal, and/or orgasm, and to search for a physical cause of irritative symptoms or pain. The examination should focus on specific areas elucidated in the history of the present illness, such as meticulous evaluation of the skin if pruritus interferes with sexual function, or careful examination of the abdominal wall and bimanual evaluation of pelvic organs if deep dyspareunia is the complaint. By the end of a patient’s history, the clinician should have a reasonable idea of what the diagnosis may be. Hence, time spent taking a careful history (see Chapters 9.2 and 9.4 of this book) is invaluable.

The physical examination addresses problems in communication. Unable to use the proper anatomic descriptor, a patient needs to point out the location of the problem. When she has difficulty communicating what “inside” means to her, the examination distinguishes the vulvar vestibule from an endovaginal or endopelvic locus. Table 9.5.1 covers history information that will help direct the physical examination when pain is the source of the dysfunction.

Specific history influencing the examination

In women under the age of 50 years, vestibulodynia is the leading cause of superficial dyspareunia.1 A total of 56% of women over the age of 50 years experience dyspareunia as a result of atrophy,2 whereas premature ovarian failure can occur at any age from the teens to age 40.

It is important to note the duration of dyspareunia. If painful intercourse has persisted since sexual activity commenced, the physician must consider the possibility of a congenital anomaly, female circumcision, or vestibulodynia, in addition to any psychosexual issues. Acquired dyspareunia has multiple etiologies.

Cyclical discomfort can suggest Candida or endometriosis. Seminal plasma allergy can manifest as itching and burning immediately on penetration or with ejaculation. Discomfort with certain partners suggests a possible problem with the relationship, although this does not rule out a physical etiology. These differences in presentation require that the clinician be attentive to the timing of the dyspareunia.

The discomfort may be located superficially or deep. Superficial pain suggests dermatitis or dermatosis, vaginal infection, or vulvodynia. Deep dyspareunia may represent a painful focus in the abdominal wall, pelvic pathology, or impaction against the cervix.

Table 9.5.1. History questions that direct the physical examination when pain causes dysfunction3

Question to patient

Information obtained

Physical diagnosis to consider

When do you feel the pain?

Timing of dyspareunia

 
 

Arousal: pain with increased blood flow

Vestibulitis, clitorodynia, vulvodynia

 

Foreplay: pain with touching

Vestibulitis, vulvodynia, Candida. albicans

 

Penetration: pain on entry

Vestibulitis, lichen planus, lichen sclerosus

 

Throughout: pain from start to finish

Vulvovaginal diseases, mixed pain of vestibulitis and vulvodynia

 

Postcoital: itching, burning, stinging,

C. albicans, contactant (lubricant, latex, spermicide),

 

soreness, and edema develop after sex

seminal plasma allergy, dermatitis, vestibulitis, vulvodynia

Where do you feel the pain? (probably

Location of the discomfort

Pelvic dyspareunia versus lower genital dyspareunia

need to have patient point during

Abdominal wall

Trigger point from intra-abdominal disease,

examination)

 

abdominal wall muscle

 

Uterus, adnexal

Pelvic: endometritis, adenomyosis, large posterior fibroid, pelvic inflammatory disease, endometriosis, adnexal pathology

 

Clitoris, labia, perineum

Lower genital: clitorodynia or clitoral lesion, dermatitis, dermatosis, vulvodynia

 

Vestibule

Lower genital: vestibulitis, dermatitis, lichen sclerosus, lichen planus, lesion, Bartholin pathology, atrophy

 

Vagina

Lower genital: vaginitis, lichen planus, lesion, levator hypertonicity, vulvodynia, atrophy

What is the discomfort like?

Itching

Seminal plasma allergy with penetration or postcoital latex allergy if condom used, C. albicans, LSC

 

Resistance, “hitting something"

Rectocele with stool, pelvic floor muscle hypertonicity, cervical contact

 

Sharp pain, ripping

Vestibulitis, synechiae of LS, LP, fissuring

Does discomfort occur at other times?

Pain only with sex

Vestibulitis

 

Symptoms at other times

Vulvar disease, vaginitis, vulvodynia

What have you tried for help?

Successful aids give clues to pathology

Estrogen relieves atrophy

Topical steroids treat dermatitis, dermatosis

Fungal suppression controls recurrent or cyclical

candidiasis

LSC = lichen simplex chronicus; LS = lichen sclerosus; LP = lichen planus.

Planning tactics before the pelvic portion of the physical examination

If this is the first pelvic examination for a young woman, the value of adequate education beforehand by the health-care professional or one of the staff must not be forgotten. Some women have had negative experiences with pelvic examinations or may not be able to tolerate a pelvic examination because of psychosexual issues. Asking about previous experience with this examination and taking measures to reduce anxiety and discomfort give the patient control over the experience. Use of premedication or the presence of a support person may be helpful. Other considerations may be a contract with the patient to stop the examination if requested, or the use of a pediatric speculum. This may allow full cooperation with a complete evaluation. Occasionally, the pelvic examination may need to be scheduled for performance under anesthesia or deferred until desensitization with a sexual therapist has been achieved.

The physical examination should be scheduled carefully. It is ideal to avoid menses. If physical symptoms are part of the problem, it is helpful to see a patient when it is flaring up. If there is dysfunction that occurs at a specific time, such as midcycle dyspareunia, the examination should be scheduled at that time. Patients with postcoital complaints may need instructions to have intercourse just before the examination. Otherwise, patients should be instructed not to have intercourse or douche for 24 h before the examination, and to discontinue 2 weeks before it all topical preparations applied to the vulva and all oral and topical antifungal medications.

Such scheduling can be challenging and may require two visits: one to start on the history and examination, and another during the worst symptoms while medication free.

The physical examination

Purpose of the examination

The goals of the examination for a woman with sexual dysfunction are to detect pathology, educate the woman about normal anatomy and physiology, and, if pain is a feature, reproduce and localize the pain.

The examination consists of the general examination with focus on the specific points listed below, the abdominal examination, the detailed pelvic examination including a rectovaginal examination, and any indicated diagnostic studies.

Step-by-step discipline is important, since omission of steps or a change in the order can lead to a missed diagnosis or obscured clues. The progression of steps also reserves the least comfortable parts of the evaluation for the end of the examination.

Step one: general examination

The practitioner should look for physical signs of diseases that may lead to sexual dysfunction. The following systems should be examined for each new patient.

Constitutional

Weight loss or gain from diabetes: with vascular disorder or chronic candidiasis (failure to arouse, anorgasmia, or dyspareunia), depression (low desire, libido-reducing drugs), anorexia (amenorrhea, low estrogen), or thyroid disorder (low desire).

Oral cavity

 lacy white reticules, cherry red gingival erosions from: lichen planus (dyspareunia)

 aphthae (also found on the vulva)

 cold sores (herpes simplex virus 1, HSV-1, can be transferred to vulva).

Integumentary

 acne, rosacea: treated with antibiotics leading to candidiasis (dyspareunia)

 psoriasis on extremities: often accompanied by vulvar lesions

 purple polygonal plaques: lichen planus may accompany the vulvovaginal gingival variant of lichen planus (dys- pareunia)

 white patches: lichen sclerosus

 scaling patches: eczema (common on vulva)

 spiders, palmar erythema: alcoholism (low desire, anorgas- mia).

Cardiovascular

Hypertension, output failure: cardiovascular disease (medications altering sexual function).

Pulmonary

Wheezing, diminished breath sounds: asthma, frequent antibiotics or steroids that cause candidiasis (dyspareunia); chronic obstructive pulmonary disease: fatigue (low desire).

Hepatic

Spiders, palmar erythema, hepatomegaly: alcoholic cirrhosis (low desire).

Breast

Lumpectomy or mastectomy: breast cancer, altered body image, chemotherapy with ovarian failure, low estrogen (low desire, dyspareunia). Tamoxifen can estrogenize the vagina and lead to chronic candidiasis (dyspareunia).

Kidney

Renal failure, dialysis (low desire).

Endocrine

 vascular abnormality, painful neuropathy: diabetes (candidiasis, anorgasmia, dyspareunia)

 goiter: hypothyroidism (low desire, orgasm)

 tachycardia, exophthalmos: hyperthyroidism: (low desire)

 pigment changes: Addison’s disease (orgasm)

 trunkal obesity, buffalo hump, striae: Cushing’s disease (orgasm, dyspareunia)

 short stature, webbed neck, ovarian failure: Turner’s syndrome (orgasm, dyspareunia)

 amenorrhea, atrophy: premature ovarian failure, hypoestro- genism (low desire, dyspareunia)

 galactorrhea: hyperprolactinemia: (low desire).

Neurologic

 seizures: epilepsy (medications inhibit desire)

 paraplegia, hemiplegia, painful spasticity: cerebrovascular accident (mechanical difficulty with intercourse)

 weakness, paralysis: multiple sclerosis (possible association with vulvodynia).

Connective tissue

 joint inflammation: arthritis (pain restricting movement)

 dry eye, mouth: Sjogren’s syndrome (vaginal dryness)

 skin, muscle, joint abnormality: lupus (vulvar lesions, steroids promoting candidiasis).

Step two: abdominal examination

The physician should palpate the abdominal wall with attention to any tender area the patient points out. Such painful spots can represent myofascial injury, or trigger points for pain referred from intraperitoneal disease within the abdomen or pelvis. If these areas are still tender to palpation as the patient flexes her abdominal wall muscles (by raising her shoulders off the table), the source is probably the muscle itself.

To identify deep tenderness, mass, or bladder tenderness, deep palpation of the lower quadrants should be performed.

Step three: the pelvic examination

The pelvic examination involves systematic evaluation from the external to the internal genitalia. There are six sequential steps to the pelvic examination. First the physician should inspect and palpate the mons, labia majora, and perineum, progressing to the labia minora, prepuce, and clitoris, and then the urethra, vestibule, and introitus. Table 9.5.2 lists the physical causes of dyspareunia, the location affected, and the specific condition and associated history.

Next, the health-care professional should perform the Q-tip test, as illustrated in Fig. 9.5.1. This should be followed by a single-digit examination. Then the physician should do a speculum examination of the vagina and collect specimens. A bimanual examination should be performed, followed by a rectovaginal examination.

Vulvar inspection

Anatomy

Vulvar anatomy, especially the prepuce and labia minora, can be silently or symptomatically altered by disease. Only careful inspection will reveal synechiae of the labia minora anteriorly and/or posteriorly, which can narrow the introitus to cause painful intromission. Fusion of the prepuce buries the glans clitoris, sometimes reducing sexual response, although this occurs often without symptoms.

During this portion of the examination, it is ideal to use a large mirror to inform the woman about normal anatomy or abnormal findings.

The physician should use gentle palpation to confirm the presence of the elastic retractable clitoral hood or prepuce. Scarring of the hood to the glans clitoris or fusion of the hood over the glans (phimosis) is a classic symptom of lichen sclerosus or lichen planus (in rare cases, pemphigus) and should prompt a search for other lesions posteriorly on the vulva. The skin on or near the prepuce should be examined for subtle white reticules of lichen planus (see Fig. 12.2.11, Chapter 12.2).

The glans clitoris should be checked to confirm that it is normal. With the prepuce gently retracted, the glans clitoris should be inspected for masses or lesions of lichen sclerosus or lichen planus under the hood. The physician should palpate the glans through the prepuce for a mass. The area should be examined for periclitoral fissures or small erosions. Vulvodynia can cause clitoral or periclitoral pain without any physical findings. Hypertrophy of the glans (>1 cm) should prompt a workup for excess androgens, but is not usually a cause of pain.

Figure 9.5.1. The Q-tip test.4 Original drawing courtesy of Dawn Danby and Paul Waggoner.

Table 9.5.2. Differential diagnoses for physical causes of dyspareunia5

Location affected

Specific condition

Important history

Source of dyspareunia

Comments and caveats

Vulva and vestibule

Dermatitis (eczema)

Atopic history, other eczema

Erythema, scaling, fissuring

Look for Candida also

 

Dermatosis: lichen

Itching, recent or lifelong,

Fissures, ulceration,

Look for Candida also

 

sclerosus

soreness, possibly no symptoms

scarring

 
 

Dermatosis: lichen planus

Itching, irritation, burning

Erosions, ulcers, scarring

Many drugs exacerbate

 

Ulcerative disease: herpes

Episodic outbreaks

Ulceration varying in size,

Behçet's disease very rare,

 

simplex or zoster,

 

tenderness

involves oral ulcers, uveitis,

 

chancroid, GI, aphthae,

   

other systems

 

Behçet's disease Labial hypertrophy

Irritation with physical activity

Elongation of labia

Look for vestibulitis

 

Female circumcision

Ethnicity and country

Absence of clitoris and

 
   

of origin

prepuce, labial fusion

 
 

Generalized dyesthesia

Episodic or virtually

Often no findings; or

Long history of unsuccessful

 

(Vulvodynia)

constant burning,

erythema and edema,

UTI, yeast, BV treatments

   

stinging, soreness

areas of hyper- or

 
   

irritation, rawness

hypo-esthesia

 
 

Radiation

History of gynecologic or

Pallor, alopecia, loss of

 
   

urinary tumor

elasticity

 

Urethra and bladder

Urinary tract infection

Dysuria, frequency, urgency

Tenderness over bladder

Sx with negative cultures suggests vulvodynia

 

Urethral diverticulum

Dysuria, dribbling, pain with penetration

Urethral tenderness, mass

 
 

Interstitial cystitis

Pelvic pain, dysuria,

Tenderness over bladder,

Look for vestibulitis

   

urgency, frequency,

along anterior vaginal

 
   

nocturia

wall

 

Vestibule and vagina

Atrophy: low or absent

Dryness, irritation, hx

Reduction in labial size,

Can occur at any age

 

estrogen

breast feeding, oligo/

mucosal color and textural

 
   

amenorrhea, low

change, fissures; elevated

 
   

estrogen/high androgenic

vaginal pH, atrophic wet

 
   

OCP, depo-Provera, anorexia, exercise, chemotherapy, radiation, BSO, premenopausal tamoxifen, aromatase inhibitors

preparation

 
 

Vulvovaginitis: Candida

Antibiotics, steroids,

Itching, erythema, edema,

Look for superimposed

 

albicans

estrogen,

discharge, fissures; or

vestibulitis

   

immunosuppression

few sx

 
 

Desquamative

Irritative sx, profuse

Erythema, sheets of wbc,

Atypical Pap. Look for

 

inflammatory

discharge

parabasals, no lactobacilli

vestibulitis

 

Vulvovaginitis:

Itching, discharge, or

Mobile trichomonads; plus

 
 

Trichomonas

few sx

culture

 
 

Bartholin cyst or

Swelling and pain

Cystic mass at base of

 
 

abscess

 

vestibule

 
 

Seminal plasma allergy

Itching on entry or

Edema and erythema

Trial of condom helps

   

ejaculation

after coitus

 
 

Dermatosis: lichen

Itching or no symptoms

Fissures, scaring around

Candida, vulvodynia

 

sclerosus

 

introitus

 
 

Dermatosis: lichen planus

Itching, burning, discharge

Erosions, ulceration, scarring

As above, atypical Pap

 

Inadequate lubrication,

Poor sexual technique,

Dryness, tenderness

No good test for lubrication;

 

dryness

sexual dysfunction,

 

hard to judge on examination;

   

Sjogren's syndrome, OCP, medications, vestibulitis

 

history important

Table 9.5.2. (Continued)

Location affected

Specific condition

Important history

Source of dyspareunia

Comments and caveats

 

Radiation

History of gynecologic or

Pallor, loss of elasticity,

 
   

urinary tumor

scarring

 

Vestibule only

Vestibulitis

Pain mainly with

Tenderness on touch or

Easily missed without Q-tip

   

penetration, tampon or speculum

pressure, erythema

testing

Perineum and anus

Episiotomy

Vaginal delivery with episiotomy

Nonhealing, tenderness

 
 

Dermatitis (eczema)

Itching, irritation

Erythema, edema, fissuring

Look for Candida

 

Inflammatory bowel:

Diarrhea, bleeding, pain

Edema, tags, fissures,

May precede bowel sx

 

Crohn's disease

 

sinuses

 

Rectum

Rectocele

Sensation of vaginal

Protrusion of stool-filled

 
   

obstruction

rectum

 

Vagina

Pelvic floor hypertonus

Aching pain, vaginismus

Levator spasm on palpation

 
 

Congenital anomaly: vaginal agenesis, imperforate hymen

Inability to be penetrated

Absent vagina, absent hymen

 

Pelvis

Retroverted or prolapsed

Pain with thrusting

Uterine retroversion or

 
 

uterus

 

descent

 
 

Leiomyomata

Pain with thrusting

Tender uterine masses

Uncommon cause of pain

 

Endometriosis,

Cramping, deep

Tender uterus, fixed

 
 

adenomyosis

dyspareunia; history of

uterus, nodules cul de

 
   

menorrhagia,

sac rv septum, adnexal

 
   

dysmenorrhea

tenderness or masses

 
 

Adnexal pathology

Deep dyspareunia, cyclical

Tenderness in adnexa

 
 

Pelvic inflammatory

Chronic pelvic pain, deep

CMT, uterine, adnexal

 
 

disease

dyspareunia

tenderness

 
 

Abdominal wall trigger

Abdominal wall injury or

Myofascial injury or

Tender point on flexion of

 

points

intra-abdominal disease

intra-abdominal pathology

abdominal wall muscle suggests pain from muscle itself

 

Irritable bowel syndrome

Deep dyspareunia

None; or pelvic tenderness

 

GI = gastrointestinal; UTI = urinary tract infections; BV = bacterial vaginosis; sx = symptoms; wbc = white blood cell; BSO = bilateral salpingoophorectomy; OCP = oral contraceptive pill; rv = rectovaginal; CMT = cervical motion tenderness.

The presence of the labia minora must be confirmed bilaterally. Flattening, resorption, and loss of a portion of labia minora posteriorly suggest the existence of lichen sclerosus or lichen planus (see Fig. 12.2.12, Chapter 12.2). Hypertrophy of the labia minora (>5 cm in width) can be a mechanical cause of dyspareunia.

The health-care professional should confim that the introitus is patent in order to rule out a thickened, inelastic hymen or the rare congenital absence of the vagina. In addition to narrowing the opening of the synechiae of the labia minora anteriorly or posteriorly, lichen planus or sclerosus can cause pain on downward retraction or painful fissuring with intromission.

Female circumcision, depending on the type, will significantly alter the genital anatomy. Atrophy associated with normal menopause or premature ovarian failure that may occur at any age may cause flattened labia, thin, dry tissue, and infantile anatomy.

Skin color

The skin should be examined for color and quality. It should be pink, supple, and elastic. Thin, dry tissue is characteristic of atrophy or Sjogren’s syndrome. Epidermal whitening and thickened, lichenified tissue is seen with lichen simplex chronicus, hypertrophic lichen planus, or lichen sclerosus. Whitening and thin inelastic tissue is also characteristic of radiation change. Erythema is a nonspecific finding, but subtle erythema is often seen under the hymenal remnants in cases of vestibulodynia.

Accurate testing for moisture and lubrication does not exist. Careful examination can give clues for atrophy, but only careful history gives information about lubrication.

Epithelial integrity

The skin should be intact. Fissures on any surface or along anatomic margins suggest Candida (see Fig. 12.2.5, Chapter 12.2), herpes, dermatitis (eczema), or dermatosis (lichen planus, lichen sclerosus, or lichen simplex chronicus) (see Fig. 12.2.17, Chapter 12.2) . Flaking of the skin characteristic of eczema is often not seen on the moist vulva, but may be seen on the labia majora. Papules, pustules, and vesicles may represent a variety of disorders. Erosions classic for lichen planus are seen in the vestibule with glassy erythema and denudation of the surface (see Fig. 12.2.12, Chapter 12.2); often these have a white linear or lacy, reticulate border (Wickham’s striae) (see Fig. 12.2.11, Chapter 12.2). Candida and herpes (see Fig. 12.2.2, Chapter 12.2) are leading causes of small ulcerations; aphthous ulcers can also be found (see Fig. 12.2.19, Chapter 12.2). These, like the ulcers of Epstein-Barr infection (see Fig. 12.2.10, Chapter 12.2), can be confused with the ulcers of Behçet’s disease, which are rare and always associated with other lesions, often oral or occular.

It is important to recognize that vulvodynia frequently gives no physical findings.

Vulvar palpation

Palpation should be over the vulva, in the clitoral area, and on the perineum. The physician should take a moistened Q-tip and gently touch over the external vulvar surfaces to rule out a focus of tenderness (Fig. 9.5.1). Women with vulvodynia will often describe such activity as unpleasant (raw, abrasive, like sandpaper), but not painful. Using the fingertips, the practitioner should gently palpate in the clitoral area to rule out painful focus or mass. The hood should be checked again for retraction. Painful scarring at an episiotomy site is a possible cause of dys- pareunia. It should be palpated carefully. Women often indicate that the perineum is the source of pain, but it is actually coming from the vestibule.

If the physician does not evaluate the vestibule but moves immediately to examination by speculum, it is easy to miss any tenderness in the vulvar vestibule. To evaluate vestibular pain, the labia minora should be gently separated and palpated with a moistened Q-tip starting at 12 o’clock and progressing around the vestibular “clock face” within Hart’s line, posterior to hymenal remnants. Tenderness may be diffuse or isolated. The sites of Bartholin ducts and the epithelium at 6 o’clock in the vestibule are often the most tender foci. While atrophy is a frequent cause of dyspareunia, a urethral caruncle is an unusual cause.

Palpation: single digit

The discomfort of the speculum examination and bimanual evaluation may cause enough pain to terminate the examination prematurely, or prevent satisfactory evaluation because the pain caused may render a woman unable to localize her symptoms. For this reason, it is important to perform the singledigit palpation before the speculum examination.

This part of the examination searches for primary or secondary vaginismus. Primary vaginismus from a psychosexual source may manifest as extreme anxiety about the examination, difficulty in assuming and maintaining the lithotomy position, or inability to cooperate, leading to termination of the evaluation. While secondary vaginismus from the repeated pain of vestibulodynia may also manifest as above, it often generates milder anxiety and tensing, with ability to complete the examination, identifying the painful tightness and muscle spasm.

To perform the single-digit palpation, the physician must gently slide a single finger into the vaginal opening and depress the bulbocavernosus muscle, looking for tightness (spasm) and pain. This should be done in the midline, then to the left and to the right. To avoid stimulating the pain of vestibulodynia, the vestibule should be avoided by gentle and slow insertion of the digit in the exact center of the vaginal orifice. Then, to do the evaluation, the finger should be crooked so that only the tip touches the muscle.

Speculum examination with pH determination and sample collection For the patient’s comfort, a warm, well-lubricated speculum should be used. If the woman has pain, a narrow or pediatric speculum may be necessary.

With the speculum opened, apply the pH paper to the upper third of the vaginal wall, just inside the speculum. A normal pH (< 4.5) rules out infection other than by Candida. An elevated pH (> 4.5) is nonspecific and can reflect infection, atrophy, recent intercourse, or bleeding.

The vagina should be evaluated for adequate estrogeniza- tion, inflammation, fissures, erosion, ulcer, and masses. Atrophy manifests first as erythema, and then pallor with flattening of rugae and sometimes petechiae. Lichen planus (and rarely pemphigus) can cause scarring of the vagina, leading to telescoping posteriorly, and eventually causing foreshortening and obliteration.

The discharge should be examined for location, amount, color, and consistency. The appearance of the discharge should not form the basis for diagnosis as this indicator is extremely unreliable.6 Measuring the pH and performing microscopy and other diagnostic studies are essential.

The health-care professional should collect samples of vaginal secretions for wet mount and yeast culture in Sabouraud’s medium; cervical swabs may be sent for gonorrhea, chlamydia, and herpes. Vaginal bacterial culture grows normal commensals, is nonspecific, and therefore is not recommended. A normal pH and wet mount, with lactobacillus dominating the flora, rule out infection.

Before removing the speculum, the physician should rotate it gently to obtain visualization of all portions of the vagina and hymenal ring. Subtle, painful fissures of the ring may be seen only in this fashion.

Palpation: bimanual and evaluation of pelvic floor

Evaluation of the pelvic floor for trigger point tenderness is essential for the evaluation of dyspareunia, but this is not a skill familiar to many physicians. A physical therapist skilled in such assessment can be an invaluable part of the diagnostic team (see Chapter 4.4 on pelvic floor anatomy, and Chapter 12.3 on physical therapy).

The bulbospongiosis and levator vaginae portions of the levator ani that enclose the introitus need to be evaluated. These muscles are readily identified by having the patient squeeze the examining fingers inserted at the orifice. The muscles can then be examined for trigger points by gentle pincer palpation around the opening. Trigger points manifest as tender, taut bands that refer the ache to the vagina and perineum, reproducing the patient’s pain complaint.7

The ischiocavernosus muscle is evaluated by pressing directly laterally from within the distal vagina against the edge of the pubic arch. A trigger point will refer pain to the perineal region.

A simple assessment of the levators and the underlying obturator internus may be achieved if the examiner places two fingers against the lateral wall of the pelvis just beyond the inside margin of the pubic arch over the obturator membrane. The upper finger overlies the anterior portion of the obturator internus while the lower finger palpates the levator ani and the underlying posterior portion of the obturator. Palpate the muscle fiber for tenderness or taut bands indicative of trigger points. Trigger points in both the levator ani and the obturator internus can cause vaginal pain.7

The lower examining hand should then evaluate the fornices and vaginal sidewalls for mass, nodularity, or tenderness. Bladder tenderness is assessed by upward palpation through the vaginal wall and downward pressure over the pubis. A tender mass along the urethra representing a diverticulum may be palpated through the anterior vaginal wall. The uterus and adnexa are then evaluated for masses, tenderness, and mobility.

Rectovaginal examination

Next, the physician should evaluate the anal sphincter tone and rectovaginal septum. Sphincter spasm may be associated with pelvic floor dysfunction; nodularity of the septum is associated with endometriosis. A rectocele filled with stool can interfere with penetration.

Step four: diagnostic studies

Wet mount

For a wet mount, the health-care professional must first mix vaginal secretions with a few drops of saline, cover this with a cover slip, and examine the slide under the microscope. The examiner needs to look for four features, epithelial cells, background flora, pathogens, and white blood cells.

Epithelial cells are large rectolinear, clean-bordered, superficial cells with small nuclei. Smaller oval cells with larger nuclei suggest parabasal cells representing atrophy or inflammation. Borders that are ragged occur with clue cells of bacterial vaginosis.

Background flora should consist mainly of long and short, motile rods representing the lactobacillus. Lack of lactobacilli is not a feature of candidal infection.

Presence or absence of pathogens should be noted. The wet mount is not highly specific; both Candida albicans and Trichomonas may be present in the vagina but are not seen on wet mount. Trichomonads must be motile. Addition of potassium hydroxide (KOH) to the secretions eliminates cells and allows better evaluation for Candida. Hyphae of C. albicans have smooth, parallel borders. They are opalescent, and spores can be seen within the hyphus, budding off the sides or ends, or adjacent and free. If yeast or trichomonads are not seen, only specific cultures rule out these infections. A negative KOH does not rule out Candida.

Multiple white blood cells are present when there is more than one white blood cell per epithelial cell. The finding is nonspecific and can represent vaginal infection with yeast or Trichomonas, inflammatory vaginitis, or lichen planus, cervicitis, gonorrhea, herpes, chlamydia, fistula, or upper tract disease, and possibly allergy.

Cultures

Material for cultures must be obtained at the time of speculum examination.

Biopsy

A biopsy can be an important diagnostic test to rule out dermatitis, dermatosis, intraepithelial neoplasia, or neoplasia. Index of clinical suspicion is also important. A review by a dermatopathologist may prove to be invaluable. If a biopsy is negative in a woman with whitening and/or scarring and loss of architecture, lichen sclerosus or lichen planus is likely and needs follow-up and treatment.

Serology

Since hormonal abnormalities are a common cause of sexual dysfunction, a panel of blood tests is indicated in the workup. Basic tests would include glucose and HbA1c, and the appropriate serology to test for any hormone-related condition in question (see Chapter 14.7). Herpes serology is invaluable to rule out the virus as a source of irritative symptoms. Other specialized testing may be indicated.

Special studies

Referral for other testing is dictated by history and clinical findings. Helpful testing may include pelvic ultrasound, magnetic resonance imaging of the pelvis or spine, duplex Doppler ultrasound, biothesiometry, vaginal photoplethysmography, thermal testing, and diagnostic nerve blocks.

Conclusion

With the completion of the workup of history, physical examination, and associated testing, the clinician will have the necessary components to assess the role of a physical problem underlying female sexual dysfunction. Figure 9.5.2 gives a helpful algorithm for the diagnosis of vulvar pain.

Figure 9.5.2. Algorithm for vulvar pain.5

References

1. Meana M, Binik YM, Khalife S et al. Biopsychosocial profile of women with dyspareunia. Obstet Gynecol 1997; 90: 583-9.

2. Jalbuena JR. Atrophic vaginitis in Filipino women. Climacteric 2001; 87: 55-8.

3. Stewart EG. Approach to the woman with dyspareunia. In BD Rose, ed. Up To Date. Wellesley: 2003.

4. Stewart EG, Spencer P. The V Book. New York: Bantam Books, 2002.

5. Haefner HK, Collins ME, Davis GD et al. The vulvodynia guideline.  2005; 9: 40-51.

6. Sobel JD. Overview of vaginitis. In BD Rose, ed. Up to Date. Wellesley: 2003.

7. Simons DG, Travell JG. Myofascial Pain and Dysfunction: The Trigger Point Manual, vol 2. The Lower Extremities. Philadelphia: Lippincott, Williams & Wilkins, 1993: 121-7.