Several Anatomic Sites, Clinical Factors Related to Deep Dyspareunia

Anatomic Sites and Associated Clinical Factors for Deep Dyspareunia

Paul J. Yong MD, PhD; Christina Williams MD; Ali Yosef MBBCh, MSc; Fontayne Wong BA; Mohamed A. Bedaiwy MD, PhD; Sarka Lisonkova MD, PhD; Catherine Allaire, MDCM

ONLINE: August 1, 2017 – Sexual Medicine



Deep dyspareunia refers to pelvic pain with intercourse and can negatively affect a woman’s sexual function, relationships, and quality of life. Often, it is caused by endometriosis, but it might also stem from contact with other pelvic structures near the vagina, such as the bladder, pelvic floor muscles, cervix, uterus, and adnexa. 

The current study had two goals:  

  • Determine whether tenderness in these areas is associated with the severity of deep dyspareunia and whether each area makes an independent contribution to this pelvic pain
  • Examine possible clinical factors that might be associated with tenderness in these structures. 


Participants included 548 women who were patients at a tertiary referral center for endometriosis and/or pelvic pain. The women were premenopausal, younger than age 50, with no history of hysterectomy or oophorectomy. Also, none had rare causes of deep dyspareunia, such as an anatomic abnormality or active infection.

The women’s mean age was 34.5 years. Their average rating of deep dyspareunia pain was 5.9 on a scale of 0 to 10, with higher scores indicating more severe pain. Fifty-four percent had had a previous surgical diagnosis of endometriosis, and 16% were clinically suspected of having this condition. 

All the women completed questionnaires and underwent a standardized pelvic examination during which a gynecologist palpated anatomic structures to reproduce dyspareunia. Endovaginal ultrasound was used to assess structures that were difficult to reach.

The following structures were evaluated: 

  • Bladder
  • Pelvic floor (levator ani)
  • Cervix and uterus
  • Adnex
  • Cul-de-sac or uterosacral ligaments

Each patient rated the tenderness of each site as absent, mild, moderate, or severe. 

Information on the following potential clinical factors was gathered through patient questionnaires and a review of medical records.  

  • Endometriosis
  • Irritable bowel syndrome
  • Painful bladder syndrome
  • Depression 
  • Anxiety
  • Pain catastrophizing
  • Reproductive history
  • Medical-surgical history
  • Family history  
  • Social-behavioral variables


Anatomic Sites

The researchers found the following rates of tenderness in each anatomic area they assessed:

Anatomic area Percentage of women experiencing tenderness
Bladder 19%
Pelvic floor 28%
Cervix and uterus 31%
Adnexa 38%
Cul-de-sac or uterosacral ligaments 57%

Some of the women had more than one tender anatomic site. Others had none, as this chart illustrates:

Five tender sites 7%
Four tender sites 9%
Three tender sites 12%
Two tender sites 19%
One tender site 29%
No tenderness 24%

Severity of dyspareunia was independently associated with tenderness of the bladder, pelvic floor, cervix and uterus, and cul-de-sac or uterosacral ligaments. This finding led the authors to propose that each site could be contacted during deep penetration and, in turn, lead to deep dyspareunia.

Severity of pain was also correlated with the number of tender anatomic sites. The more tender sites a woman had, the greater her pain. This “[suggests] that the association between the four anatomic sites and deep dyspareunia is cumulative,”the authors wrote.

However, adnexa were not independently related to pain severity, possibly because the ovaries are located farther from the vagina and are not likely to be contacted during intercourse. 

The authors noted that tenderness did not appear to be associated with a woman’s menstrual cycle or amenorrhea. 

Also, women with and without endometriosis had tenderness in the bladder, pelvic floor, and cervix and uterus. “This could account for why women with the same type and location of endometriosis can have wide variability in deep dyspareunia symptoms,” the authors wrote. 

Tenderness of the cul-de-sac or uterosacral ligaments was more common in women with endometriosis. 

Associated Clinical Factors

Clinical associated factors for each of the independently-associated anatomic sites were reported as follows: 

Bladder More severe depression
Painful bladder syndrome
Family history of chronic pain
Younger age
Pelvic floor More severe depression
Younger age
Lower education level
Lower income
Cervix and uterus History of at least one miscarriage
Higher red meat consumption
More pain catastrophizing
Painful bladder syndrome
Cul-de-sac or uterosacral ligaments Endometriosis
Painful bladder syndrome
Family history of chronic pain
Lower level of education

Severe depression (but not anxiety or abuse) was associated with tenderness of the bladder and pelvic floor, but the connection did not appear to be linked to antidepressant usage. Rather, depression itself could worsen pain by affecting genital physiology, the central nervous system, or emotional distress. However, it is important to note that women can develop depression in response to deep dyspareunia, too.


The study findings should be generalizable to women in similar endometriosis referral centers, but not to postmenopausal women or those who had had ahysterectomy, the authors said. 

They acknowledged that assessing only one aspect of the pelvic floor (the levator ani) was a limitation. The fact that not all women had had surgery to assess for endometriosis was another.

The authors recommended further research focusing on the roles of miscarriage, red meat consumption, painful bladder syndrome, and family history of chronic pain. 

In the meantime, these results could “provide a standardized framework” for the diagnosis and management of deep dyspareunia. 

“[C]linicians should be aware that there could be multiple anatomic factors for deep dyspareunia in this population (women with and without endometriosis),” the authors wrote.