Taking Sexual History Patients Vulvovaginal Complaints

TAKING A SEXUAL HISTORY IN PATIENTS WITH VULVOVAGINAL COMPLAINTS

Sexual concerns often exist with vulvar pain and disease. It can be awkward to assess these concerns if a practitioner is not sure what or how to ask these problems. The following is recommended as part of the investigation of our patients with vulvovaginal complaints without obvious pathology. It can be more productive if discussion on sexual issues is face-to-face, rather than by questionnaire.

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The rationale for these questions is the identification of the cause and consequences of the patients’ symptoms, without which the treatment is likely to be empirical (treating the symptom not the cause) and possibly counterproductive. Question 1 identifies dyspareunia, which the patient may not mention spontaneously and will require management. Question 2 will help differentiate functional causes (such as levator hypertonia) from pelvic causes such as endometriosis. Question 3 is to identify arousal difficulties which can result in frictional trauma to sensitive genital epithelium, a common contributing cause for presentation. If a woman has no difficulty with orgasm (question 4), a sexual cause of her problem is less likely and this will assist in making the diagnosis. Furthermore, those with orgasmic difficulty are likely to appreciate help with this symptom. Finally, occasionally it will be appropriate to ask question 5, for example when you suspect the patient has been forced into an unwanted relationship.

It may be wise to introduce the subject with:

“Are you currently, or have you been sexually active? (Continue unless the patient denies any sexual activity). It may be that sexual factors are relevant to your symptoms, so I would like to ask you some questions about your sexual experiences as it could help me understand your vulvar symptoms.”

The questions may need modification for cultural reasons and/or the patient’s educational level and your level of rapport with the patient:

1. Do you have pain or discomfort with sexual penetration? If so, has this always been the case?
2. Is your discomfort with sex felt at the opening of the vagina, on deep penetration, or both?
3. Do you use lubricants or have you felt the need to use them?
4. Are you able to achieve a climax with sex?
5. How would you describe your relationship with your partner?