Counseling a Patient with Dyspareunia Prior to Pelvic Examination

Essential Pre-Examination Counseling Elements

The American Academy of Pediatrics recommends explicitly stating that the patient controls the pace and can stop the examination at any point by saying "Wait," "Stop," or expressing discomfort, which is particularly critical for patients with dyspareunia who may have heightened anxiety about genital pain 1, 2
The patient should be encouraged to give continuous feedback during the examination if she is not comfortable, either physically or emotionally, to ensure a safe and respectful experience 1, 2
If the patient does not appear to be tolerating the examination, the examiner should stop immediately and reschedule for another time to minimize negative experiences that could perpetuate pain cycles 1, 2

Patients with dyspareunia should be taught relaxation techniques before beginning the examination, such as pressing on the perineal muscle without inserting a finger and practicing contracting and relaxing that area, which helps with later speculum or finger insertion 1, 2
The patient should be asked to empty her bladder before the examination to minimize pain or discomfort during bimanual palpation 1, 2

The examiner should ensure adequate time is allotted for the examination, which should not be rushed, particularly if this is the patient's first examination or if she has had a previous negative experience 1, 2
Depending on the patient's preference, a trusted female relative or support person may be offered to be present for both the preparation and examination itself, as this can be reassuring 1, 2

The examiner should never force or coerce a pelvic examination, and if the patient is not tolerating it, stop and try again later rather than creating a traumatic experience that will worsen her dyspareunia and avoidance behaviors 1, 2, 3