Management of Pelvic Pain During Sexual Intercourse with Normal Transvaginal Ultrasound

Initial Assessment After Normal Ultrasound

The American College of Radiology recommends performing a thorough bimanual examination to assess for uterine tenderness, cervical motion tenderness, and adnexal tenderness that may indicate underlying inflammation or infection despite normal imaging 3
Distinguishing between deep dyspareunia and superficial dyspareunia helps narrow the differential diagnosis, according to the American College of Radiology 1, 2
Evaluating for pelvic floor muscle hypertonicity, which can cause pain during intercourse but may not be visible on standard ultrasound, is recommended by the American College of Radiology 4

The American College of Radiology notes that even with a normal transvaginal ultrasound, chronic pelvic inflammatory disease may still be present, as it can manifest with subtle findings or adhesions that are difficult to visualize on standard imaging 5, 6
Pelvic adhesions are notoriously difficult to diagnose non-operatively and may require dynamic ultrasound assessment to document abnormal adherence or lack of mobility of pelvic structures, according to the American College of Radiology 7, 6
The American College of Radiology suggests considering pelvic venous disorders, especially if pain worsens with prolonged standing and improves with lying down 6, 4
Vaginal atrophy, vaginismus, vulvodynia, or pelvic myofascial pain may be underlying causes of dyspareunia despite normal imaging, as noted by the American College of Radiology 2, 4

The American College of Radiology recommends that if symptoms persist despite normal transvaginal ultrasound, MRI pelvis may provide additional anatomic detail and evaluation of soft tissue components 1, 4
MRI enables accurate depiction of pelvic floor muscular anatomy, integrity, and function, which is particularly useful for assessment of muscular hypertonicity in chronic pelvic pain syndromes, according to the American College of Radiology 4
The American College of Radiology suggests including color and spectral Doppler evaluation as part of the standard ultrasound examination to evaluate internal vascularity and distinguish between fluid/cysts and soft tissue 7, 6
A combined transabdominal and transvaginal approach provides the most comprehensive evaluation of pelvic structures, as recommended by the American College of Radiology 5

The American College of Radiology notes that physical examination remains the foundation of clinical evaluation for suspected pathology in the perineum, vulva, or vagina 4
For patients with suspected pelvic floor dysfunction, referral to a pelvic floor physical therapist may be beneficial, according to the American College of Radiology 1, 2
If pelvic venous disorders are suspected, color and spectral Doppler evaluation may document engorged periuterine and periovarian veins, as suggested by the American College of Radiology 6