Family medicine
Dyspareunia
Dyspareunia is recurrent or persistent genital pain associated with sexual intercourse, which can occur in both women and men due to various structural, inflammatory, hormonal, or psychogenic causes.
Murtagh Diagnostic Strategy
| Category | Diagnosis | Key Discriminator | Cantonese Question / Finding |
|---|---|---|---|
| Probability Diagnosis | Vulvovaginal atrophy (postmenopausal) | Postmenopausal + vaginal dryness + superficial pain [1][6] | 「有冇收經？陰道有冇覺得好乾？」(Menopause? Dryness?) |
| Vulvovaginal candidiasis | Itch + white curdy discharge + superficial | 「有冇痕癢、白色豆腐渣樣分泌物？」 | |
| Inadequate lubrication / arousal disorder | Poor foreplay, stress, relationship issues | 「你覺得親密嗰陣有冇足夠興奮同埋濕潤？」 | |
| Endometriosis | Cyclical deep pain + dysmenorrhoea + infertility [4] | 「經期嗰陣痛唔痛？痛係咪深入去嗰種？」 | |
| Serious Not To Miss | Pelvic inflammatory disease (PID) | Deep pain + fever + vaginal discharge + cervical motion tenderness [2][3] | 「有冇發燒、下腹痛、分泌物多？」 |
| Ovarian/pelvic mass (incl. cancer) | Deep pain + palpable mass + bloating | 「有冇覺得個肚脹大咗？有冇摸到硬嘢？」 | |
| Cervical cancer | Post-coital bleeding + abnormal Pap smear | 「親密之後有冇流血？幾時做過子宮頸抹片？」 | |
| Pitfalls | Vaginismus | Inability to tolerate penetration + involuntary muscle spasm, may have hx of trauma [1] | 「有冇試過完全唔可以進入？係咪好似鎖住咗咁？」 |
| Interstitial cystitis / painful bladder syndrome | Chronic suprapubic pain + frequency + pain with full bladder | 「有冇長期下腹痛同埋成日想去廁所？」 | |
| Lichen sclerosus / lichen planus | White patches, introital stenosis, chronic itch | 「外陰有冇變白或者收窄？長期痕癢？」 Exam: whitish plaques on vulva | |
| Masquerades | Depression | Low mood, anhedonia, loss of libido | 「你心情點？有冇失去興趣做嘢？」 |
| Diabetes (autonomic neuropathy) | Known DM + ↓vaginal lubrication [8] | 「你有冇糖尿病？」 Exam: check BG, monofilament | |
| Drugs (OCP, antihistamines, SSRIs) | Temporal relationship to starting medication | 「呢個問題係咪食咗某隻藥之後先開始？」 | |
| Trying to Tell Me Something? | Relationship/sexual dissatisfaction | Partner conflict, avoidance of intimacy | 「你同伴侶之間有冇嘢唔開心想傾？」 |
| History of sexual abuse/trauma | Avoidance, anxiety, primary vaginismus [7] | 「（敏感地問）以前有冇唔愉快嘅經歷影響到你？」 | |
| Fear of cancer / STI / infertility | Health anxiety driving consultation | 「你最擔心嘅係咩？」 |
Minute-by-Minute 6-Minute Consultation
| Time | Task | Cantonese Key Phrases | Why It Scores Marks |
|---|---|---|---|
| 0:00–0:30 | Friendly opening, rapport, set agenda | 「你好，我係X醫生。今日想了解吓你嘅情況，方便嘅話可以同我講多啲。我會問幾個問題，有啲可能比較私人，但係為咗幫到你，希望你唔介意。」 | Greeting + permission + signposting = interpersonal marks. Sets safe tone for sensitive topic. |
| 0:30–2:00 | HPI: pain character, timing, location, superficial vs deep | 「可唔可以形容吓嗰種痛係點樣？」「係一開始入嘅時候就痛，定係深入去先痛？」「幾時開始有呢個問題？」「有冇越嚟越嚴重？」「除咗性行為嗰陣，平時有冇落腹痛或者其他唔舒服？」 | Distinguishes superficial vs deep dyspareunia — the single most important clinical discriminator [1]. |
| 2:00–3:00 | Targeted Hx: menstrual, obstetric, gynae, sexual, discharge | 「你月經正唔正常？有冇經痛？」「有冇異常分泌物、痕癢或者出血？」「有冇生過BB？順產定開刀？」「你同伴侶嘅關係點樣？」「有冇用避孕方法？」 | Screens for endometriosis (dysmenorrhoea), infections (discharge), atrophic vaginitis, relationship issues. |
| 3:00–3:45 | Red flags + PMHx + Drug Hx | 「有冇試過流血量好多？有冇摸到肚入面有嘢脹大？」「有冇長期病、做過手術？食緊咩藥？有冇食荷爾蒙藥或者避孕藥？」 | Screens for pelvic mass, endometriosis, iatrogenic causes (e.g. hormonal). |
| 3:45–4:30 | ICE + Hidden agenda | 「你自己覺得呢個痛可能係咩原因？」(Ideas)「你最擔心嘅係咩？」(Concerns)「你今日嚟最想我幫你做啲咩？」(Expectations)「其實今日點解決定嚟睇醫生？」(Hidden agenda trigger) | ICE directly tested on CRF. Hidden agenda often = fear of cancer, relationship breakdown, fertility concern, history of abuse. |
| 4:30–5:15 | Social & Psych Hx, functional impact | 「呢個問題有冇影響到你同伴侶嘅關係？」「你心情點？有冇瞓得差、食唔落嘢？」「返工方面有冇受影響？」 | Biopsychosocial marks. Depression/anxiety screening. |
| 5:15–6:00 | Summarise, check understanding, safety-net, close | 「等我總結吓：你嘅主要問題係…你最擔心嘅係…你想我…我嘅計劃係幫你做個檢查同埋安排…如果情況惡化，例如劇烈腹痛或者發燒，就要即刻返嚟。有冇嘢想問？」 | Summarising + safety-net + checking understanding = high interpersonal marks. |
Hidden Agenda Strategy: Dyspareunia patients often present with a surface complaint but the real worry may be: fear of cancer, infertility, relationship/sexual dissatisfaction, history of sexual abuse/trauma, or STI anxiety. Ask 「其實今日點解決定嚟睇醫生？」 and 「有冇其他嘢想傾？」 near the end.
| Domain | English Question | Cantonese Question | Why It Matters | If Positive, Think Of |
|---|---|---|---|---|
| Onset & Duration | When did it start? First time or worsening? | 「幾時開始痛？係第一次有定係越嚟越差？」 | Primary vs secondary dyspareunia [1] | Primary → vaginismus, anatomical; Secondary → acquired cause |
| Location: Superficial vs Deep | Does it hurt at the entrance or deep inside? | 「痛係喺入口嗰度，定係深入去先痛？」 | Superficial dyspareunia → vulvodynia, vaginitis, atrophy; Deep dyspareunia → endometriosis, PID, pelvic mass [1] | Superficial → vulvar/vaginal cause; Deep → pelvic pathology |
| Character | What does the pain feel like? | 「痛嘅感覺係點？刺痛、脹痛、灼熱？」 | Burning → atrophy/infection; Aching → endo/PID | Burning = vaginitis/atrophy; Deep ache = endometriosis |
| Vaginal discharge | Any unusual discharge, smell, or itch? | 「有冇白帶多咗、有味、或者痕癢？」 | Screens for vaginitis (Candida, Trichomonas, BV), STI [2][3] | Discharge → infective vaginitis/cervicitis |
| Menstrual Hx | Are your periods regular? Any painful periods? Heavy bleeding? | 「月經準唔準？經期痛唔痛？量多唔多？」 | Dysmenorrhoea + dyspareunia = endometriosis [4] | Endometriosis, adenomyosis, fibroid |
| Post-coital bleeding | Any bleeding after intercourse? | 「親密之後有冇流血？」 | Red flag for cervical pathology (cervicitis, cervical cancer) [5] | Cervical ectropion, cervical cancer, cervicitis |
| Menopausal Sx | Any hot flushes, vaginal dryness, or mood change? | 「有冇潮熱、陰道乾、或者情緒波動？」 | Postmenopausal dyspareunia → urogenital atrophy [1][6] | Atrophic vaginitis |
| Sexual Hx | Number of partners? Condom use? Any STI history? | 「你有幾多個性伴侶？有冇用安全套？以前有冇性病？」 | STI risk → PID, cervicitis → deep dyspareunia [2][3] | PID, gonococcal/chlamydial cervicitis |
| Obstetric Hx | Any pregnancies? Vaginal or C-section? Tears or episiotomy? | 「有冇生過BB？順產定開刀？有冇撕裂或者剪會陰？」 | Scarring, pelvic floor damage | Perineal scarring, pelvic floor dysfunction |
| Psych/Relationship | How is your relationship? Any stress, low mood, anxiety? | 「你同伴侶關係點？最近有冇壓力大、唔開心？」 | Psychosexual cause, vaginismus, history of abuse [7] | Vaginismus, psychosexual dysfunction, somatic symptom disorder [7] |
| Hx of abuse/trauma | (If appropriate) Has anyone ever hurt you or made you do something you didn't want? | 「（如果適合問）有冇人傷害過你，或者迫你做唔想做嘅嘢？」 | Safeguarding; past trauma → vaginismus | Vaginismus, PTSD, psychosexual |
| Drug Hx | Any medications? OCP? HRT? Antihistamines? | 「有冇食藥？避孕藥？荷爾蒙藥？」 | OCPs can cause dryness; antihistamines reduce lubrication | Drug-induced vaginal dryness |
| PMHx | DM, skin conditions (lichen sclerosus), previous pelvic surgery/radiation? | 「有冇糖尿病、皮膚病？做過盆腔手術？」 | DM → ↓vaginal lubrication via autonomic neuropathy [8]; Lichen sclerosus → introital stenosis | DM neuropathy [8], lichen sclerosus, post-surgical adhesions |
| Fertility concern | Are you trying to have a baby? | 「你有冇計劃生BB？」 | Endometriosis/PID → infertility; shapes management | Endometriosis, tubal damage from PID |
| Functional impact | How does this affect your daily life and relationship? | 「呢個問題對你日常生活同關係有幾大影響？」 | Marks for biopsychosocial assessment | Functional impairment → severity |
Case Report Form Answer Builder
- CC: Dyspareunia (pain during sexual intercourse) for [duration]
- HPI must capture:
- Superficial vs deep pain
- Onset: primary or secondary
- Timing: during penetration, during thrusting, or after intercourse
- Associated symptoms: discharge, bleeding (esp. post-coital), dysmenorrhoea, dryness
- Menstrual/menopausal status
- Sexual history: partners, contraception, STI risk
- Impact on relationship and quality of life
- Red flags: post-coital bleeding, fever, pelvic mass
- Examples: "Pain during intercourse affecting her relationship" / "Concerned that pain may indicate a serious gynaecological problem" / "Worried about infertility due to painful intercourse"
- How to phrase: Choose the reason that combines the presenting symptom with the patient's main concern or trigger for attending today. Use the patient's own words if possible.
| Likely Content | Example Wording for CRF | |
|---|---|---|
| Ideas | "I think I might have an infection" / "Maybe it's because I'm going through menopause" | Patient thinks she may have an infection / hormonal problem causing the pain |
| Concerns | "I'm worried it could be cancer" / "I'm scared my husband will leave me" / "I'm afraid I can't have children" | Patient is worried that the pain may indicate cancer / is concerned about effect on her marriage |
| Expectations | "I want tests to find out what's wrong" / "I want treatment to stop the pain" / "I want a referral" | Patient wants investigation and treatment / wants referral to gynaecologist |
Choose based on age, menopausal status, and superficial vs deep:
| Patient Profile | Most Likely Dx | Minimum Supporting Evidence |
|---|---|---|
| Postmenopausal + superficial pain + dryness | Atrophic vaginitis | Postmenopausal status + vaginal dryness + superficial dyspareunia + pale/thin vaginal mucosa on exam |
| Premenopausal + deep pain + dysmenorrhoea | Endometriosis | Cyclical deep dyspareunia + dysmenorrhoea ± infertility + tender nodule in posterior fornix |
| Young + discharge + fever + STI risk | PID / infective vaginitis | Vaginal discharge + fever + cervical motion tenderness + sexual risk factors |
| Inability to penetrate + anxiety/trauma hx | Vaginismus | Involuntary pelvic floor spasm preventing examination/penetration + anxiety |
| DDx | Key Discriminator |
|---|---|
| Endometriosis | Deep dyspareunia + cyclical pain + dysmenorrhoea + tender posterior fornix nodule |
| Vulvovaginal candidiasis | Superficial pain + itch + white curdy discharge + erythematous vulva |
| Vaginismus | Inability to tolerate penetration + involuntary spasm + often psychosocial trigger |
(Adjust based on stem — substitute PID if STI risk, atrophic vaginitis if postmenopausal, etc.)
| Domain | Problem |
|---|---|
| Biological | Underlying cause of pain (e.g. atrophic vaginitis / endometriosis / infection) requiring treatment |
| Psychological | Anxiety about the diagnosis (e.g. fear of cancer); possible depression; avoidance of intimacy; ?history of sexual trauma |
| Social/Functional | Strain on marital/partner relationship; impact on quality of life and sexual function; potential fertility implications |
| Diagnosis/DDx | Best Supporting Physical Sign | How to Elicit | Why It Supports This Dx |
|---|---|---|---|
| Atrophic vaginitis | Pale, thin, dry vaginal mucosa ± petechiae | Speculum examination | Loss of oestrogen → mucosal atrophy → superficial dyspareunia [1][6] |
| Endometriosis | Tender nodule palpable in posterior vaginal fornix | Bimanual exam ± rectovaginal exam | Deeply infiltrating endometriotic deposits in pouch of Douglas [4] |
| PID | Cervical motion tenderness (cervical excitation) | Bimanual exam: gently move cervix side to side | Indicates pelvic peritoneal inflammation from ascending infection [2][3] |
| Vulvovaginal candidiasis | White curdy discharge + vulvar erythema | Speculum exam + cotton swab test | Classic Candida appearance |
| Vaginismus | Involuntary adductor spasm / inability to tolerate speculum | Attempt gentle single-digit vaginal exam | Pelvic floor muscle spasm preventing penetration; no organic pathology found |
| Cervical cancer | Visible cervical lesion (mass, ulcer, friable tissue) | Speculum exam | Abnormal cervical tissue visible on inspection |
| Lichen sclerosus | White, atrophic patches on vulva ± introital narrowing | Visual inspection of vulva | Characteristic "parchment-like" skin changes [9] |
Exam Discriminators and Traps
Top Traps That Lose Marks
- Not asking superficial vs deep — this is THE key discriminator and examiners expect it. Superficial = vulvar/vaginal; deep = pelvic [1].
- Forgetting to ask about menstrual/menopausal status — postmenopausal atrophy is the most common cause in older women.
- Skipping sexual history — embarrassment leads students to omit STI/partner questions. Examiners specifically mark this.
- Not exploring ICE — patients with dyspareunia almost always have a hidden concern (cancer, relationship, fertility, abuse). Marks are lost if not elicited.
- Diagnosing vaginismus without considering organic causes — always exclude physical causes first.
- Missing post-coital bleeding — a red flag for cervical pathology that must be asked.
- Not asking about history of abuse/trauma — sensitively, but it must be explored, especially if vaginismus is suspected.
- Post-coital bleeding + abnormal cervix on speculum → urgent gynae referral (r/o cervical cancer)
- Pelvic mass on bimanual examination → urgent imaging + referral
- Fever + purulent discharge + cervical motion tenderness → treat PID empirically, consider admission if severe
- Suspected sexual assault/domestic violence → safeguarding pathway, involve social worker
「我建議幫你做個檢查，包括睇吓外陰同埋入面嘅情況。之後可能需要抽血或者照超聲波。如果你之後有劇烈腹痛、發燒、或者大量出血，就要即刻去急症室。」
(I'd like to do an examination including looking at the vulva and internally. We may need blood tests or an ultrasound. If you develop severe abdominal pain, fever, or heavy bleeding, please go to A&E immediately.)
High Yield Summary
What to ASK:
- Superficial vs deep? Primary vs secondary? Menstrual/menopausal status? Discharge? Post-coital bleeding? Sexual history? Relationship? Psych? Abuse? ICE?
What to WRITE on the CRF:
- CC: Dyspareunia × [duration], superficial/deep, with relevant associated features
- RFC: Link symptom + patient's main concern in one sentence
- ICE: Ideas (infection/cancer/menopause), Concerns (cancer/relationship/fertility), Expectations (tests/treatment/referral)
- Most Likely Dx: Match to age/menopause/depth of pain
- DDx: Endometriosis, candidiasis/vaginitis, vaginismus (adjust to stem)
- BPS: Biological cause + psychological distress + relationship/social impact
- Sign: Atrophic mucosa (if postmenopausal), posterior fornix nodule (if endo), cervical motion tenderness (if PID)
What NOT to miss:
- Post-coital bleeding → cervical cancer screen
- Fever + discharge → PID → treat urgently
- Abuse/trauma history → safeguarding
- Always ask ICE and hidden agenda
Active Recall - Family Medicine Clinical Test
[1] Taylor's Differential Diagnosis Manual 3ed, Section 11.5 Dyspareunia [2] MBBS Final MB (Medicine) (Felix PY Lai), Neisseria gonorrhoeae infection (p.1049–1052) [3] MBBS Final MB (Medicine) (Felix PY Lai), Chlamydia trachomatis infection (p.1052–1054) [4] MBBS Final MB (Medicine) (Felix PY Lai), Suprapubic pain - Endometriosis (p.627–629) [5] GC 112. Abnormal vaginal bleeding Gynaecological cancer (lecture slide, inferred from slide list) [6] GC 114. Climacteric symptoms menopause and related illness; amenorrhoea (lecture slide) [7] Ryan Ho Psychiatry, Somatic symptom disorder (p.202) [8] Ryan Ho Endocrine, Diabetic autonomic neuropathy - Genitourinary (p.98) [9] Ryan Ho Rheumatology, Long-term sequelae of GVHD / immunoblistering - vulvovaginal (p.151)
Dysmenorrhoea
Dysmenorrhoea is painful menstrual cramping, typically caused by excessive prostaglandin-mediated uterine contractions (primary) or underlying pelvic pathology such as endometriosis (secondary).
Dyspepsia
Dyspepsia is a symptom complex of recurrent epigastric pain or discomfort, often accompanied by bloating, early satiety, or nausea, originating from the gastroduodenal region.