Dyspareunia

Dyspareunia is defined as persistent or recurrent genital pain that occurs just before, during or after intercourse.

Dyspareunia is painful sexual intercourse due to medical or psychological causes. The pain can primarily be on the external surface of the genitalia or deeper in the pelvis upon deep pressure against the cervix. It can affect a small portion of the vulva or vagina or be felt all over the surface. Understanding the duration, location, and nature of the pain is important in identifying the causes of the pain.

There are numerous physical, psychological, and social/relationship causes that can contribute to pain during sexual encounters. Commonly multiple underlying causes contribute to the pain. The pain can be acquired or congenital. Symptoms of dyspareunia may also occur after menopause. Diagnosis is typically by physical examination and a medical history.

Signs and Symptoms

Women who experience pain with attempted intercourse describe their pain in many ways. This reflects how many different and overlapping causes there are for dyspareunia. The location, nature, and time course of the pain help to understand potential causes and treatments.

Some women describe superficial pain at the opening of the vagina or surface of the genitalia when penetration is initiated. Other women feel deeper pain in the vault of the vagina or deep within the pelvis upon deeper penetration. Some women feel pain in more than one of these places. Determining whether the pain is more superficial or deep is important in understanding what may be causing a woman's pain.

Some women have always experienced pain with intercourse from their very first attempt. Other women begin to feel pain with intercourse after an injury or infection or cyclically with menstruation. Sometimes the pain increases over time.

When pain occurs, the woman may be distracted from feeling pleasure and excitement. Both vaginal lubrication and vaginal dilation decrease. When the vagina is dry and undilated, penetration is more painful. Fear of being in pain can make the discomfort worse. Even after the original source of pain has disappeared, a woman may feel pain simply because she expects pain. Fear, avoidance, and psychologic distress around attempting intercourse can become large parts of a woman's experience of dyspareunia.

Physical examination of the vulva (external genitalia) may reveal clear reasons for pain including lesions, thin skin, ulcerations or discharge associated with vulvovaginal infections or vaginal atrophy. An internal pelvic exam may also reveal physical reasons for pain including lesions on the cervix or anatomic variations.

Causes

In women, common causes for discomfort during sex include

  • Infections. Infections that mostly affect the labia, vagina, or lower urinary tract like yeast infections, chlamydia, trichomoniasis, urinary tract infections, or herpes tend to cause more superficial pain. Infections of the cervix, or fallopian tubes like pelvic inflammatory diseases tend to cause deeper pain.
  • Tissue Injury. Pain after trauma to the pelvis from injury, surgery or birth.
  • Anatomic variations. hymenal remnants, vaginal septa.thickened undilatable hymen, hypoplasia of the introitus, retroverted uterus or uterine prolapse can contribute to discomfort.
  • Hormonal Causes: endometriosis and adenomyosis. Estrogen deficiency is a particularly common cause of sexual pain complaints related to vaginal atrophy among postmenopausal women and may be a result of similar changes in menstruating women on hormonal birth control. Estrogen deficiency is associated with lubrication inadequacy, which can lead to painful friction during intercourse.Vaginal dryness is often reported by lactating women as well. Women undergoing radiation therapy for pelvic malignancy often experience severe dyspareunia due to the atrophy of the vaginal walls and their susceptibility to trauma.
  • Presence of objects that take up space in the pelvic like ovarian cysts, tumors]and uterine fibroids can cause deep pain
  • Pain from bladder irritation: Dyspareunia is a symptom of a disease called interstitial cystitis (IC). Patients may struggle with bladder pain and discomfort during or after sex. For men with IC, pain occurs at the moment of ejaculation and is focused at the tip of the penis. For women with IC, pain usually occurs the following day, the result of painful, spasming pelvic floor muscles. Interstitial cystitis patients also struggle with urinary frequency and/or urinary urgency
  • Vulvodynia: Vulvodynia is a diagnosis of exclusion in which women experience either generalized or localized vulvar pain most often described as burning without physical evidence of other causes on exam. Pain can be constant or only when provoked (as with intercourse). Localized provoked vulvodynia is the most recent terminology for what used to be called vulvar vestibulitis when the pain is localized to the vaginal opening.
  • Conditions that affect the surface of the vulva including LSEA (lichen sclerosus et atrophicus), or xerosis (dryness, especially after the menopause). Vaginal dryness is sometimes seen in Sj√∂gren's syndrome, an autoimmune disorder which characteristically attacks the exocrine glands that produce saliva and tears.
  • Muscular dysfunction- For example, levator ani myalgia
  • Psychologic

Treatment

The treatment for pain with intercourse depends on what is causing the pain. After proper diagnosis one or more treatments for specific causes may be necessary. For pain thought to be due to yeast or fungal infections, a clinician may prescribe mycogen cream (nystatin and triamcinolone acetonide) which can treat both a yeast infection and associated painful inflammation and itching because it contains both an antifungal and a steroid.

  • For pain thought to be due to post-menopausal vaginal dryness, estrogen treatment can be used.
  • For women with diagnostic criteria for endometriosis, medications or surgery are possible options. In addition, the following may reduce discomfort with intercourse:
  • Clearly explaining to the patient what has happened, including identifying the sites and causes of pain. Making clear that the pain will, in almost all cases, disappear over the time or at least will be greatly reduced. If there is a partner, also explaining to him or her the causes and treatment and encouraging him or her to be supportive.
  • Encouraging the patient to learn about her body, to explore her own anatomy and learn how she likes to be caressed and touched.
  • Encouraging the couple to add pleasant, sexually exciting experiences to their regular interactions, such as bathing together (in which the primary goal is not cleanliness), or mutual caressing without intercourse. In couples where a woman is preparing to receive vaginal intercourse, such activities tend to increase both natural lubrication and vaginal dilation, both of which decrease friction and pain. Prior to intercourse, oral sex may relax and lubricate the vagina (providing both partners are comfortable with it).
  • Use of water-soluble sexual or surgical lubricant during intercourse. Discourage petroleum jelly. Lubricant should be liberally applied (two tablespoons full) to both the penis and the orifice. A folded bath towel under the receiving partner's hips helps prevent spillage on bedclothes.
  • Instructing the receiving partner to take the penis of the penetrating partner in their hand and control insertion themselves, rather than letting the penetrating partner do it.
  • For those who have pain on deep penetration because of pelvic injury or disease: Recommending a change in coital position to one admitting less penetration. In women receiving vaginal penetration: maximum vaginal penetration is achieved when the receiving woman lies on her back with her pelvis rolled up off the bed, compressing her thighs tightly against her chest with her calves over the penetrating partner's shoulders. Minimal penetration occurs when a receiving woman lies on her back with her legs extended flat on the bed and close together while her partner's legs straddle hers. A device has also been described for limiting penetration.