Dyspareunia

Dyspareunia (from Greek, meaning "badly mated"^[1][2]) is painful sexual intercourse, due to medical or psychological causes. The symptom is significantly more common in women than in men, affecting up to one-fifth of women at some point in their lives.^[3] The causes are often reversible, even when long-standing, but self-perpetuating pain is a factor after the original cause has been removed.

A medical evaluation of dyspareunia focuses initially on physical causes, which must be ruled out before psychogenic or emotional causes are considered. In the majority of instances of dyspareunia, there is an original physical cause. An extreme form, in which the woman's pelvic floor musculature contracts involuntarily, is termed vaginismus.

According to DSM-IV,^[4] the diagnosis of dyspareunia is made when the patient complains of recurrent or persistent genital pain before, during, or after sexual intercourse that is not caused exclusively by lack of lubrication or by vaginismus. Clinically, it is often difficult to separate dyspareunia from vaginismus, since vaginismus may occur secondary to a history of dyspareunia and even mild vaginismus is often accompanied by dyspareunia. It is important to establish whether the dyspareunia is acquired or congenital and whether it is generalized (complete) or situational. Further inquiry should determine whether the pain is superficial or deep - whether it occurs primarily at the vaginal outlet or vaginal barrel or upon deep thrusting against the cervix. Even when the pain can be reproduced during a physical examination, the possible role of psychological factors in either causing or maintaining the pain must be acknowledged and dealt with in treatment. After the text revision of the fourth edition of the DSM, a debate arose, with arguments to recategorize dyspareunia as a pain disorder instead of a sex disorder,^[5] with Charles Allen Moser, a physician, arguing for the removal of dyspareunia from the manual altogether.^[6]

Symptoms in women

When pain occurs, the woman experiencing dyspareunia may be distracted from feeling pleasure and excitement. Both vaginal lubrication and vaginal dilation decrease. When the vagina is dry and undilated, thrusting of the penis is painful. Even after the original source of pain (a healing episiotomy, for example) has disappeared, a woman may feel pain simply because she expects pain. In brief, dyspareunia can be classified by the time elapsed since the woman first felt it:

• During the first two weeks or so of symptoms, dyspareunia caused by penis insertion or movement of the penis in the vagina or by deep penetration is often due to disease or injury deep within the pelvis.
• After the first two weeks or so of symptoms, the original cause of dyspareunia may still exist with the woman still experiencing the resultant pain. Or it may have disappeared, but the woman has anticipatory pain associated with a dry, tight vagina.

Causes

Numerous medical causes of dyspareunia exist, and they can be broken down into congenital and acquired causes in this non-comprehensive list:

• Congenital
  • endometriosis^[7]
  • vaginal septa^[1]
  • thickened undilatable hymen^[1]
  • hypoplasia of the introitus ^[1]
  • ovarian cysts can cause deep pain^[8]

• Acquired
  • infections (candidiasis, chlamydia, trichomoniasis, urinary tract infections, pelvic inflammatory disease^[9])
  • vulvar vestibulitis
  • tumors like uterine fibroids can cause deep pain^[9]
  • xerosis (dryness, especially after the menopause)
  • interstitial cystitis
  • uterine prolapse^[9]
  • LSEA (lichen sclerosus et atrophicus)
  • Surgical complications, including female genital mutilation, when the introitus has become too small for normal penetration (often worsened by scarring)

• Causes that can be either acquired or congenital
  • retroverted uterus^[9]
  • vaginismus

Physical causes

Because there are numerous physical conditions that can contribute to pain during sexual encounters, a careful physical examination and medical history are always indicated with such complaints. In women, common physical causes for coital discomfort include infections of the vagina, lower urinary tract, cervix, or fallopian tubes (e.g., mycotic organisms (esp. candidiasis), chlamydia, trichomonas, coliform bacteria); endometriosis; surgical scar tissue (following episiotomy); and ovarian cysts and tumors.^[10] In addition to infections and chemical causes of dyspareunia such as monilial organisms and herpes, anatomic conditions, such as hymenal remnants, can contribute to coital discomfort (Sarrell and Sarrell 1989). 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. Vaginal dryness is often reported by lactating women as well.^[11] Women undergoing radiation therapy for pelvic malignancy often experience severe dyspareunia due to the atrophy of the vaginal walls and their susceptibility to trauma. Vaginal dryness is sometimes seen in Sjögren's syndrome, an autoimmune disorder which characteristically attacks the exocrine glands that produce saliva and tears.

Dyspareunia is now believed to be one of the first symptoms 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.

Physical causes in men

In men, as in women, there are a number of physical factors that may cause sexual discomfort. Pain is sometimes experienced in the testicular or glans area of the penis immediately after ejaculation. Infections of the prostate, bladder, or seminal vesicles can lead to intense burning or itching sensations following ejaculation. Men suffering from interstitial cystitis may experience intense pain at the moment of ejaculation. Gonorrheal infections are sometimes associated with burning or sharp penile pains during ejaculation. Urethritis or prostatitis can make genital stimulation painful or uncomfortable. Anatomic deformities of the penis, such as exist in Peyronie's disease, may also result in pain during coitus. One cause of painful intercourse is due to the painful retraction of a too-tight foreskin, occurring either during the first attempt at intercourse or subsequent to tightening or scarring following inflammation or local infection.^[10] Another cause of painful intercourse is due tension in a short and slender frenulum, frenulum breve, as the foreskin retracts on entry to the vagina irrespective of lubrication. In one study frenulum breve was found in 50% of patients who presented with dyspareunia.^[12] During vigorous or deep or tight intercourse or masturbation, small tears may occur in the frenum of the foreskin and can bleed and be very painful and induce anxiety which can become chronic if left unresolved. If stretching fails to ease the condition, and uncomfortable levels of tension remain, a frenuloplasty procedure may be recommended. Frenuloplasty is an effective procedure, with a high chance of avoiding circumcision, giving good functional results and patient satisfaction.^[13]

Differential diagnosis

Many sufferers will see several doctors before a correct diagnosis is made. Many gynecologists are not familiar with this family of conditions, but awareness has spread with time. Sufferers are also often hesitant to seek treatment for chronic vulvar pain, especially since many women begin experiencing symptoms around the same time they become sexually active. Moreover, the absence of any visible symptoms means that before being successfully diagnosed many patients are told that the pain is "in their head".

Complaints of sexual pain that is – dyspareunia or vulvodynia – typically fall into one of three categories: vulvar pain (pain at the opening or at the external genitalia), vaginal pain, or deep pain, or some combination of all three. There is some evidence for the existence of several subtypes of dyspareunia (Binik et al., 2000): vulvar vestibulitis syndrome (VVS) – the most common type of premenopausal dyspareunia – vulvar or vaginal atrophy (which typically occurs postmenopausally), and deep dyspareunia or pelvic pain (associated with such gynecological conditions as endometriosis, ovarian cysts and pelvic adhesions, inflammatory disease, or congestion).

Vulvar vestibulitis is the most common subtype of vulvodynia affecting premenopausal women which causes dyspareunia, and it tends to be associated with a highly localized "burning" or "cutting" type of pain.

Vaginal atrophy as a source of dyspareunia is most frequently seen in postmenopausal women and is generally associated with estrogen deficiency. Estrogen deficiency is associated with lubrication inadequacy, which can lead to painful friction during intercourse.

In women with VVS and vulvar/vaginal atrophy, the pain is associated with penetration or with discomfort in the anterior portion of the vagina. There are some women, however, who report deeper vaginal or pelvic pain. Little is known about these deeper types of pain syndromes, except that they are thought to be associated with gynecological conditions such as endometriosis, ovarian cysts, pelvic adhesions, or inflammatory disease.

Dyspareunia is a complex problem and frequently has a multifactorial aetiology. A new way has been recently suggested to define dyspareunia by dissecting it into primary, secondary, and tertiary sources of pain.^[14]

Treatment

After proper diagnosis involving carefully taking a complete history and examining the pelvis to duplicate as closely as possible the discomfort and to identify a site or source of the pelvic pain, one or more treatments may be necessary.

• 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 the causes and treatment and encouraging him to be supportive.
• Removing the source of pain when needed.
• 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 also prove very useful to relax and lubricate the vagina (providing both partners are comfortable with it).
• Prescribing very large amounts of water-soluble sexual or surgical lubricant during intercourse. Discourage petroleum jelly. Moisturizing skin lotion may be recommended as an alternative lubricant, unless the patient is using a condom or other latex product. 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.^[15]
• Estrogen treatment is often used in cases of vaginal dryness, usually in post-menopausal women.^[16] In certain cases, surgery can also be an option.^[17]

See also

• Endometriosis

References

• The original text for this article is taken from a public domain CDC document PDF).

Further reading

• Sandra Risa Leiblum, Ph.D. Sexual Pain Disorders - Dyspareunia
• Binik YM, Bergeron S, Khalifé S (2000). "Dyspareunia". In Leiblum SR, Rosen RC. Principles and Practice of Sex Therapy (3rd ed.). New York: The Guilford Press. pp. 154–80. ISBN 1-57230-574-6. 

External links

• Vaginismus Awareness Network - Misdiagnosis: Vaginismus vs Dyspareunia
• Interstitial Cystitis Network
• WhenSexHurts - a support community for couples struggling with intimacy due to disability
• Therapy for Vaginismus