Dyspareunia

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Overview
Dyspareunia is painful sexual intercourse, due to medical or psychological causes. The term is used almost exclusively in women, although the problem can also occur in men. The causes are often reversible, even when long-standing, but self-perpetuating pain is a factor after the original cause has been removed.

Dyspareunia is considered to be primarily a physical, rather than an emotional, problem until proven otherwise. In most instances of dyspareunia, there is an original physical cause. Extreme forms, in which the woman's pelvic floor musculature contracts involuntarily, is termed vaginismus.

According to DSM-IV (American Psychiatric Association 1994), 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 lifelong 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.

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 phallus 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 2 weeks or so, dyspareunia caused by phallus insertion or movement of the phallus in the vagina or by deep penetration is often due to disease or injury deep within the pelvis.
 * After the first 2 weeks or so, the original cause of dyspareunia may still exist with the 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, ranging from infections (candidiasis, chlamydia, trichomoniasis, urinary tract infections), endometriosis, tumors, xerosis (dryness, especially after the menopause) and LSEA. Dyspareunia may result from female genital mutilation, when the introitus has become too small for normal penetration (often worsened by scarring).

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 (Bancroft 1989). 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 among postmenopausal women, although vaginal dryness is often reported by lactating women as well (Bachmann et al 1984). 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 (Bancroft 1989). During vigorous intercourse or masturbation, small tears may occur in the frenum of the foreskin and can be very painful.

A rare form of male dyspareunia - postejaculatory pain syndrome - is characterized by persistent and recurring pain in the genital organs during ejaculation or immediately thereafter. The painful sensations are experienced as sharp, stabbing, and/or burning. Although the duration of pain is usually brief, it can persist and be quite intense. Although the immediate cause of psychogenic postejaculatory pain syndrome is the involuntary painful spasm or cramping of certain pain-sensitive muscles in the male genital and reproductive organs, the excruciatingly painful muscle cramps may be attributable to a man’s conflict about ejaculating. A pelvic floor disorder can also be the cause of pain during and after sex. Spasming, inflammed, overtoned or shortened pelvic muscles can result in the compression or sometimes the entrapment of the pudendal nerve. Guilt about sexual pleasure or about the paraphiliac nature of the erotic fantasies can lead to pain with orgasm. In other cases, men with liberal sexual attitudes might feel general resentment, or be angry at their current sexual partners for unconscious or conscious reasons.

Differential diagnosis
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 (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 Syndrome (VVS) is the most common subtype of vulvodynia affecting premenopausal women. It tends to be associated with a highly localized “burning” or “cutting” type of pain. The feelings of irritation and burning can persist for hours or days following sexual activity, engendering a sense of hopelessness and depression (Bergeron et al. 1997; Marinoff and Turner 1991; Peckham et al. 1986).

The prevalence of VVS is quite high: the syndrome has been cited as affecting about 10%-15% of women seeking gynecological care (Bergeron et al. 1997). It is characterized by severe pain with attempted penetration of the vaginal introitus and complaints of tenderness with pressure within the vulvar vestibule. Usually there are no reports of pain with pressure to other surrounding areas of the vulva. Diagnosis is readily made by the cotton-swab test, in which pressure is applied in a circular fashion around the vulvar vestibule to assess complaints of pain. Laboratory tests are used to exclude bacterial or viral infection, and a careful examination of the vulvo/vaginal area is conducted to assess whether any atrophy is present.

VVS involves multiple tiny erythematous sores in the vulvar vestibule (Friedrich 1987; Marinoff and Turner 1991). A number of etiological factors may be involved, including subclinical human papillomavirus infection, chronic recurrent candidiasis, or chronic recurrent bacterial vaginosis (Marinoff and Turner 1991; Peckham et al. 1986). Muscular causes have been implicated as well, since chronic vulvar pain may be the result of chronic hypertonic perivaginal muscles, leading to vaginal tightening and subsequent pain. Some investigators have postulated the existence of neurological causes such as vestibular neural hyperplasia. Finally, psychological factors may contribute to or exacerbate the problem, since the anticipation of pain often results in a conditioned spasmodic reflex along with sexual desire and arousal problems. Relationship problems are generally the result of chronic frustration, disappointment, and depression associated with the condition.

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 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.

Treatment
Dyspareunia is treated by the taking following steps:
 * Carefully taking a history.
 * Carefully examining the pelvis to duplicate as closely as possible the discomfort and to identify a site or source of the pelvic pain.
 * Clearly explaining to the patient what has happened, including identifying the sites and causes of pain.
 * Removing the source of pain when possible.
 * 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 (2 tablespoons full) to both the phallus 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 phallus of the penetrating partner in their hand and control insertion themself, rather than letting the penetrating partner do it.
 * 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), mutual caressing without intercourse, and using sexual books and pictures. 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.
 * Recommending a change in coital position to one admitting less penetration. In women receiving vaginal penetration, this is recommended for those who have pain on deep penetration because of pelvic injury or disease:
 * 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.
 * If no penetration is tolerable, the couple may substitute oral sex and masturbation for intercourse.

Related conditions

 * Vaginismus
 * Endometriosis