Dyspareunia

 

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.

Numerous physical, psychological, and social or relationship causes 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 medical history.

Underlying causes determine treatment. Many women experience relief when physical causes are identified and treated. Even when the pain can be reproduced during a physical examination, doctor and patient must acknowledge the possible role of psychological factors in either causing or maintaining the pain.

Globally, dyspareunia has been estimated to affect between 8–21% of women, at some point in their lives.

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 psychological 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 variation.

When there are no visible findings on vulvar exam that would suggest a cause for superficial dyspareunia, a cotton-swab test may be performed. This is a test to assess for localized provoked vulvodynia. A cotton tip applicator is applied at several points around the opening of the vagina and a woman reports whether she experiences pain on a scale from 0–10.

Differential diagnosis
Dyspareunia is a condition that has many causes and is not a diagnosis of itself. It is combined with vaginismus into genito-pelvic pain/penetration disorder in the DSM-5. Criteria for genito-pelvic pain/penetration disorder include multiple episodes of difficulty with vaginal penetration, pain associated with intercourse attempts, anticipation of pain due to attempted intercourse, and tensing of the pelvis in response to attempted penetration. To meet criteria for this disorder, a patient must experience the symptoms for at least six months and suffer “significant distress”.

The differential diagnosis for dyspareunia is long because of its complicated and multifactorial nature. Often there are physiologic conditions underlying the pain, as well as psychosocial components that must be assessed to find appropriate treatment. A differential diagnosis of underlying physical causes can be guided by whether the pain is deep or superficial:

Superficial dyspareunia or vulvar pain: infection, inflammation, anatomic causes, tissue destruction, psychosocial factors, muscular dysfunction
Superficial dyspareunia without visible exam findings: When no other physical cause is found the diagnosis of vulvodynia should be considered. Vaginal atrophy may also not be seen clearly on exam but commonly affects postmenopausal women and is generally associated with estrogen deficiency.
Deep dyspareunia or pelvic pain: endometriosis, ovarian cysts, pelvic adhesions, inflammatory diseases (interstitial cystitis, pelvic inflammatory disease), infections, congestion, psychosocial factors

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 example:

For pain due to yeast or fungal infections, a clinician may prescribe mycogen cream (nystatin and triamcinolone acetonide), which treats both a yeast infection and associated painful inflammation and itching because it contains both an antifungal and a steroid.
For pain that is likely 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 explain to the patient what has happened, including identifying sites and causes of pain. Make clear that the pain, in almost all cases, disappears over time, or at least greatly lessens. If there is a partner, explain the causes and treatment and encourage them to be supportive.
Encourage the patient to learn about her body, explore her own anatomy and learn how she likes to be caressed and touched.
Encourage 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).
For those who have pain on deep penetration because of pelvic injury or disease, recommend a change in coital position to one with less penetration. For vaginal penetration in women, the maximum vaginal penetration can be achieved when the receiving woman lies on her back with her pelvis rolled up off the bed, her thighs compressed tightly against her chest, and her calves placed over the shoulders of the penetrating partner. 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.
Recommend 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.
Instruct the receiving partner to take the penis of the penetrating partner in their hand and control insertion themselves, rather than let the penetrating partner do it.

History
The word “dyspareunia” comes from Greek δυσ-, dys- “bad” and πάρευνος, pareunos “bedfellow”, meaning “badly mated”. The previous Diagnostic and Statistical Manual of Mental Disorders, the DSM-IV, stated that 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 vaginal spasm (vaginismus). 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, with Charles Allen Moser, a physician, arguing for the removal of dyspareunia from the manual altogether. The most recent version, the DSM 5 has grouped dyspareunia under the diagnosis of Genito-Pelvic Pain/Penetration Disorder.

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