Dyspareunia is pain prior to, during, or after, sexual intercourse. Dyspareunia is more common in women but can affect either sex.Dyspareunia can have several different causes. For instance, Vaginismus is a ‘spasm’ or contractions of the muscles surrounding the vagina.

Dyspareunia is pain prior to, during, or after, sexual intercourse. Dyspareunia is more common in women but can affect either sex. Many women will experience dyspareunia at some time in their life. Sometimes a medial or physical etiology may not be obvious and psychosocial factors also can play an important role. In men, dyspareunia can be related to an allergic reaction to a condom or spermicidal. An infection of the prostate or prostatitis may also cause pain. If a female partner has a vaginal infection or dryness, the male can experience discomfort during intercourse.

Dyspareunia can have several different causes. For instance, Vaginismus is a “spasm” or contractions of the muscles surrounding the vagina. Women with Vaginismus have pain with insertion of tampons as well as with penile penetration.

Vulvodynia and vulvar vestibullitis are both conditions that are characterized by painful intercourses. They are also characterized by vulvar burning and itching. The discomfort may not necessarily be associated with intercourse.

In older women vaginal dryness is a common cause of dyspareunia. This is a common problem for women that are not on hormone replacement. Dyspareunia can also be caused by abnormalities of the uterus or pelvic organs. Woman may describe the pain as feeling that something is being “pushed” or “bumped” during intercourse. An enlarged uterus or ovary can cause painful intercourse especially during deep penetration. A prolapsed or “dropped” uterus or bladder may also cause discomfort. Dyspareunia can also result from previous pelvic surgery or infection. These conditions can reduce movement of the pelvic organs resulting in pain with deep penetration.

Women who experience trauma such as rape or sexual assault may also experience dyspareunia. Unfortunately, many women may have difficulty sharing this information with their health care providers.

In order to treat dyspareunia appropriately the cause must be identified. The time at which the pain occurs during intercourse and other associated symptoms can help determine the potential etiology. For instance, pain during entry may have a different etiology than pain with deep penetration.

It is also important for a health care provider to know when in a woman’s life symptoms began. For example, if a woman’s symptoms began around or shortly after menopause; her symptoms could result from atrophic vaginal tissue. She may describe her symptoms as burning or “friction” with intercourse. Vaginal lubricants or estrogen can improve dryness and decrease pain. For women with a history of endometriosis, pelvic surgery, or infection, treatment of dyspareunia is aimed at restoring pelvic organs to their normal positions and reducing scar tissue. Surgical management may also be recommended for women with symptomatic prolapsed of the uterus, rectum, or bladder.

Women with a history of sexual abuse or treatment may benefit from psychological evaluation and treating any depressive symptoms that are present.

Types of dyspareunia:

It is useful to differentiate between the different types of dyspareunia to arrive at the appropriate diagnosis, treatment, and eventual prognosis.

  1. 1. Superficial dyspareunia. Vaginismus is a specific type of dyspareunia that refers to spasms of the levator ani and perineal muscles, making intercourse difficult, painful. Undesirable, and often impossible. May clinicians have defined Vaginismus as an almost certain psychogenic illness. However, organic disorders of the external genitalia and introital areas can cause such severe discomfort that any attempts at penetration can leas to spasm. This particular cycle, primarily caused by situational and anticipatory anxiety, can become self perpetuating often both organic and functional and can be solely a result of recognized disease entities.
  2. 2. Deep dyspareunia refers to a deeper pelvic pain that is experienced at any time during intercourse. Again, this may be secondary to pelvic abnormality, or it may be functional in origin. It also tends to overlap more with chronic pelvic pain syndrome.

Etiology of dyspareunia:

The presence of organic disease is often the cause of dyspareunia. Virtually all gynecologic disease entities list dyspareunia as a possible symptom.

Prominent in the list of diseases associated with dyspareunia are the following:

  1. Chronic pelvic infection.
  2. Endometriosis
  3. Pelvic carcinoma
  4. Extensive prolapsed or organ displacement
  5. Episiotomy.
  6. Acute vulvovaginitis
  7. Cystitis
  8. Urethral syndrome or other urinary tract disorders.
  9. Introital, vaginal, and cervical scarring.
  10. All space occupying lesions.
  11. Levator ani myalgia.
  12. Vulvar vestibullitis.
  13. 1. As with chronic pelvic pain syndromes, gastrointestinal (GI) diseases (e.g., bowel motility disorders) must be excluded.
  14. 2. Estrogen deprivation, irritating vaginal medications, sympathomimetic drugs, amphetamines, and cocaine are also causes, primarily in superficial dyspareunia and Vaginismus.
  15. 3. The most common causes of superficial dyspareunia include vaginitis (atrophic or infectious) or lack of lubrication (either caused by physiologic conditions or suboptimal sexual technique.
  16. 4. Lesions in the cul-de-sac are said to correlate most often with deep penetration dyspareunia.
  17. 5. Women who have deep penetration dyspareunia and who do not have superficial pain on penetration or Vaginismus usually do not have a causative external inflammatory syndrome.
  18. 6. Some individual with external dyspareunia or Vaginismus have small, almost imperceptible scar tissue secondary to surgery or childbirth.
  19. 7. Two clinical syndromes not usually recognized involve broad ligament varicosities and the broad ligament tear syndrome.
  20. 8. Frequently unrecognized etiology, particularly on first, interview, is a history or sexual assault or abuse.

Diagnostic workgroup

It is extremely important to look for evidence of sexual abuse both on history and physical examination before undertaking an expensive workup. Routine studies include a CBC, sedimentation rate, urinalysis, urine culture and sensitivity, and vaginal smear and culture. A Pap smear should also be done. If pregnancy is suspected, a pregnancy test should be done. If there is a pelvic mass, pelvic ultrasound may be helpful. A referral to gynecologist is usually made before ordering this study, however. If Vulval dystrophy is suspected, a vaginal biopsy may be useful. If the vaginal examination is normal, perhaps a psychiatrist should be consulted.

  1. Abnormal pelvic examination
  2. Normal pelvic examination

Abnormal pelvic examination

  1. Difficult penetration
  2. Difficult during intercourse
  3. With abnormal rectal examination

Difficult penetration

  1. Inflamed
  2. Hymeneal
  3. Orifice
  4. Bartholinitis
  5. Vulvitis
  6. Vulval
  7. Dystrophy
  8. Cystitis
  9. Urethritis

Difficult during intercourse

  1. Salpingooophoritis
  2. Retroverted
  3. Uterus
  4. Endometriosis
  5. Ovarian cyst.

With abnormal rectal examination

  1. Hemorrhoids
  2. Anal fissure
  3. Impacted
  4. Feces

B-Normal pelvic examination

  1. With sexual desire                             2. Without sexual desire

Functional dyspareunia                            not true dyspareunia

Differential diagnosis

  • Sexual pain disorder: persistent recurrent genital pain or nonorganic cause associated with sexual stimulation.
  • Vaginismus: painful, involuntary spasm of the vagina, preventing intercourse
  • Vulvar vestibullitis: a chronic and persistent clinical syndrome characterized by severe pain with vestibular touch or attempted vaginal entry, tenderness in response to pressure within the vulvar vestibule, and physical findings confined to various degrees of vestibular erythema.
  • Vulvodynia: chronic vulvar discomfort (e.g. burning, stinging, irritation, rawness).
  • Female sexual dysfunction (disorders of desire, arousal, or orgasm)

Treatment of dyspareunia

Medical

Inflammatory etiology (up regulation of mast cells)

  • Pharmacologic modulation of mast cell’s hyperactivity

– With antidepressants

– With topical gels

  • Reduction of agonist factors causing hyperactivity of mast cells

–      Recurrent Candida or Gardnerella vaginitis

–      Micro abrasions of the introital mucosa: from

–      Intercourse with a dry vagina or from inappropriate lifestyle

–      Allergens or chemical irritants

–      Physical agents

–      Neurogenic stimuli

Muscular etiology (up regulation of the muscular system)

  • Self massage and levator ani stretching
  • Physical therapy of the levator ani
  • Electromyographic biofeedback

Neurologic etiology (up regulation of the pain system)

  • Systemic analgesia
  • Local analgesia
  • Surgical therapy
  • Hormonal etiology

Hormonal therapy

–      Local: vaginal estrogens, or testosterone for the vulva

–      Systemic: with hormonal replacement therapies

Psychosexual

  • Behavioral cognitive group therapy
  • Individual psychotherapy
  • Couple psychotherapy

Homeopathic treatment of dyspareunia – Homeopathy is one of the most popular holistic systems of medicine. The selection of remedy is based upon the theory of individualization and symptoms similarity by using holistic approach. This is the only way through which a state of complete health can be regained by removing all the sign and symptoms from which the patient is suffering. The aim of homeopathy is not only to treat dyspareunia but to address its underlying cause and individual susceptibility. As far as therapeutic medication is concerned, several remedies are available to cure dyspareunia that can be selected on the basis of cause, sensations and modalities of the complaints.  For individualized remedy selection and treatment, the patient should consult a qualified homeopathic doctor in person. There are following remedies which are helpful in the treatment of dyspareunia:

Platina, Aconite, Belladonna, Thuja, Caulophyllum, Coffea, Ignatia, Murex, Mag Phos, Staphysagria, Kreosote, Lyssinum, Conium Mac, Causticum, Nux vomica, Nitric Acid, Silicea and many other medicines.

References:

Sana Loue, Martha, Sajatovic; Encyclopedia of Aging and Public Health; 297; 2008

Carol Havens, Nancy D. Sullivan: Manual of outpatient gynecology; 2002; 146-47

R. Douglas Collins: Algorithmic diagnosis of symptoms and signs: a cost effective approach; 2002; 128

Scott Kahan, Redonda Miller, Ellen G. Smith: in a page: Signs and Symptoms; 93; 2008

Hartmut Porst, Jacques Buvat: Standard Practice in Sexual Medicine; 2006; 347

About the author

Ashish Sharma

Ashish Sharma

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  • There is also a new procedure for dyspareunia to cause stem cells to generate new healthy tissue.
    More can be seen at OShot.info
    Hope this helps.
    Charles Runels, MD