Dyspareunia
Encyclopedia
Dyspareunia
is pain
ful sexual intercourse
, due to medical or psychological causes. The symptom is reported almost exclusively by 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. It is a common condition that affects up to one-fifth of women at some point in their lives.
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,
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,
with Charles Allen Moser
, a physician, arguing for the removal of dyspareunia from the manual altogether.
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:
Frisch also found a statistically significant association between male circumcision and dyspareunia in women; 12% of the female partners of circumcised men reported it, as compared with 3% of the partners of intact men.
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 tube
s (e.g., mycotic organisms (esp. candidiasis
), chlamydia, trichomonas
, coliform bacteria
); endometriosis
; surgical scar
tissue (following episiotomy
); and ovarian cysts and tumors. In addition to infections and chemical causes of dyspareunia such as monilial organisms and herpes, anatomic conditions, such as hymen
al remnants, can contribute to coital discomfort (Sarrell and Sarrell 1989). Estrogen
deficiency is a particularly common cause of sexual pain complaints among postmenopausal women. 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. 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.
or glans
area of the penis
immediately after ejaculation
. Infections of the prostate
, bladder
, or seminal vesicle
s can lead to intense burning or itching sensations following ejaculation. Men suffering from interstitial cystitis
may experience intense pain at the moment of ejaculation. Gonorrhea
l 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, or iatrogenic deformities from circumcision such as 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 scar
ring following inflammation or local infection. 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, inflamed, 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 paraphilia
c 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.
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 cyst
s 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. It often causes dyspareunia.
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.
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.
Estrogen treatment is often used in cases of vaginal dryness - usually in post-menopausal women. In certain cases, surgery can also be an option. For example, in the case of vulvar vestibulitis, a study done involving 69 women showed moderate to excellent improvement in 83% of the surgeries, with an additional 7% of the patients obtaining further improvement from repeat surgery..
is pain
Pain
Pain is an unpleasant sensation often caused by intense or damaging stimuli such as stubbing a toe, burning a finger, putting iodine on a cut, and bumping the "funny bone."...
ful sexual intercourse
Sexual intercourse
Sexual intercourse, also known as copulation or coitus, commonly refers to the act in which a male's penis enters a female's vagina for the purposes of sexual pleasure or reproduction. The entities may be of opposite sexes, or they may be hermaphroditic, as is the case with snails...
, due to medical or psychological causes. The symptom is reported almost exclusively by 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. It is a common condition that affects up to one-fifth of women at some point in their lives.
A medical evaluation of dyspareunia focuses initially on physical causes, which must be ruled out before psychogenic
Psychogenesis
Psychogenesis is a term primarily used in psychology referring to the origin and development of psychological processes, personality, or behavior or the development of a physical disorder or illness resulting from psychological, rather than physiological, factors.-See also:*Carl Jung*Reality...
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
Pelvic floor
The pelvic floor or pelvic diaphragm is composed of muscle fibers of the levator ani, the coccygeus, and associated connective tissue which span the area underneath the pelvis. The pelvic diaphragm is a muscular partition formed by the levatores ani and coccygei, with which may be included the...
musculature contracts involuntarily, is termed vaginismus
Vaginismus
Vaginismus, sometimes anglicized vaginism, is the German name for a condition which affects a woman's ability to engage in any form of vaginal penetration, including sexual intercourse, insertion of tampons and/or menstrual cups, and the penetration involved in gynecological examinations...
.
According to DSM-IV,
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
Vaginal lubrication
Vaginal lubrication is a lubricating fluid that is naturally produced in a woman's vagina. Vaginal lubrication or moistness is present at all times, but production increases significantly during a woman's sexual arousal in anticipation of sexual intercourse...
or by vaginismus
Vaginismus
Vaginismus, sometimes anglicized vaginism, is the German name for a condition which affects a woman's ability to engage in any form of vaginal penetration, including sexual intercourse, insertion of tampons and/or menstrual cups, and the penetration involved in gynecological examinations...
. 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
Cervix
The cervix is the lower, narrow portion of the uterus where it joins with the top end of the vagina. It is cylindrical or conical in shape and protrudes through the upper anterior vaginal wall...
. 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,
with Charles Allen Moser
Charles Allen Moser
Charles Allen Moser is an American physician specializing in internal medicine and focusing on sexual medicine. Moser is based in San Francisco and focuses his research and practice on individuals in the LGBT, kink, and fetish communities...
, a physician, arguing for the removal of dyspareunia from the manual altogether.
Symptoms in women
When pain occurs, the woman experiencing dyspareunia may be distracted from feeling pleasure and excitement. Both vaginal lubricationVaginal lubrication
Vaginal lubrication is a lubricating fluid that is naturally produced in a woman's vagina. Vaginal lubrication or moistness is present at all times, but production increases significantly during a woman's sexual arousal in anticipation of sexual intercourse...
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
Episiotomy
An episiotomy , also known as perineotomy, is a surgically planned incision on the perineum and the posterior vaginal wall during second stage of labor. The incision, which can be midline or at an angle from the posterior end of the vulva, is performed under local anaesthetic , and is sutured...
, 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 list non-comprehensive list:- Congenital
- endometriosisEndometriosisEndometriosis is a gynecological medical condition in which cells from the lining of the uterus appear and flourish outside the uterine cavity, most commonly on the ovaries. The uterine cavity is lined by endometrial cells, which are under the influence of female hormones...
- vaginal septa
- thickened undialatable hymen
- hypoplasiaHypoplasiaHypoplasia is underdevelopment or incomplete development of a tissue or organ. Although the term is not always used precisely, it properly refers to an inadequate or below-normal number of cells. Hypoplasia is similar to aplasia, but less severe. It is technically not the opposite of hyperplasia...
of the introitusVaginal orificeThe vaginal orifice is a median slit below and behind the opening of the urethra; its size varies inversely with that of the hymen.-External links: - "The Female Perineum: The Vulva"... - Ovarian cystOvarian cystAn ovarian cyst is any collection of fluid, surrounded by a very thin wall, within an ovary. Any ovarian follicle that is larger than about two centimeters is termed an ovarian cyst. An ovarian cyst can be as small as a pea, or larger than an orange....
s can cause deep pain
- Acquired
- infectionInfectionAn infection is the colonization of a host organism by parasite species. Infecting parasites seek to use the host's resources to reproduce, often resulting in disease...
s (candidiasisCandidiasisThrush redirects here. For the hoof infection see Thrush .Candidiasis or thrush is a fungal infection of any of the Candida species , of which Candida albicans is the most common...
, chlamydia, trichomoniasisTrichomoniasisTrichomoniasis, sometimes referred to as "trich", is a common cause of vaginitis. It is a sexually transmitted disease, and is caused by the single-celled protozoan parasite Trichomonas vaginalis producing mechanical stress on host cells and then ingesting cell fragments after cell death...
, urinary tract infectionUrinary tract infectionA urinary tract infection is a bacterial infection that affects any part of the urinary tract. Symptoms include frequent feeling and/or need to urinate, pain during urination, and cloudy urine. The main causal agent is Escherichia coli...
s, pelvic inflammatory diseasePelvic inflammatory diseasePelvic inflammatory disease is a generic term for inflammation of the uterus, fallopian tubes, and/or ovaries as it progresses to scar formation with adhesions to nearby tissues and organs. This may lead to infections. PID is a vague term and can refer to viral, fungal, parasitic, though most...
) - Vulvar vestibulitisVulvar vestibulitisVulvar Vestibulitis Syndrome , vestibulodynia, or simply vulvar vestibulitis is vulvodynia localized to the vulvar region. It tends to be associated with a highly localized “burning” or “cutting” type of pain....
- tumorTumorA tumor or tumour is commonly used as a synonym for a neoplasm that appears enlarged in size. Tumor is not synonymous with cancer...
s like Uterine fibroids can cause deep pain - xerosisXerosisXerosis cutis is the medical term for dry skin.It can have many different causes, including general dehydration, atopic dermatitis, Vitamin A deficiency, and maybe diabetes. Treatment is primarily symptomatic. "Xero", meaning dry or dehydrated, "osis" usually referring to a medical disease or...
(dryness, especially after the menopauseMenopauseMenopause is a term used to describe the permanent cessation of the primary functions of the human ovaries: the ripening and release of ova and the release of hormones that cause both the creation of the uterine lining and the subsequent shedding of the uterine lining...
) - Interstitial CystitisInterstitial cystitisInterstitial cystitis or bladder pain syndrome is a chronic, oftentimes severely debilitating disease of the urinary bladder...
- Uterine prolapseUterine prolapseUterine prolapse is a form of female genital prolapse Uterine prolapse is a form of female genital prolapse Uterine prolapse is a form of female genital prolapse (also called pelvic organ prolapse or prolapse of the uterus (womb).Treatment is surgical, and the options include hysterectomy or a...
- LSEA
- Surgical complications, including female genital mutilation, when the introitusVaginal orificeThe vaginal orifice is a median slit below and behind the opening of the urethra; its size varies inversely with that of the hymen.-External links: - "The Female Perineum: The Vulva"...
has become too small for normal penetration (often worsened by scarScarScars are areas of fibrous tissue that replace normal skin after injury. A scar results from the biological process of wound repair in the skin and other tissues of the body. Thus, scarring is a natural part of the healing process. With the exception of very minor lesions, every wound results in...
ring)
- Causes that can be either acquired or congenital
- Retroverted uterusRetroverted uterusA retroverted uterus is a uterus that is tilted backwards instead of forwards. This is in contrast to the slightly "anteverted" uterus that most women have, which is tipped forward toward the bladder, with the anterior end slightly concave.Between 1 in 3 and 1-in-5 women has a retroverted...
- VaginismusVaginismusVaginismus, sometimes anglicized vaginism, is the German name for a condition which affects a woman's ability to engage in any form of vaginal penetration, including sexual intercourse, insertion of tampons and/or menstrual cups, and the penetration involved in gynecological examinations...
Frisch also found a statistically significant association between male circumcision and dyspareunia in women; 12% of the female partners of circumcised men reported it, as compared with 3% of the partners of intact men.
Physical causes
Because there are numerous physical conditions that can contribute to pain during sexual encounters, a careful physical examinationPhysical examination
Physical examination or clinical examination is the process by which a doctor investigates the body of a patient for signs of disease. It generally follows the taking of the medical history — an account of the symptoms as experienced by the patient...
and medical history
Medical history
The medical history or anamnesis of a patient is information gained by a physician by asking specific questions, either of the patient or of other people who know the person and can give suitable information , with the aim of obtaining information useful in formulating a diagnosis and providing...
are always indicated with such complaints. In women, common physical causes for coital discomfort include infections of the vagina, lower urinary tract
Urinary tract infection
A urinary tract infection is a bacterial infection that affects any part of the urinary tract. Symptoms include frequent feeling and/or need to urinate, pain during urination, and cloudy urine. The main causal agent is Escherichia coli...
, cervix
Cervix
The cervix is the lower, narrow portion of the uterus where it joins with the top end of the vagina. It is cylindrical or conical in shape and protrudes through the upper anterior vaginal wall...
, or fallopian tube
Fallopian tube
The Fallopian tubes, also known as oviducts, uterine tubes, and salpinges are two very fine tubes lined with ciliated epithelia, leading from the ovaries of female mammals into the uterus, via the utero-tubal junction...
s (e.g., mycotic organisms (esp. candidiasis
Candidiasis
Thrush redirects here. For the hoof infection see Thrush .Candidiasis or thrush is a fungal infection of any of the Candida species , of which Candida albicans is the most common...
), chlamydia, trichomonas
Trichomonas
Trichomonas is a genus of anaerobic protists that are parasites of vertebrates. They are included with the parabasalids.Species of Trichomonas include:*Trichomonas vaginalis, an organism generally living inside the vagina of humans...
, coliform bacteria
Coliform bacteria
Coliform bacteria are a commonly used bacterial indicator of sanitary quality of foods and water. They are defined as rod-shaped Gram-negative non-spore forming bacteria which can ferment lactose with the production of acid and gas when incubated at 35-37°C...
); endometriosis
Endometriosis
Endometriosis is a gynecological medical condition in which cells from the lining of the uterus appear and flourish outside the uterine cavity, most commonly on the ovaries. The uterine cavity is lined by endometrial cells, which are under the influence of female hormones...
; surgical scar
Scar
Scars are areas of fibrous tissue that replace normal skin after injury. A scar results from the biological process of wound repair in the skin and other tissues of the body. Thus, scarring is a natural part of the healing process. With the exception of very minor lesions, every wound results in...
tissue (following episiotomy
Episiotomy
An episiotomy , also known as perineotomy, is a surgically planned incision on the perineum and the posterior vaginal wall during second stage of labor. The incision, which can be midline or at an angle from the posterior end of the vulva, is performed under local anaesthetic , and is sutured...
); and ovarian cysts and tumors. In addition to infections and chemical causes of dyspareunia such as monilial organisms and herpes, anatomic conditions, such as hymen
Hymen
The hymen is a membrane that surrounds or partially covers the external vaginal opening. It forms part of the vulva, or external genitalia. The size of the hymenal opening increases with age. Although an often practiced method, it is not possible to confirm with certainty that a girl or woman is a...
al remnants, can contribute to coital discomfort (Sarrell and Sarrell 1989). Estrogen
Estrogen
Estrogens , oestrogens , or œstrogens, are a group of compounds named for their importance in the estrous cycle of humans and other animals. They are the primary female sex hormones. Natural estrogens are steroid hormones, while some synthetic ones are non-steroidal...
deficiency is a particularly common cause of sexual pain complaints among postmenopausal women. 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. Vaginal dryness is sometimes seen in Sjögren's syndrome
Sjögren's syndrome
Sjögren's syndrome , also known as "Mikulicz disease" and "Sicca syndrome", is a systemic autoimmune disease in which immune cells attack and destroy the exocrine glands that produce tears and saliva....
, 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
Interstitial cystitis
Interstitial cystitis or bladder pain syndrome is a chronic, oftentimes severely debilitating disease of the urinary bladder...
(IC). Patients may struggle with bladder
Bladder
Bladder usually refers to an anatomical hollow organBladder may also refer to:-Biology:* Urinary bladder in humans** Urinary bladder ** Bladder control; see Urinary incontinence** Artificial urinary bladder, in humans...
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 testicularTesticle
The testicle is the male gonad in animals. Like the ovaries to which they are homologous, testes are components of both the reproductive system and the endocrine system...
or glans
Glans penis
The glans penis is the sensitive bulbous structure at the distal end of the penis. The glans penis is anatomically homologous to the clitoral glans of the female...
area of the penis
Penis
The penis is a biological feature of male animals including both vertebrates and invertebrates...
immediately after ejaculation
Ejaculation
Ejaculation is the ejecting of semen from the male reproductory tract, and is usually accompanied by orgasm. It is usually the final stage and natural objective of male sexual stimulation, and an essential component of natural conception. In rare cases ejaculation occurs because of prostatic disease...
. Infections of the prostate
Prostate
The prostate is a compound tubuloalveolar exocrine gland of the male reproductive system in most mammals....
, bladder
Bladder
Bladder usually refers to an anatomical hollow organBladder may also refer to:-Biology:* Urinary bladder in humans** Urinary bladder ** Bladder control; see Urinary incontinence** Artificial urinary bladder, in humans...
, or seminal vesicle
Seminal vesicle
The seminal vesicles or vesicular glands are a pair of simple tubular glands posteroinferior to the urinary bladder of male mammals...
s can lead to intense burning or itching sensations following ejaculation. Men suffering from interstitial cystitis
Interstitial cystitis
Interstitial cystitis or bladder pain syndrome is a chronic, oftentimes severely debilitating disease of the urinary bladder...
may experience intense pain at the moment of ejaculation. Gonorrhea
Gonorrhea
Gonorrhea is a common sexually transmitted infection caused by the bacterium Neisseria gonorrhoeae. The usual symptoms in men are burning with urination and penile discharge. Women, on the other hand, are asymptomatic half the time or have vaginal discharge and pelvic pain...
l infections are sometimes associated with burning or sharp penile pains during ejaculation. Urethritis
Urethritis
Urethritis is inflammation of the urethra. The most common symptom is painful or difficult urination.-Causes:The disease is classified as either gonococcal urethritis, caused by Neisseria gonorrhoeae, or non-gonococcal urethritis , most commonly caused by Chlamydia trachomatis...
or prostatitis
Prostatitis
Prostatitis is an inflammation of the prostate gland, in men. A prostatitis diagnosis is assigned at 8% of all urologist and 1% of all primary care physician visits in the United States.-Classification:...
can make genital stimulation painful or uncomfortable. Anatomic deformities of the penis, or iatrogenic deformities from circumcision such as Peyronie's disease
Peyronie's disease
Peyronie's Disease Peyronie's Disease Peyronie's Disease (also known as "Induratio penis plastica", or more recently Chronic Inflammation of the Tunica Albuginea (CITA), is a connective tissue disorder involving the growth of fibrous plaques in the soft tissue of the penis affecting up to 10% of men...
, may also result in pain during coitus. One cause of painful intercourse is due to the painful retraction of a too-tight foreskin
Foreskin
In male human anatomy, the foreskin is a generally retractable double-layered fold of skin and mucous membrane that covers the glans penis and protects the urinary meatus when the penis is not erect...
, occurring either during the first attempt at intercourse or subsequent to tightening or scar
Scar
Scars are areas of fibrous tissue that replace normal skin after injury. A scar results from the biological process of wound repair in the skin and other tissues of the body. Thus, scarring is a natural part of the healing process. With the exception of very minor lesions, every wound results in...
ring following inflammation or local infection. During vigorous intercourse or masturbation, small tears may occur in the frenum of the foreskin
Frenulum of prepuce of penis
The word frenulum on its own is often used for the frenulum of prepuce of penis, which is an elastic band of tissue under the glans penis that connects to the prepuce, or foreskin to the vernal mucosa, and helps contract the prepuce over the glans. This is sometimes colloquially known as the "banjo...
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, inflamed, overtoned or shortened pelvic muscles can result in the compression or sometimes the entrapment of the pudendal nerve
Pudendal nerve
The pudendal nerve is a sensory and somatic nerve in the pelvic region which is a large branch of the sacral plexus that innervates the external genitalia of both sexes, as well as sphincters for the bladder and the rectum...
. Guilt about sexual pleasure or about the paraphilia
Paraphilia
Paraphilia is a biomedical term used to describe sexual arousal to objects, situations, or individuals that are not part of normative stimulation and that may cause distress or serious problems for the paraphiliac or persons associated with him or her...
c 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
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
Vulvodynia
Vulvodynia is a chronic pain syndrome that affects the vulvar area and occurs without an identifiable cause or visible pathology categorized in the ICD-9 group 625—specifically ICD-9 625.7, which is for pain and other disorders of the female genital organs...
- 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
Irving M. Binik
Yitzchak M. "Irv" Binik is an American-Canadian psychologist whose main research interest is human sexuality, specifically sexual pain .-Career:...
et al. 2000): vulvar vestibulitis
Vulvar vestibulitis
Vulvar Vestibulitis Syndrome , vestibulodynia, or simply vulvar vestibulitis is vulvodynia localized to the vulvar region. It tends to be associated with a highly localized “burning” or “cutting” type of pain....
(the most common type of premenopausal dyspareunia), vulvar or vaginal atrophy
Atrophic vaginitis
Atrophic vaginitis is an inflammation of the vagina due to the thinning and shrinking of the tissues, as well as decreased lubrication...
(which typically occurs postmenopausally), and deep dyspareunia or pelvic pain (associated with such gynecological conditions as endometriosis
Endometriosis
Endometriosis is a gynecological medical condition in which cells from the lining of the uterus appear and flourish outside the uterine cavity, most commonly on the ovaries. The uterine cavity is lined by endometrial cells, which are under the influence of female hormones...
, ovarian cyst
Ovarian cyst
An ovarian cyst is any collection of fluid, surrounded by a very thin wall, within an ovary. Any ovarian follicle that is larger than about two centimeters is termed an ovarian cyst. An ovarian cyst can be as small as a pea, or larger than an orange....
s and pelvic adhesions
Adhesion (medicine)
Adhesions are fibrous bands that form between tissues and organs, often as a result of injury during surgery. They may be thought of as internal scar tissue that connect tissues not normally connected.-Pathophysiology:...
, 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. It often causes dyspareunia.
Vaginal atrophy as a source of dyspareunia is most frequently seen in postmenopausal women and is generally associated with estrogen
Estrogen
Estrogens , oestrogens , or œstrogens, are a group of compounds named for their importance in the estrous cycle of humans and other animals. They are the primary female sex hormones. Natural estrogens are steroid hormones, while some synthetic ones are non-steroidal...
deficiency. Estrogen deficiency is associated with lubrication
Vaginal lubrication
Vaginal lubrication is a lubricating fluid that is naturally produced in a woman's vagina. Vaginal lubrication or moistness is present at all times, but production increases significantly during a woman's sexual arousal in anticipation of sexual intercourse...
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.
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, dyspareunia is treated by the taking following steps:- 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, explaining him also 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 lubricationVaginal lubricationVaginal lubrication is a lubricating fluid that is naturally produced in a woman's vagina. Vaginal lubrication or moistness is present at all times, but production increases significantly during a woman's sexual arousal in anticipation of sexual intercourse...
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 sexualPersonal lubricantPersonal lubricants are specialized lubricants to reduce friction between body parts, or between body parts and other objects...
or surgical lubricantSurgical lubricantSurgical lubricants are substances used by health care providers to provide lubrication and lessen discomfort to the patient during certain medical/surgical procedures such vagina examinations or per rectal examination)....
during intercourse. Discourage petroleum jellyPetroleum jellyPetroleum jelly, petrolatum, white petrolatum or soft paraffin, CAS number 8009-03-8, is a semi-solid mixture of hydrocarbons , originally promoted as a topical ointment for its healing properties...
. Moisturizing skin lotion may be recommended as an alternative lubricant, unless the patient is using a condomCondomA condom is a barrier device most commonly used during sexual intercourse to reduce the probability of pregnancy and spreading sexually transmitted diseases . It is put on a man's erect penis and physically blocks ejaculated semen from entering the body of a sexual partner...
or other latexLatexLatex is the stable dispersion of polymer microparticles in an aqueous medium. Latexes may be natural or synthetic.Latex as found in nature is a milky fluid found in 10% of all flowering plants . It is a complex emulsion consisting of proteins, alkaloids, starches, sugars, oils, tannins, resins,...
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.
- A manual physical therapy (Wurn TechniqueThe Wurn TechniqueThe Wurn Technique is a manual manipulation of internal adhesions that form in the body as a response to infection, inflammation, trauma or surgical intervention 1, 2. Subsequent further surgery may thus be avoided. The Wurn Technique has been cited in peer-reviewed medical journals for its...
) which treats pelvic and vaginal adhesionsAdhesion (medicine)Adhesions are fibrous bands that form between tissues and organs, often as a result of injury during surgery. They may be thought of as internal scar tissue that connect tissues not normally connected.-Pathophysiology:...
and microadhesions may decrease or eliminate intercourse pain. In a controlled study, Increasing orgasm and decreasing intercourse pain by a manual physical therapy technique, twenty-three (23) women reporting painful intercourse and/or sexual dysfunction received a 20-hour program of manipulative physical therapy. The results were compared using the validated Female Sexual Function Index, with post-test versus pretest scores. Results of therapy showed improvements in all six recognized domains of sexual dysfunction. The results were significant (P
Estrogen treatment is often used in cases of vaginal dryness - usually in post-menopausal women. In certain cases, surgery can also be an option. For example, in the case of vulvar vestibulitis, a study done involving 69 women showed moderate to excellent improvement in 83% of the surgeries, with an additional 7% of the patients obtaining further improvement from repeat surgery..
Further reading
- Sandra Risa Leiblum, Ph.D. Sexual Pain Disorders - Dyspareunia