Dyspareunia – Causes, Symptoms, Diagnosis, Treatment

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.

The medical term for painful intercourse is dyspareunia. This definition includes recurrent or persistent discomfort that happens before, during, or after intercourse. Dyspareunia is a complex disorder that can be further classified as superficial or deep, and primary or secondary [rx–rx]. Superficial dyspareunia is pain localized to the vulva or vaginal entrance, and deep dyspareunia is pain perceived inside the vagina or lower pelvis, which is often associated with deep penetration [rx–rx]. Primary dyspareunia occurs at initial intercourse, and secondary dyspareunia occurs after some time of pain-free intercourse.

Causes of Dyspareunia

Women

The cause of the pain may be anatomic or physiologic, including but not limited to lesions of the vagina, retroversion of the uterus, urinary tract infection, lack of lubrication, scar tissue, abnormal growths, or tender pelvic sites.^[rx] Some cases may be psychosomatic, which can include fear of pain or injury, feelings of guilt or shame, ignorance of sexual anatomy and physiology, and fear of pregnancy.^[rx]

In women, common causes for discomfort during sex include

• Infections – Infections that mostly affect the labia, vagina, or lower urinary tract like yeast infections, chlamydia, trichomoniasis, urinary tract infections, or herpes tend to cause more superficial pain. Infections of the cervix or fallopian tubes like pelvic inflammatory disease tend to cause deeper pain.
• Cancer of the reproductive tract – including the ovaries, cervix, uterus, or vagina.
• Tissue Injury – Pain after trauma to the pelvis from injury, surgery, or childbirth.
• Anatomic variations – hymenal remnants, vaginal septa, thickened undeletable hymen, hypoplasia of the introitus retroverted uterus or uterine prolapse can contribute to discomfort.
• Hormonal causes:
  • Endometriosis^[rx] and adenomyosis
  • 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.^[rx]
  • Estrogen deficiency is associated with lubrication inadequacy, which can lead to painful friction during intercourse. Vaginal dryness is often reported by lactating women as well.^[rx] Women undergoing radiation therapy for pelvic malignancy often experience severe dyspareunia due to the atrophy of the vaginal walls and their susceptibility to trauma.
• Pelvic masses – including ovarian cysts,^[rx] tumors,^[rx] and uterine fibroids can cause deep pain.^[rx]
• Pain from bladder irritation – Dyspareunia is a symptom 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.
• Vulvodynia – Vulvodynia is a diagnosis of exclusion in which women experience either generalized or localized vulvar pain most often described as burning without physical evidence of other causes on the exam. Pain can be constant or only when provoked (as with intercourse). Localized provoked vulvodynia is the most recent terminology for what used to be called vulvar vestibulitis when the pain is localized to the vaginal opening.
• Conditions – that affect the surface of the vulva including LSEA (lichen sclerosus et atrophicus), or xerosis (dryness, especially after menopause). Vaginal dryness is sometimes seen in Sjögren’s syndrome, an autoimmune disorder that characteristically attacks the exocrine glands that produce saliva and tears.
• Muscular dysfunction –  For example, levator ani myalgia
• Psychological, such as vaginismus. Most vaginal pain disorders were officially discovered or coined during a time when rape culture was more normalized than it is now^[rx] (marital rape was only recognized as non-consensual by all 50 US states in 1993^[rx]). Some in the medical community are now starting to take into account factors like rape/sexual assault/ fear of rape/sexual harassment as strong enough psychological stressors to cause such pain disorders.^[rx]
• Dermatologic diseases – such as lichen planus, lichen sclerosis, and psoriasis can cause significant inflammation to the vaginal mucosa as well. Perivaginal and pelvic infections such as urethritis, vaginitis, and pelvic inflammatory disease can result from gonorrhea, chlamydia, candida, trichomoniasis, bacterial vaginosis, and virals pathogens such as herpes. Postpartum dyspareunia more commonly presents after perineal trauma from delivery than those with an uncomplicated vaginal delivery with intact perineum or unsutured tear.[rx]
• Vaginismus  – is a more common condition in younger women and defined as an involuntary contraction of the pelvic floor muscles on attempted vaginal penetration and can be the result of a pelvic floor dysfunction or psychosocial issues such as a history of sexual abuse.[rx]
• Not enough lubrication – This is often the result of not enough foreplay. A drop in estrogen levels after menopause or childbirth or during breast-feeding also can be a cause. Certain medications are known to affect sexual desire or arousal, which can decrease lubrication and make sex painful. These include antidepressants, high blood pressure medications, sedatives, antihistamines, and certain birth control pills.
• Injury, trauma, or irritation –This includes injury or irritation from an accident, pelvic surgery, female circumcision, or a cut made during childbirth to enlarge the birth canal (episiotomy).
• Inflammation, infection, or skin disorder – An infection in your genital area or urinary tract can cause painful intercourse. Eczema or other skin problems in your genital area also can be the problem.

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.^[rx]
• Another cause of painful intercourse is due to tension in a short and slender frenulum, frenulum breve, as the foreskin retracts on entry to the vagina irrespective of lubrication.

Origin	Treatable cause
Hormonal	Vulvovaginal atrophy (hypoestrogenic states such as menopause, breastfeeding, use of low-dose birth control)
Infectious	Candidiasis, herpes simplex virus
Inflammatory or dermatoses	Dermatitis, lichen sclerosis, lichen planus, immunobullous disorders
Muscular	Vaginismus, myofascial pain
Neurologic	Herpes neuralgia, pudendal neuralgia, spinal nerve compression or injury, neuroma
Anatomic	Clitoral adhesions, narrowing of the vaginal opening
Neoplastic	Paget disease, squamous cell carcinoma
Iatrogenic	Postoperative, chemotherapy, pelvic radiation
Trauma	Female genital cutting, obstetrical

Symptoms of Dyspareunia

• Ask about the nature of the pain – When and where does she feel the pain? Is it near the vaginal entrance on initial penetration or is it felt more deeply on thrusting? Does she have any other abdominal pains? Does she feel that she is “too tight” to allow penetration? The dyspareunia may be accompanied by vaginismus. Does she experience pain every time she attempts intercourse? If not, what is different about the times when she doesn’t have pain? Is she more relaxed, and if so why?
• Other symptoms – Does she have a vaginal discharge? This may indicate infection or other pathology. Is she depressed?
• Sex before she had the baby – Was intercourse previously free of pain, and did she enjoy sex? How did pregnancy affect sex?
• The delivery – Was there trauma? Did she have a tear or episiotomy? If so, does she feel confident that it healed well? Did she examine herself after the birth to ascertain when penetration might be painless? Are there other issues about birth?
• Foreplay and non-penetrative sexual behavior – Is she becoming aroused and lubricating? Lubrication and expansion of the upper vagina occur only with arousal. Does she reach orgasm?
• Her relationship – Has her relationship with her partner changed since birth? If so, how? Do they find time to enjoy themselves as a couple? Are they affectionate? Do they find it difficult to switch roles from parents to lovers? Is she concerned about her pain and her loss of interest in sex, or is it just her husband who views it as a problem?
• Feelings about becoming a parent – Ask her what becoming a parent has meant to them both. Was the pregnancy planned? Does the baby sleep in their bedroom? If so, how do they feel about this? Is she using contraception, and does she trust it? Is she still breastfeeding?

Diagnosis of Dyspareunia

Patient History

Women suffering from dyspareunia may struggle to find support and acknowledgment that their pain is “real.” Many women report being dismissed and invalidated [rx]. Thus, the first step in evaluating the patient should include validation of the patient’s pain and establishing rapport and trust between the patient and provider. The next step in the evaluation should include obtaining a detailed history that reviews the following:

• 1) pain characteristics (location, duration, exacerbating factors);
• 2) associated symptoms such as bowel, bladder, or musculoskeletal symptoms;
• 3) sexual behavior and sexuality;
• 4) psychological history;
• 5) comorbid medical problems;
• 6) previous treatments; and
• 7) physical or sexual abuse [rx].

Physical Exam

Patients want information about the examination process before, during, and after the evaluation is performed. Therefore, it is helpful to begin the physical inspection by first educating the patient about the examination and her anatomy while explaining what information has been obtained from each step of the assessment [rx,rx–rx].

Physical examination of patients with genital pain should include an external musculoskeletal evaluation, followed by an external visual and sensory examination, as well as internal single-digit palpation of the pelvic floor muscles. If tolerated by the patient, the provider may proceed to a bimanual examination and a speculum exam. It is important to recognize the possible discomfort and anxiety associated with assessments of the pelvis, particularly in patients with pain. A common strategy used to minimize anxiety and discomfort is the interactive educational pelvic examination process, which includes

• 1) explanations to the patient while performing the assessment;
• 2) describing the specific actions during each step;
• 3) using a mirror to enable the patient to visualize her anatomy and the examination [rx,rx]. This allows the clinician to thoroughly evaluate the patient’s pain, exclude diagnoses, educate the patient regarding normal anatomy and sexual function, and reassure the patient when no pathology is uncovered [rx,rx].

The external musculoskeletal examination – includes a complete lower back, abdomen, and pelvic inspection. It begins by observing any asymmetry or pain in the patient’s gait and her posture in the standing and sitting positions [rx,rx]. Next, the abdominal, gluteal, back, and lower extremity muscles are palpated to identify areas of tension and/or pain [20]. Last, an assessment of muscle strength, range of motion, sensation, and reflexes should be performed [rx].

The vulvar examination – is performed systematically by inspecting the external genitalia, perineum, perianal areas, and mons pubis, and assessing for the presence of infection, trauma, atrophy, fissure, and dermatosis [rx]. The standard test for the diagnosis of vulvodynia is the cotton swab test. This test can help determine the location of pain as well as distinguish between mechanical allodynia and hyperalgesia [rx,rx].

The internal musculoskeletal  – and vaginal single-digit exam is the most reliable method for evaluating pelvic muscle tenderness [rx]. Using the index finger, the examiner can palpate the lateral, anterior, and posterior walls of the vagina, the urethra, and pelvic floor muscles (levator ani, coccygeus, piriformis, and obturator internus). The purpose is to access the specific areas for tone, tenderness, or involuntary spasms of the muscles of the introitus and pelvic floor [rx,rx]. Tenderness during minimal or moderate palpation is considered abnormal; pelvic and vaginal structures can tolerate approximately 2 kg of pressure without pain. The patient is then asked to squeeze or contract around the single-digit to assess their muscle strength. An effort should also be made to identify any scars from previous surgeries, episiotomy, or trauma.

Treatment of Dyspareunia

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 asteroid.
• For pain that is likely due to post-menopausal vaginal dryness, estrogen treatment can be used.^[rx]
• For women with diagnostic criteria for endometriosis, medications or surgery are possible options.^[rx]
• Medical treatment options available for dyspareunia include oral TCA’s, oral or topical hormonal replacement, oral NSAIDs, botox injections, cognitive behavioral therapy, and other brain-based therapies.
• Dyspareunia due to post-menopausal vaginal atrophy can have treatment with systemic and topical hormone replacement therapy, selective estrogen receptor modulator therapy, and the use of vaginal dehydroepiandrosterone.[rx]
• Clinicians treat infectious causes with the appropriate antibiotic, antifungal, or antiviral therapy based upon culture results.
• Post-partum dyspareunia can respond to vaginal lubricants, scar tissue massage, or surgery for persistent cases. Botulinum toxin injection has proved to be effective in the treatment of dyspareunia caused by pelvic floor myalgia and contracture.[rx][rx]

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.^[rx]
• 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.
• Pelvic floor physical therapy can serve as an adjuvant treatment option in most cases of dyspareunia. It relaxes the pelvic floor muscles and re-educates the pain receptors.[rx]
• Cognitive-behavioral therapy has shown promising results in reducing anxiety and fear related to dyspareunia. It is the most commonly used behavioral intervention and is a strong recommendation.[rx]

Surgical treatment is adopted as a last resort when all conservative medical and behavioral treatment options have failed. It is usually useful in identifying and/or treat pelvic adhesions, endometriosis, and pelvic organ prolapse.[rx]

References

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