Dyspareunia

oPatientPlus articles are written by UK doctors and are based on research evidence, UK and European Guidelines. They are designed for health professionals to use, so you may find the language more technical than the condition leaflets.

Dyspareunia is pain during or after sexual intercourse. It can affect men, but is more common in women. Women with dyspareunia may have pain in the vagina, clitoris or labia. There are numerous causes of dyspareunia - many of which are easily treatable.

It is difficult to estimate the incidence of dyspareunia accurately, as the majority of cases are unreported. In Scandinavia in 2003, a large group (3,017) showed a prevalence of 9.3% for the whole group, 13% for women aged 20-29 years and 6.5% for women aged 50-60 years.[1] In this study co-existent nervousness and depression increased the likelihood of dyspareunia and both frequent sexual intercourse and having had more than two pregnancies were protective against it (although clearly one could argue about cause and effect).

A population-based study, using an anonymous, self-report questionnaire, was completed by 200 Brazilian-born women, aged 40-65 years, with eleven years or more of formal education.[2] The prevalence of dyspareunia was 39.5%.

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Risk factors

It occurs most frequently in:

  • Those who are sexually inexperienced (particularly if their partners are also inexperienced)
  • Those who are peri- or post-menopausal[3]

Hysterectomy might be expected to increase the risk but the opposite is observed.[4]

Symptoms

Ask if it is superficial dyspareunia on penetration (felt at the introitus) or deep dyspareunia that is felt with penile thrusting, usually felt more deeply within the pelvis). Both may be present.

Tightening of the vaginal muscles on penetration is called vaginismus. This is often extremely painful and often makes penetration physically impossible.

Ask the patient:

  • Is it recent or has there always been dyspareunia?
  • Has the dyspareunia followed childbirth? If so, is there a history of episiotomy or of traumatic birth?
  • Where is the pain felt (superficial, deep or both)?
  • When is the pain felt (before, during or after incourse or a combination of these)?
  • If pain continues after intercourse, how long does it last?
  • Does anything else produce the same pain? (For example, IBS pain may be experienced during periods of bowel activity.)
  • Has successful intercourse taken place in the past?
  • Is intercourse possible at present?
  • If not, does the patient wish to be sexually active?
  • Have artificial lubricants been tried?

Ask about sexual history to help assess the risk of sexually transmitted disease:

  • Has there been sexual abuse, rape or trauma to the genitals, including childbirth?

Also ask:

  • Has there been female genital mutilation?
  • Is she having sex when she would prefer not to?
  • Is there ever any threatened or actual violence associated with intercourse?

Ask about symptoms suggestive of the menopause.

  • Is the patient experiencing vaginal dryness, hot flushes or menstrual disturbance?
  • Is she still having periods?

Establish the following:

  • Is there a symptomatic prolapse?[5]
  • Are there symptoms of urinary tract infection (UTI)?
  • Is she breast-feeding? This can also lead to vaginal dryness and dyspareunia.
  • Note comorbid medical history, particularly of bowel or bladder disease, of abdominal surgery (which may lead to adhesions) and of psychiatric conditions which may increase anxiety or somatisation. Medical conditions which can affect vaginal sensation include Sjögren's syndrome (which may cause vaginal dryness), and diabetes (which increases the tendency to thrush but which can also be associated with reduced vaginal lubrication).

Signs

  • Perform an abdominal examination to detect any masses or suprapubic tenderness.
  • Proceed to external genital examination. This may include sensitivity testing with a cotton-topped bud to detect vulvar vestibulitis.
  • Look for:
    • Skin disease, such as psoriasis or lichen sclerosus et atrophicus.
    • Whether vaginal secretions seem normal or sparse.
    • Inflammation.
    • Infection like candida, herpes simplex or genital warts
    • Scarring.
    • In particular, posterior skin bridge where there is a history of superficial dyspareunia following childbirth.

Examination

  • Vaginal examination needs to be done with great care and the patient may need some persuasion of its importance. Patients with vaginismus may be extremely worried at the prospect of vaginal examination, and gentle digital examination should be attempted before speculum examination. The latter may need to be done using a vaginal speculum.
  • Careful vaginal examination may allow direct observation of vaginismus. The latter may produce an obvious reflex tightening. It is important not to interpret this or any psychological problems as indicating that the problem is purely psychosomatic, as it may be the result, rather than the cause, of the pain.
  • Initial examination should be with a single, gloved finger and the patient may be asked to contract and relax her 'vaginal' muscles to allow assessment of her control of these muscles. Advancing the finger allows palpation of the pelvic floor muscles at the 4-5 o'clock and 7-8 o'clock positions and may give a clue that muscular contraction of the levator muscles (often associated with vaginismus) is contributing to coital pain.

Bimanual examination of the pelvis is then indicated:

  • Palpation of the bladder base bimanually usually produces mild urgency, but in women with chronic interstitial cystitis, pain may then be reproduced.
  • Cervical sensitivity may be elicited with the finger or with a cotton bud on speculum examination. Cervical excitation pain suggests pelvic inflammatory disease (PID). This may be an appropriate time to take swabs.
  • Assessment of the size, shape, position and mobility of the uterus and adnexae may reveal tenderness or bulkiness, retroversion with associated posterior uterine prolapse or the pelvic scarring associated with endometriosis or adhesions. Gently feel for abnormal pelvic masses, tenderness or lack of mobility of the pelvic organs, which may suggest endometriosis.
  • Tenderness on posterior palpation of the rectum is common with irritable bowel syndrome (IBS). Tender bowel loops may also be felt in this condition, particularly in the right iliac fossa and the ileo-caecal junction.

Finally, although patients may prefer to postpone this, rectovaginal examination can be helpful in revealing tenderness in the pouch of Douglas, which may be due to endometrial deposits. Many GPs will not be comfortable with, or experienced at, recto-vaginal examination and, unless familiar with the technique, this may be better deferred to secondary care.

Symptoms can give a good indication of cause:

Psychological dyspareunia, including that associated with lack of desire, or that associated with prior or ongoing sexual or domestic violence may cause any one or combination of these.

  • Pain with arousal:
    • Hymenal ring bands cause pain during arousal
    • Swelling of a Bartholin's gland cyst during intercourse
    • Bromocriptine may cause painful clitoral tumescence
  • Sensitive external genitalia:
    • Chronic vulvitis from infection, chemical irritation or allergy, including candida, herpes simplex, trichomonas, gardnerella
    • Clitoral irritation and hypersensitivity
    • Vulvar vestibulitis, increasing sensitivity
    • Skin disorders, including lichen planus and lichen sclerosus
  • Pain at introitus with entry of penis:
    • Painful episiotomy scar or posterior skin bridge
    • Surgery and radiotherapy for malignant disease
    • Rigidity of the hymenal ring
    • Inadequate lubrication (including psychological problems like past or present abuse,[6] anxiety and depression, or atrophic vaginitis)
    • Problems of arousal (including insufficient foreplay, and medication)
    • Congenital abnormality of the vagina
    • Vaginitis (from infection, chemical irritation or allergy, including from spermicides)
    • Vaginismus
  • Mid-vaginal pain:
  • Pain with orgasm:
    • Uterine contractions
    • Desipramine (not available in UK)
  • Pain with deep penetration:
    • Chronic PID
    • Vaginitis
    • Cervicitis
    • Intrauterine contraceptive device (IUCD) or intrauterine system (IUS) sitting in the cervical canal
    • Endometriosis/adenomyosis
    • Enlarged uterus from myoma
    • Fixed retroverted uterus
    • Inadequate sexual arousal (as with pain at the introitus)
    • IBS
    • Inflammatory bowel disease (IBD)[8] or chronic constipation
    • Pelvic mass
    • Interstitial cystitis
    • Retroverted uterus with prolapsed ovaries (into the pouch of Douglas)
  • Pain after intercourse:
    • Vaginismus
    • Vaginitis
    • Cervicitis
    • IUCD or IUS sitting in the cervical canal
    • Endometriosis/adenomyosis
    • IBS
    • IBD
    • Retroverted uterus with prolapsed ovaries (into the pouch of Douglas)
  • Appropriate swabs and transport media are required for candida, gonorrhoea, chlamydia and various other sexually transmitted infections.
  • Send a midstream specimen of urine to check for UTI.
  • Investigation of the gastrointestinal or urinary tract will be based on history and examination.
  • Laparoscopy is useful if endometriosis or adhesions are suspected as the source of pain.

As with erectile dysfunction, the problem should be approached by the couple rather than just the individual.

General measures

  • Treatment should be directed at the underlying cause.
  • Where psychological causes are contributory then appropriately directed counselling is essential.
  • Vaginal lubricants, local anaesthetic or pelvic relaxation exercises may also be helpful to break the cycle of spasms in women with vaginismus.
  • The most effective treatment for vaginismus is a combination of behavioural modification, vaginal dilatation, and emotional counselling. Vaginal dilatation is not a mechanical procedure, but a process of learning that something can be inserted into the vagina without causing pain.
  • Modification of sexual technique may help to reduce pain with intercourse. Increasing the amount of foreplay and delaying penetration until maximal arousal will increase vaginal lubrication and decrease pain with insertion.
  • Women may be concerned that their vagina is too small to allow entry of a penis. In response to sexual arousal, the vagina increases in length by about 35-40% and expands in width at the upper end by about 6 cm. The vagina can be tight enough to hold a pencil or wide enough to accommodate a baby's head.

Pharmacological

  • Vaginal infection may need treatment.
  • Hormonal manipulation may benefit endometriosis.
  • Local injections of corticosteroids, local anaesthetic and hyaluronidase have been well tolerated with significant improvements in pain scores and sexual function for chronic localised pain following childbirth or vaginal surgery.
  • Hormone replacement therapy (HRT) can help symptoms associated with the climacteric, including atrophic vaginitis.[9][10] Ospemifene is a non-hormonal oestrogen receptor agonist/antagonist effective in the treatment of vulvovaginal atrophy, but is not yet licensed in the UK.[11]
  • Sildenafil is still under investigation, but may be helpful for some with arousal problems.[12]

Surgical

  • Surgery is required for pelvic masses and sometimes to remove chronically infected tubes or to clear endometriosis or adhesions.
  • Occasionally, ventrosuspension to fix the uterus in an anteverted position is beneficial.
  • Fenton's operation (to enlarge a tight introitus) may help.
  • Removal of sensitive scar tissue bridge can be highly effective when there is pain following episiotomy.

Many women do not consult a doctor. The sex life of the couple suffers, as does their relationship.

The doctor must take a positive and sympathetic approach to get the best results, as there is often a combination of physical and psychological problems. Great care with internal examination is essential.

The causes and complications of the condition take time and confidence to overcome.

  • In the Scandinavian study mentioned earlier, of the women who had ever had prolonged and severe dyspareunia, only 28% had consulted a doctor for their symptoms.
  • 20% recovered after treatment.
  • 31% recovered spontaneously.[1]

Further reading & references

  1. Danielsson I, Sjoberg I, Stenlund H, et al; Prevalence and incidence of prolonged and severe dyspareunia in women: results from a population study. Scand J Public Health. 2003;31(2):113-8.
  2. Valadares AL, Pinto-Neto AM, Conde DM, et al; A population-based study of dyspareunia in a cohort of middle-aged Brazilian Menopause. 2008 Nov-Dec;15(6):1184-90.
  3. Kao A, Binik YM, Kapuscinski A, et al; Dyspareunia in postmenopausal women: A critical review. Pain Res Manag. 2008 May-Jun;13(3):243-54.
  4. Rhodes JC, Kjerulff KH, Langenberg PW, et al; Hysterectomy and sexual functioning. JAMA. 1999 Nov 24;282(20):1934-41.
  5. Handa VL, Cundiff G, Chang HH, et al; Female sexual function and pelvic floor disorders. Obstet Gynecol. 2008 May;111(5):1045-52.
  6. John R, Johnson JK, Kukreja S, et al; Domestic violence: prevalence and association with gynaecological symptoms. BJOG. 2004 Oct;111(10):1128-32.
  7. Salonia A, Zanni G, Nappi RE, et al; Sexual dysfunction is common in women with lower urinary tract symptoms and urinary incontinence: results of a cross-sectional study. Eur Urol. 2004 May;45(5):642-8; discussion 648.
  8. Guidelines on the Irritable Bowel Syndrome: Mechanisms and Practical Management; British Society of Gastroenterology (May 2007)
  9. Castelo-Branco C, Blumel JE, Araya H, et al; Prevalence of sexual dysfunction in a cohort of middle-aged women: influences of menopause and hormone replacement therapy. J Obstet Gynaecol. 2003 Jul;23(4):426-30.
  10. Johnston SL, Farrell SA, Bouchard C, et al; The detection and management of vaginal atrophy. J Obstet Gynaecol Can. 2004 May;26(5):503-15.
  11. McCall JL, DeGregorio MW; Pharmacologic evaluation of ospemifene. Expert Opin Drug Metab Toxicol. 2010 Jun;6(6):773-9.
  12. Gregersen N, Jensen PT, Giraldi AE; Sexual dysfunction in the peri- and postmenopause. Status of incidence, pharmacological treatment and possible risks. A secondary publication. Dan Med Bull. 2006 Aug;53(3):349-53.

Disclaimer: This article is for information only and should not be used for the diagnosis or treatment of medical conditions. EMIS has used all reasonable care in compiling the information but make no warranty as to its accuracy. Consult a doctor or other health care professional for diagnosis and treatment of medical conditions. For details see our conditions.

Original Author:
Dr Hayley Willacy
Current Version:
Peer Reviewer:
Dr Hayley Willacy
Document ID:
1369 (v25)
Last Checked:
09/07/2013
Next Review:
08/07/2018