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 treatable.

Epidemiology

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 the women aged 50-60 years.¹

A population-based study, using an anonymous, self-report questionnaire, was completed by 200 Brazilian-born women, aged 40-65 years, with 11 years or more of formal education.² The prevalence of dyspareunia was 39.5%.

Risk factors

It occurs most frequently in:

• Those who are sexually inexperienced (as are their partners).
• The time of the menopause.³

Hysterectomy may be expected to increase the risk but the opposite is observed.⁴

Presentation

Symptoms

Ask if it is superficial dyspareunia on penetration or deep dyspareunia that is felt with penile thrusting. Tightening of the vaginal muscles on penetration is called vaginismus.

Ask the patient:

• Is it recent or has there always been dyspareunia?
• Has she tried artificial lubricants?
• Ask about sexual history to help assess the risk of sexually transmitted disease.
• Has there been sexual abuse or trauma to the genitals, including childbirth?
• Ask about symptoms suggestive of the menopause.
• Is there a symptomatic prolapse?⁵
• Are there symptoms of urinary tract infection (UTI)?
• Is she breast-feeding, as that can also lead to vaginal dryness and dyspareunia?
• Note comorbid medical history.

Signs

• First perform an abdominal examination to detect any masses or suprapubic tenderness and then a sympathetic vaginal examination. 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.
• Look for skin disease.
• Note if vaginal secretions seem normal or sparse.
• Look for inflammation, infection like candida, herpes simplex or genital warts, and scarring.
• Gently feel for abnormal pelvic masses, tenderness or lack of mobility of the pelvic organs, suggesting endometriosis. Cervical excitation pain suggests pelvic inflammatory disease (PID). This may be an appropriate time to take swabs.
• Tenderness on posterior palpation of the rectum is common with irritable bowel syndrome (IBS).

Differential diagnosis

Symptoms can give a good indication of cause:

• 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.
  • 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).
• Midvaginal pain:
  • Congenitally shortened vagina.
  • Acute or chronic cystitis, or interstitial cystitis.⁷
  • Urethritis.
• Pain with orgasm:
  • Uterine contractions.
  • Desipramine (not available in UK).
• Pain with deep penetration:
  • Chronic PID.
  • Endometriosis.
  • Enlarged uterus from myoma or adenomyosis.
  • Fixed retroverted uterus.
  • Inadequate sexual arousal (as with pain at the introitus).
  • Inflammatory bowel disease, IBS⁸ or chronic constipation.
  • Pelvic mass.

Investigations

• 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.

Management

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.
• 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.⁹
• 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 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.¹⁰
• Hormone replacement therapy (HRT) can help symptoms associated with the climacteric, including atrophic vaginitis.^11,12 Ospemifene is a non-hormonal oestrogen receptor agonist/antagonist effective in the treatment of vulvovaginal atrophy, but is not yet licensed in the UK.¹³
• Sildenafil is still under investigation, but may be helpful for some with arousal problems.¹⁴

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.

Complications

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

Prognosis

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. The latter take time and confidence to overcome.

• In the Scandinavian study mentioned above, 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

Document 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. [abstract]
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. [abstract]
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. [abstract]
4. Rhodes JC, Kjerulff KH, Langenberg PW, et al; Hysterectomy and sexual functioning. JAMA. 1999 Nov 24;282(20):1934-41. [abstract]
5. Handa VL, Cundiff G, Chang HH, et al; Female sexual function and pelvic floor disorders. Obstet Gynecol. 2008 May;111(5):1045-52. [abstract]
6. John R, Johnson JK, Kukreja S, et al; Domestic violence: prevalence and association with gynaecological symptoms. BJOG. 2004 Oct;111(10):1128-32. [abstract]
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. [abstract]
8. Fass R, Fullerton S, Naliboff B, et al; Sexual dysfunction in patients with irritable bowel syndrome and non-ulcer dyspepsia. Digestion. 1998;59(1):79-85. [abstract]
9. Brauer M, de Jong PJ, Huijding J, et al; Automatic and Deliberate Affective Associations with Sexual Stimuli in Women with Superficial Dyspareunia. Arch Sex Behav. 2008 Jun 3. [abstract]
10. Doumouchtsis SK, Boama V, Gorti M, et al; Prospective evaluation of combined local bupivacaine and steroid injections for Arch Gynecol Obstet. 2010 Nov 16. [abstract]
11. 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. [abstract]
12. 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. [abstract]
13. McCall JL, DeGregorio MW; Pharmacologic evaluation of ospemifene. Expert Opin Drug Metab Toxicol. 2010 Jun;6(6):773-9. [abstract]
14. 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. [abstract]

Internet and further reading

• Frank JE, Mistretta P, Will J; Diagnosis and treatment of female sexual dysfunction. Am Fam Physician. 2008 Mar 1;77(5):635-42. [abstract]

Acknowledgements