Dyspareunia

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.

It is difficult to accurately estimate the incidence of dyspareunia, as the majority of cases are unreported. In 1990 one survey of 105 women found that:¹

• 21% reported dyspareunia as "rare"
• 55% as "occasional"
• 24% as "frequent" or "always"
• 47% had less frequent intercourse because of dyspareunia
• 33% said that it had an adverse effect on their relationship

In Scandinavia in 2003 a much larger group (n=3017) showed a prevalence of 9.3% for the whole group, and 13% for women aged 20-29 and 6.5% for the women aged 50-60.²

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

Symptoms

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

• 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 UTI?
• Is she breastfeeding as that can also lead to vaginal dryness and dyspareunia?
• Note co-morbid 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 PID. This may be an appropriate time to take swabs.
• Tenderness on posterior palpation of the rectum is common with irritable bowel syndrome (IBS).

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 increases sensitivity.
  • Skin disorders including lichen planus and lichen sclerosis.
• 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 or chemical irritation or allergy including from spermicides)
• Midvaginal pain:
  • Congenitally shortened vagina
  • Acute or chronic cystitis, or interstitial cystitis⁷
  • Urethritis
• Pain with orgasm:
  • Uterine contractions
  • Desipramine (can cause painful orgasm)
• Pain with deep penetration:
  • Chronic pelvic inflammatory disease
  • Endometriosis
  • Enlarged uterus from myoma or adenomyosis
  • Fixed retroverted uterus
  • Inadequate sexual arousal (as with pain at the introitus)
  • Inflammatory bowel disease, irritable bowel syndrome⁸ or chronic constipation
  • Pelvic mass

• Appropriate swabs and transport media are required for candida, gonorrhoea, chlamydia and various other sexually transmitted infections.
• Send a MSU to check for urinary tract infection (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.
• 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 behaviour 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 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 to 40% and expands in width at the upper end 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.
• HRT can help symptoms associated with the climacteric, including atrophic vaginitis.^10,11
• 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 removed 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.

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. 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.²