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|Classification and external resources|
Dyspareunia (from Greek, meaning "badly mated") is painful sexual intercourse, due to medical or psychological causes. The symptom is significantly more common in women than in men, affecting up to one-fifth of women at some point in their lives. The causes are often reversible, even when long-standing, but self-perpetuating pain is a factor after the original cause has been removed.
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.
When pain occurs, the woman experiencing dyspareunia may be distracted from feeling pleasure and excitement. Both vaginal lubrication 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:
Numerous medical causes of dyspareunia exist, and they can be broken down into congenital and acquired causes in this non-comprehensive list:
Because there are numerous physical conditions that can contribute to pain during sexual encounters, a careful physical examination 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 tubes (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 hymenal remnants, can contribute to coital discomfort (Sarrell and Sarrell 1989). 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. 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.
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. Another cause of painful intercourse is due tension in a short and slender frenulum, frenulum breve, as the foreskin retracts on entry to the vagina irrespective of lubrication. In one study frenulum breve was found in 50% of patients who presented with dyspareunia. During vigorous or deep or tight intercourse or masturbation, small tears may occur in the frenum of the foreskin and can bleed and be very painful and induce anxiety which can become chronic if left unresolved. If stretching fails to ease the condition, and uncomfortable levels of tension remain, a frenuloplasty procedure may be recommended. Frenuloplasty is an effective procedure, with a high chance of avoiding circumcision, giving good functional results and patient satisfaction.
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 – 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 syndrome (VVS) – 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 cysts and pelvic adhesions, inflammatory disease, or congestion).
Vulvar vestibulitis is the most common subtype of vulvodynia affecting premenopausal women which causes dyspareunia, and it tends to be associated with a highly localized "burning" or "cutting" type of pain.
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.
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, one or more treatments may be necessary.