Sexual Pain (DYSPAREUNIA)

Dyspareunia is painful sexual intercourse, due to medical or psychological causes. The term is used almost exclusively in women, although the problem may occur in men. The causes are often reversible, even when long-standing, but self-perpetuating pain is a factor after the original cause has been removed.

Dyspareunia is considered to be primarily a physical, rather than an emotional, problem until proven otherwise. In most instances of dyspareunia, there is an original physical cause. Extreme forms, in which the woman's pelvic floor musculature contracts involuntarily, is termed vaginismus.

According to DSM-IV (American Psychiatric Association 1994), 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 lifelong 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.

Symptoms
When pain occurs, the woman may be distracted from feeling pleasure and excitement. Both vaginal lubrication and vaginal dilation decrease. When the vagina is dry and undilated, penile thrusting 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:
* During the first 2 weeks or so, dyspareunia caused by penile insertion or movement of the penis in the vagina or by deep penetration is often due to disease or injury deep within the pelvis;
* After the first 2 weeks or so, the original cause of dyspareunia may still exist with the woman still experiencing the resultant pain. Or it may have disappeared, but the woman has anticipatory pain associated with a dry, tight vagina;

Causes
Numerous medical causes of dyspareunia exist, ranging from infections (candidiasis, chlamydia, trichomoniasis, urinary tract infections), tumours, xerosis (dryness, especially after the menopause) and LSEA. Dyspareunia may result from female genital mutilation, when the introitus has become too small for normal penetration (often worsened by scarring).

Physical Causes of Dyspareunia in Women
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., Trichomonas, coliform bacteria, mycotic organisms); endometriosis; surgical scar tissue (following episiotomy); and ovarian cysts and tumours (Bancroft 1989). 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 among postmenopausal women, although vaginal dryness is often reported by lactating women as well (Bachmann et al 1984). Women undergoing radiation therapy for pelvic malignancy often experience severe dyspareunia due to the atrophy of the vaginal walls and their susceptibility to trauma.

Physical Causes of Painful Intercourse in Males
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. Gonorrhoeal 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 (Bancroft 1989). During vigorous intercourse or masturbation, small tears may occur in the frenum of the foreskin and can be very painful.

A rare form of male dyspareunia - postejaculatory pain syndrome - is characterized by persistent and recurring pain in the genital organs during ejaculation or immediately thereafter. The painful sensations are experienced as sharp, stabbing, and/or burning. Although the duration of pain is usually brief, it can persist and be quite intense. Although the immediate cause of psychogenic postejaculatory pain syndrome is the involuntary painful spasm or cramping of certain pain-sensitive muscles in the male genital and reproductive organs, the excruciatingly painful muscle cramps may be attributable to a man’s conflict about ejaculating. A pelvic floor disorder can also be the cause of pain during and after sex. Spasming, inflammed, overtoned or shortened pelvic muscles can result in the compression or sometimes the entrapment of the pudendal nerve. Guilt about sexual pleasure or about the paraphiliac nature of the erotic fantasies can lead to pain with orgasm.

Treatment
Treatment for dyspareunia involves treating any STDs present, treating conditions like pelvic inflammatory disease, and using lubrication during sex.

Sex therapy may also be useful in women with psychological causes for this condition.