Dyspareunia

What is dyspareunia?

Dyspareunia is pain during or after sexual intercourse. It can affect men but is more common in women. This article concerns female dyspareunia.

There are numerous causes of dyspareunia - many of which are easily treatable. It is often multifactorial and a biopsychosocial approach is usually required to elicit a full understanding of the contributing factors.¹

The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) classification combined vaginismus and dyspareunia into genito-pelvic pain/penetration disorder. This disorder of sexual pain is defined as fear or anxiety, marked tightening or tensing of the abdominal and pelvic muscles, or actual pain with vaginal penetration that is persistent or recurrent for at least six months. ¹Other classifications continue to regard these as separate conditions.²

Superficial dyspareunia is pain localised to the vulva or vaginal entrance. Deep dyspareunia is pain perceived inside the upper vagina or deep within pelvis.³

Dyspareunia may be associated with other sexual difficulties. See also the separate Female sexual dysfunction article.

How common is dyspareunia? (Epidemiology)

It is difficult to estimate the incidence of dyspareunia accurately, as it is likely that many women do not report it. The prevalence of dyspareunia and vulvodynia varies by how they are defined and by geographic location. The World Health Organization reported a global prevalence of painful intercourse ranging between 8% and 21.1% in 2006, which varied by country.³

Risk factors^{3 4}

• Comorbidities which can evoke pain felt in the pelvis, including irritable bowel syndrome, fibromyalgia, pelvic floor dysfunction, endometriosis, fibroids and inflammatory bowel disease.

• Genital scar tissue. Childbirth is a risk factor for developing pelvic pain and/or dyspareunia during and potentially beyond the postpartum period due to sensitive scar tissue formation. Pelvic floor surgery, episiotomy and female genital mutilation are all risk factors.

• Psychosocial factors including a history of sexual abuse.

Causes of dyspareunia

Some causes are specific to either superficial or deep dyspareunia, other causes may result in either superficial or deep.

Superficial dyspareunia

• Hymen tissue.

• Vaginismus.

• Vulvodynia.

• Skin disorders affecting the genitals such as eczema, psoriasis, or Lichen sclerosus.

• Female genital mutilation.

• Congenital vaginal abnormalities.

Superficial and deep dyspareunia

• Vaginal trauma and resultant scar tissue, for example postpartum.

• Vaginal or genital infection.

• Vaginal dryness due to lack of lubrication - eg, associated with anxiety, inadequate arousal before penetration, pregnancy, breastfeeding, menopause or Sjögren's syndrome.

• Vaginal atrophy associated with menopause.

• Rape and sexual assault.

Deep dyspareunia

Deep dyspareunia may be caused by psychological causes or conditions affecting the genital tract or adjacent lower abdominal structures.

• Cervical pain. This can be secondary to infection, particularly herpes.

• Intrauterine device migration.

• Endometriosis.

• Ovarian masses such as Ovarian cysts or neoplasm

• Fibroids

• Gastrointestinal - eg, Crohn's disease, ulcerative colitis or irritable bowel syndrome.

• Pelvic inflammatory disease.

• Bladder pain - eg, urinary tract infections, interstitial cystitis.

• Uterine retroversion.

Symptoms of dyspareunia

It is useful to determine if it is superficial or deep dyspareunia, though both can be present. Superficial dyspareunia begins almost immediately or shortly after penetration. It is a sharp pain and felt at the vulva, introitus or lower vagina. It may improve soon after ceasing penetration though the area may be sore to the touch for some time after. Deep dyspareunia is felt deep within the pelvis during or after penetration and may spread to the front or inner thighs. It may be sharp or dull and may stop when penetration ceases but may continue for minutes or hours afterwards.

Take a full medical history, including a sexual history:

• 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 intercourse or a combination of these)?

• If pain continues after intercourse, how long does it last?

• Does anything else produce the same pain? (For example, pain from irritable bowel syndrome (IBS) 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?

• Has the patient found any way of improving the symptoms?

• Have artificial lubricants been tried?

• Is there any history of sexual abuse, rape or trauma to the genitals.

• Are there any symptoms suggestive of the menopause.

Also establish the following:

• Is there an increased risk of a sexually transmitted infection (STI)?

• Are there any symptoms of a pelvic prolapse?

• Are there symptoms of urinary tract infection (UTI)?

• Is she breastfeeding? This can lead to vaginal dryness and dyspareunia.

• Note comorbid medical history, particularly of bowel or bladder disease, abdominal surgery (which may lead to adhesions), prolapse surgery (leading to vaginal scarring) and of psychiatric conditions which may increase anxiety or somatisation. Medical conditions which can affect vaginal health 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).

• Ask about medication, including contraception. Many medications can cause vaginal dryness which may cause or contribute to dyspareunia.

Examination⁴

• Perform a gentle abdominal examination to palpate for masses or suprapubic tenderness.

• Patients with dyspareunia may be anxious about genital examination. Reassurance about the patient being in control throughout, explaining what examination would entail, and the use of a patient-held mirror so they can see what is happening and their genital anatomy have all been reported as ways to minimise this anxiety.³

• Inspection may identify superficial causes such as scar tissue (particularly episiotomy sites postpartum), infection or skin disorders. Sensitivity testing with a cotton-bud can assess vulvodynia or be used to locate specific areas of pain reported by patients.

• Vaginal examination should be with a single, lubricated, gloved finger. It should be noted that patients with vaginismus may not tolerate vaginal examination at all. If examination is possible, advancing the finger may demonstrate vaginismus. Palpation of the pelvic floor muscles at the 4-5 o'clock and 7-8 o'clock positions may indicate tenderness or increased muscle tension if pelvic floor dysfunction is present.

• Bimanual examination is then indicated, if possible. This allows palpation of adjacent organs to see if this reproduces the dyspareunia pain. Palpation of the bladder is likely to produce a feeling of needing to pass urine, but pain may indicate interstitial cystitis. Gentle bimanual palpation of the uterus and adnexae may demonstrate tenderness which may suggest endometriosis or adhesions. Uterine position and ovarian masses may be palpated. Palpating the rectum or large bowel through the posterior vaginal wall may indicate a gastrointestinal cause.

• If tolerated, a speculum examination allows visualisation of the cervix to assess for infection and cervical sensitivity. In patients with vaginismus who are able to attempt speculum examination, use of a virgin speculum is recommended. Cervical excitation pain suggests pelvic inflammatory disease (PID). Vaginal discharge can be assessed and swabs taken for possible infections.

Investigations

• Appropriate swabs for infection, both STI and non-STI if suspected.

• Dipstick urine and/or 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 may be useful if endometriosis or adhesions are suspected as the source of pain.

Treatment for dyspareunia

Treatment should be directed at the underlying cause, where possible. Specialist input is likely to be required, often in the form of a multidisciplinary team.⁴

General measures

• A multidisciplinary approach, which includes psychosexual medicine, physiotherapy, CBT, clinical psychology and pain management teams, may be required.

• Modification of sexual technique and altering position 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.

• Vulvar hygiene to reduce vulvar skin irritation. This includes the use of emollients, wearing 100% cotton underwear, and avoiding chemical and physical irritants.³

Pharmacological

• Vaginal infection may need treatment.

• Hormonal manipulation may benefit endometriosis.

• Depending on the aetiology, options include topical, oral and injection medications. Nerve stimulators may be used.⁴

• Vaginal oestrogens are a safe and effective treatment for genitourinary syndrome of menopause. Non-hormonal vaginal moisturisers are effective in many for whom vaginal oestrogen is contraindicated.⁵ Ospemifene, a vaginal selective oestrogen receptor modulator (SERM), is effective in the treatment of menopausal vulvovaginal atrophy and may be an alternative for women who cannot use vaginal oestrogen therapy.⁶

Surgical

• Surgery may help ease symptoms but is often considered a last resort. Surgical options depend on the aetiology.

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. Immense care when carrying out an internal examination is essential.

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

Dr Mary Lowth is an author or the original author of this leaflet.