painful sex (dyspareunia) - Causes, investigations and treatments

Two types of painful sex relating to their site are recognised - superficial dyspareunia and deep dyspareunia. Sometimes there may be more than one causative factor involved.

Superficial dyspareunia

Superficial dyspareunia is pain during sex associated with problems around the entrance to the vagina. It may be due to:-

• vulval problems - vulvitis - vulvodynia (1) including genital herpes sores and inflamed genital warts
• vestibulitis (13)
• vaginal problems such as vaginitis (vaginal infections). A foreign body such as a forgotten tampon will cause discharge and inflamation
• vaginismus where there is tension or spasm of the muscles around the vaginal entrance.
  This may be associated with a physical cause for the pain and emotional factors but can arise from sexual assault and perhaps rape.

  The spasm may be such that the couple believe that there is an obstruction requiring surgical correction. Sometimes there is deeper pain and vaginismus is a protective mechanism. More frequently there is no disease but a functional problem due to an earlier sexual encounter, fear of pregnancy or inadequate arousal.

• painful scar tissue following episiotomy or a vaginal tear injury during childbirth
• bruising - haematoma

Deep dyspareunia is pain deep inside the vagina and pelvis.

The causes of deep painful sex include:

• endometriosis (18)
• fibroids
• pelvic inflammatory disease - PID (Q 20.2).
• local inflammation within the womb (endometritis) may be due to an intrauterine contraceptive device or infection after childbirth or a miscarriage. The womb is tender to touch.
• ovarian cysts (8)
• misplaced ovary - for example if the ovaries are conserved at hysterectomy, they may be trapped low in the pelvis
• ectopic pregnancy (Q12.23) - although this is not the usual presenting symptom.
• when the ovaries are conserved at hysterectomy (hysterectomy), they may become stuck in adhesions near the vault of the vagina resulting in painful sex.
• atrophic vaginitis - oestrogen levels fall at the menopause leading to vaginal dryness and reduced natural lubrication
• cancer in the genital tract can be an common cause for painful intercourse
• non gynaecological conditions.

   

  • The urethra and bladder are close to the front wall of the vagina and the rectum, lower colon and small bowel are behind. Disease in these organs, including
    • irritable bowel syndrome (34), may cause pain during intercourse. Bowel symptoms together with painful sex may alert the clinician to this diagnosis.
    • bladder infections, cystitis, urinary tract infection
    • urethral caruncle
  • The majority of women presenting with deep painful sex and pelvic pain will have no detectable disease. During sexual arousal (foreplay) the inner two thirds of the vagina expands and the uterus, ovaries and Fallopian tubes are lifted up. If arousal is not complete deep penetration can cause pain.

Diagnosis of the Cause of Painful sex

The story, vaginal and pelvice examination findings and appropriate investigations will indicate the underlying cause of the problem.

Some doctors have a special interest in caring for patients with sexually related problems.

 

How can painful sexual intercourse (dyspareunia) be treated?


Painful sex may result in apareunia (love-making has stopped or never commenced) and relationships may be put in jeopardy.

Painful sex and reduced libido are about the most sensitive of symptoms that a woman may experience and support and understanding are essential.

If a psychological or marital problem is suspected an appropriate counsellor or psychiatrist may be required to provide support.

When a specific cause is found appropriate treatment can be instituted.

Sometimes pelvic congestion may occur if there has been a high degree of arousal but no orgasm.

Lubricants, such as KY jelly may help when natural lubrication is inadequate. Vaginal moisturizers such as Rephresh may also help.

Local trauma (physical damage) either arising from childbirth or from injudicious sexual activity will usually heal with time. Sometimes healing tissue (granulation) may require cauterisation with a silver nitrate stick in the clinic (this is not painful).

Infections, such as:

• such as a folliculitis (a boil),
• candida / thrush (Q 22. 6) or
• trichomonas (vaginal infections)

will respond to appropriate medication.

Atrophic vaginitis may respond to topical estrogen such as Premarin cream or Vagifem vaginal tablets.

Superficial dyspareunia may be the first sign of infection of the Bartholin's duct ( 9).

Frequently, there is a feeling that the vagina is too small. Gentle clinical examination should be able to distinguish whether there is a physical problem. When examination shows no physical problem, vaginal dilators (sometimes called trainers) are often successful.



Picture of Amielle Vaginal Trainers

These come in six sizes. The smallest dilator (No.1) is gently introduced and the woman taught to remove it and re-introduce it for herself. She can then use it at home for tenor fifteen minutes twice daily. When she can use the smallest trainer without difficulty she can move up to the next size. Encouragement, reassurance and frequent review may be required initially.

 

 

 

 

 

 

 Occasionally surgical correction maybe indicated if the vaginal introitus is small or if the difficulties are not over come by the dilators. The operation most commonly employed is a Fenton's procedure. A small incision is introduced in the direction of the vagina at the introitus. The incision is closed horizontally to increase the vaginal diameter.

• Vaginal dilator therapy - An outpatient gynaecological option in the management of dyspareunia. (2000)
• Amielle vaginal trainers - A patient evaluation. (1998)












Please click on the required question.

•  Pelvic Pain. Is this a common problem?
•  What are the common causes of pelvic pain in women?
   What are the more common gynaecological causes of pelvic pain?
   What are the more common non-gynaecological causes of pelvic pain?
   What are primary and secondary dysmenorrhoea - painful periods?
   What is retrograde menstruation?
   How can dysmenorrhoea - painful periods be treated?
   What are ovarian cysts?
   How do ovarian cysts cause pain?
   How are ovarian cysts diagnosed?
   How are ovarian cysts treated?
   I think I may be pregnant and I have some pelvic pain. What should I do?
   What is pelvic inflammatory disease and how can it be treated?
  
  
• 3 What are the more common gynaecological causes of pelvic pain?
• 4 What are the more common non-gynaecological causes of pelvic pain?
• 5 What are primary and secondary dysmenorrhoea - painful periods?
• 6 What is retrograde menstruation?
• 7 How can dysmenorrhoea - painful periods be treated?
• 8 What are ovarian cysts?
• 9 How do ovarian cysts cause pain?
• 10 How are ovarian cysts diagnosed?
• 11 How are ovarian cysts treated?
• 12 I think I may be pregnant and I have some pelvic pain. What should I do?
• 13 What is pelvic inflammatory disease and how can it be treated?

  FIBROIDS

•  What are Fibroids?
   I have Fibroids. What difficulties might they cause for me?
   How are Fibroids diagnosed?
   How could my Fibroids be treated?
  
  
• 
   I have Fibroids. What difficulties might they cause for me?
   How are Fibroids diagnosed?
   How could my Fibroids be treated?
  
• 16 How are fibroids diagnosed?
• 17 How could my fibroids be treated?

  ENDOMETRIOSIS

• 18 What is endometriosis?
• 19 How prevalent is endometriosis?
• 20 What causes endometriosis?
• 21 How can my endometriosis be treated?
• 22 How can my doctor determine the cause of my pelvic pain?
• 23 What investigations might be recommended by my gynaecologist to investigate my pelvic pain?
• 24 What is laparoscopy?
• 25 What are pelvic adhesions?
• 26 I have chronic pelvic pain. Could this be related to adhesions?
• 27  What is uterine retroversion (retroverted uterus)
• 28  Does a retroverted uterus cause symptoms?
• 29 How is a retroverted uterus treated?
• 30 What is pelvic congestion?
• 31 What causes pain associated with sexual intercourse (dyspareunia)
• 32 How can painful sexual intercourse (dyspareunia) be treated?
• 33 What is a pelvic mass?

  IRRITABLE BOWEL SYNDROME - IBS

• 34 What is irritable bowel syndrome?
• 35 How can we find out if I have irritable bowel syndrome?
• 36 Is irritable bowel syndrome (IBS) a common condition?
• 37 What causes IBS?
• 38 What is the pain associated with IBS like?
• 39 Can IBS be mistaken for gynaecological problems?
• 40 How can my IBS be managed?
• 41 What other treatments are available for IBS?
• 42 What can be done to reduce the amount of bowel gas(flatus)
• 43 What is constipation?
• 44 What causes constipation?
• 45  How can constipation be treated?
• 46 How could we summarise the treatments that are available for my pelvic pain?
• 47 Where can I obtain more information?
• 48 Pelvic Pain Support Groups.
• 49 Endometriosis Support Groups.
• 50 IBS Support Groups.
• Painful intercourse
• Pain during intercourse





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This is the personal website of David A Viniker MD FRCOG, Consultant Obstetrician and Gynaecologist at Whipps Cross University Hospital, London - Specialist Interests - Reproductive Medicine including Infertility, PCOS, PMS, Menopause and HRT.

I do hope that you find the answers to your women's health questions in the patient information and medical advice provided.