Painful Intercourse – Dyspareunia

What causes dyspareunia (painful sex)?

Painful sex is a very distressing problem, which may have dire effects on a relationship.

Two types of dyspareunia relating to their site are recognised.

Superficial dyspareunia

Superficial dyspareunia is pain around the entrance to the vagina.
It may be due to

  • vulval problems (1)
  • vestibulitis (13)
  • vaginal problems such as vaginitis (vaginal infections).
  • vaginismus where there is tension or spasm of the muscles around the vaginal entrance.
    • 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.

Deep dyspareunia is pain deep inside the vagina and pelvis.

The causes of deep dyspareunia include:

  • endometriosis (18)
  • pelvic inflammatory disease (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)
  • 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
    dyspareunia.
  • atrophic vaginitis
  • 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.
  • The majority of women presenting with deep dyspareunia 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.

How can dyspareunia (painful sexual intercourse) 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.

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

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