Dyspareunia

Dyspareunia is a sexual pain disorder. Dyspareunia is genital pain that accompanies sexual intercourse. Both males and females can experience this disorder, but the disorder is more common in women. Recurrent pain associated with intercourse, in women not due to vaginismus, poor lubrication, and in women and men not due to drugs or other physical causes. The most common cause of pain during sex is inadequate vaginal lubrication occurring from a lack of arousal, medications or hormonal changes. There is a relationship of this disorder with victims of rape and sexual abuse.

Dyspareunia can be divided into three types of pain: superficial, vaginal and deep.

Superficial dyspareunia occurs with attempted penetration, usually secondary to anatomic or irritative conditions, or vaginismus.

Vaginal dyspareunia is pain related to friction (i.e., lubrication problems), including arousal disorders.

Deep dyspareunia is pain related to thrusting, often associated with pelvic disease or relaxation

Physical causes of dyspareunia :

Females

Failure of vaginal lubrication

Failure of vasocongestion

Failure of uterine elevation and vaginal ballooning during arousal

Oestrogen deficiency leading to atrophic vaginitis

Radiotherapy for malignancy

Vaginal infection e.g. Trichomonas or herpes

Vaginal irritation e.g. sensitivity to creams or deodorants

Abnormal tone of pelvic floor muscles

Scarring after episiotomy or surgery

Bartholin's gland cysts/abscess

Rigid hymen, small introitus

Males

Painful retraction of the foreskin

Herpetic and other infections

Asymmetrical erection due to fibrosis or Peyronie's disease

Hypersensitivity of the glans penis

The physical examination must include meticulous detail, with the physician's focus on recreating the pain. To detect the cause of dyspareunia patients need a complete history and physical exam by a clinician. This exam also include detailed vaginal exam with fingers and vaginal speculum to rule out any physical cause like vaginits, infection, cancer or any other reason. if no obvious reasons are detected then other diagnostic modalities including ultrasound, CT scan and laparoscopy may be neede.

Treatment of the underlying etiology is fundamental, but as in long-term pain disorders, counseling and pain control strategies are essential. treatment of a patient with recurrent cystitis as a cause of dyspareunia should include the use of lubricants and distraction techniques at first intercourse to assure adequate lubrication and relaxation, respectively. To be specific for the possible treatment of different types of dyspareunia several methods can be tried as below.

Superficial: female astride for control of penetration, topical lidocaine, warm baths before intercourse, biofeedback.

Vaginal: same as for superficial dyspareunia but with the addition of lubricants.

Deep: position changes so that force is away from pain and deep thrusts are minimized, nonsteroidal anti-inflammatory drugs before intercourse.

Sex therapy and behavioral therapy may be an important part of complete treatment if there are no medical or pathological reasons for dyspareunia and if it is considered as secondary to past sexual trauma. Experienced therapist can address the underlying issues during sex therapy sessions and sometime it can resole the problem completely.

For treatment in males should include relieving the underlying cause as circumcision, surgery, use of lubricants and lidocaine jelly and medical treatment for infections,