Painful Intercourse (Dyspareunia)

Women With Vaginal Pain Discussing With Her Gynecologist

• Pain during intercourse (dyspareunia) is pain or discomfort in a woman's labial, vaginal, or pelvic areas during or immediately following sexual intercourse.
• The word dyspareunia comes from the early Greek language, and its meanings include "difficulty mating" or "badly mated." Pain during intercourse is described in medical literature dating back to the ancient Egyptian scrolls.
• Today, most causes of dyspareunia can be easily discovered and treated.
• Many women experience some pain during their first experience of vaginal sexual intercourse.
• The number of women who experience pain during intercourse is unknown because the symptoms vary. Also, both doctors and patients may feel uncomfortable discussing sexual practices.
• Recent studies suggest that more than many women report current or previous episodes of pain during sex.
• Fewer than half of these women discussed this pain with their doctors.

Painful intercourse or painful sex can be experienced as pelvic pain, vaginal pain, or pain in the labial or vulvar areas during sex. Pain may be experienced as deep pain, sharp pain, or a burning sensation.

Pain during intercourse is one of the most common causes of problems of sexual dysfunction. The prevalence of such pain seems to be increasing over time. Possible reasons for this apparent increased prevalence include the following:

• Changes in sexual behavior
• An increase in the frequency of sexually transmitted diseases
• Increased willingness to discuss sexual behavior and dysfunction
• Due to thinning and dryness of the vaginal walls after menopause, some women report that sex is more painful than prior to menopause.
• Vulvodynia is a condition that causes chronic pain in the vulvar area that is not related to a known cause. Women with vulvodynia may experience pain with sexual intercourse.
• Other conditions that can cause painful intercourse include
  • injuries or irritation of the vagina due to any cause,
  • infections,
  • vaginismus (muscle spasms of the vaginal wall muscles),
  • urinary tract infection, and
  • skin conditions that affect the genital areas.

Symptoms of pain related to sexual intercourse can occur when entry is attempted or during and/or immediately following sexual intercourse.

• The most common symptom is pain on entry (intromission). The pain may be described as sharp or burning.
• The second most common symptom is deep pain.
• Other symptoms include feelings of muscle spasms, pelvic cramping, or muscle tightness.

Pain during intercourse may be described as primary or secondary; as complete or situational; and as superficial-entrance or deep thrust types.

• Primary pain with intercourse is pain that has existed for the woman's entire sexual lifetime.
• Secondary pain develops after a symptom-free period of time.
• Complete pain means the woman experiences pain in all times during intercourse.
• Situational pain occurs with a particular partner or a certain type of stimulation.
• Superficial-entrance pain is noticeable at penetration.
• Deep thrust pain is located at the cervix or in the lower abdominal area and is noticeable during or after penetration.

A woman may perceive pain during intercourse even without any physical cause. Sexual pain without an apparent physical cause may have a psychological origin.

A woman should always consult a health care professional if she is experiencing new or worsening pain, bleeding, or discharge following intercourse.

Pain related to intercourse is a condition most appropriately checked by a primary health care professional or a women's health specialist (gynecologist). Other specialists, such as a psychiatrist, psychologist or a urologist, may also be consulted depending on the underlying cause.

Pain during intercourse is generally not an emergency. A woman should seek care in a hospital's emergency department if she experiences any of the following symptoms:

• New onset of pain or pain more severe than previous episodes and that lasts more than just a few minutes
• Bleeding following pain, particularly new onset or severe pain
• Nausea, vomiting, or rectal pain following intercourse
• A new discharge

A healthcare professional should ask about a woman's history of pain during intercourse. A thorough history and an extensive physical examination often reveal the most probable cause of this pain.

• Medical history: Medical history identifying pain at the vaginal opening may suggest one of the following:
  • Inadequate lubrication during the arousal phase (may be associated with hormonal changes or medications)
  • Inflammation at the opening into the vagina
  • Painful spasms of the vagina that prevent intercourse
• Symptoms: Pain located in the entire vaginal area may indicate conditions such as vulvar muscle degeneration, chronic vulvar pain, or a vaginal infection (fungal, parasitic, or bacterial).
  • At times, a specific area of discomfort may be identified that might suggest another cause for the pain, such as inflammation of the urethra (the tube through which urine exits the body).
  • Deep thrust dyspareunia refers to pain that occurs with deep repetitive vaginal penetration by her partner. A common complaint is that it feels as though her partner is "bumping" into something which causes pain with pelvic thrusting. This type of pain may suggest abnormalities of the pelvic organs, such as endometriosis, adhesions, or uterine prolapse.
  • Pain in the middle of the pelvis may suggest a uterine origin. Pain on one or both sides of the pelvis is more suggestive of pathology involving the fallopian tubes, ovaries, and ligaments.
• Physical exam: A healthcare professional may perform an extensive physical examination of the woman's pelvis, abdomen, and lower back to better understand both her anatomy and the location of her pain. The exam may also allow the woman to better guide the doctor to the location of the discomfort. Part of this exam should include a rectal exam or rectovaginal exam. The exam may include a Pap smear, the collection of vaginal or cervical fluids for culture, an analysis of the urine (urinalysis), and other laboratory tests.
• Radiological tests: A healthcare professional may recommend special radiological tests, such as a pelvic ultrasound or a CT scan, or an MRI of the pelvis.
• Other tests: The doctor may perform a urethrogram (an X-ray procedure to provide an image of the urinary tract), a cystogram (an x-ray exam that images the urinary bladder), or both, or the woman may be referred to a specialist (urologist) for these procedures. Another diagnostic procedure that may be used to look for urinary abnormalities is a cystoscopy, in which the doctor uses a thin, lighted probe to see the interior lining of the bladder and urethra. Frequently, referral to a urologist may be necessary to complete these procedures.

Applying lubricating gels to the outer sexual organs, the vulva and labia, as well as using lubricating products in the vagina may be helpful to some women and ease pain during intercourse. Sex toys, such as vibrators or dildos, may also be useful. A woman should talk with her health care professional before attempting to use a vaginal dilator.

Treatment of pain during intercourse depends on the cause. Introital pain may be treated when the cause is identified.

• Atrophy (thinning of the vaginal walls) due to menopause: Entrance (introital) pain caused by vaginal atrophy is common among postmenopausal women who do not take estrogen replacement medication. Blood flow and lubricating capacity respond directly to estrogen replacement. The most rapid reversal of vaginal atrophy occurs when topical estrogen vaginal cream is applied directly to the vagina and its opening. This cream is available by prescription only. Newer non-estrogen products are also now available.
• Urethritis and urethral syndrome: Irritation of the urethra and lower bladder can be caused by a lack of estrogen. This may result in urinary burning, frequency, and hesitancy. In such cases there may be no evidence of bacterial infection on microscopic examination of the urine. In the absence of any chronic inflammation of the urethra, these symptoms may be caused by these symptoms may be caused by muscle spasms, anxiety, low estrogen levels, or a combination of these factors. The doctor may dilate the urethra or may prescribe low-dose antibiotics. At times, antidepressants and antispasmodic medications to reduce muscle contractions in the bladder may also be prescribed.
• Inadequate lubrication: Treatment of inadequate lubrication depends on its specific etiology. One option of treatment includes water-soluble lubricants (for use with condoms, as other types of lubricants may damage wall of the prophylactic). If adequate arousal does not take place, more extensive foreplay might be helpful in increasing vaginal moisture.
• Vaginismus: Painful spasms of muscles at the opening of the vagina may be an involuntary but appropriate response to painful stimuli. These spasms may be due to several factors, including painful intromission, previous painful sexual experiences, prior sexual abuse, or an unresolved conflict regarding sexuality. For a woman with vaginismus, her doctor may recommend behavior therapy, including vaginal relaxation exercises.
• Vaginal strictures (abnormal narrowing): Doctors commonly see vaginal strictures following pelvic surgery, pelvic irradiation, or menopause. Passive dilation and estrogen are used to treat these strictures. Occasionally, vaginal reconstructive surgery is necessary.
• Interstitial cystitis: This condition refers to chronic inflammation of the bladder with no known cause. However, painful intercourse is a common symptom. A physician may perform a cystoscopy (a procedure to look inside the bladder) and distend (stretch) the bladder wall in order to attempt treatment of the condition. Other treatments include bladder washings with dimethyl sulfoxide (DMSO), as well as oral medications, e.g. imipramine (Tofranil) or pentosan (Elmiron).
• Endometriosis: Endometriosis occurs when the lining of the uterus is found in ectopic locations outside the interior of the uterus. Pain during intercourse caused by endometriosis is seen frequently. Relief of this pain often indicates success in treating endometriosis.
• Vulvovaginitis (inflammation of the vulva and vagina): Whether recurrent or chronic, this problem is common despite the rise in the number of over-the-counter treatments.
  • If not responsive to self-treatment with lubricating gels or initial treatment by a physician, a woman may need a more thorough evaluation to identify the cause.
  • A physician may ask a woman if she is using an antibiotic or antifungal medication or if she douches. If so, these practices should be stopped to help determine whether a specific disease-causing organism is present. Instruction in proper vaginal hygiene may be helpful.
  • Treatment is based on the presence of bacteria or other organisms. Often, no single organism is identified. The doctor may talk to the woman about proper hygiene.
  • If recurring symptoms are shared with a sexual partner, both individuals should be tested for sexually transmitted diseases (STDs).
  • A physician should consider the possibility of intermittent urethral infection with chlamydia, (an STD), as well as the more common urinary tract infection. If either is discovered, they should be treated with the appropriate antibiotics.
• Pelvic adhesions (tissue that has become stuck together, sometimes developing after surgery): Pain with intercourse caused by pelvic adhesions can be relieved by removing or cutting free the adhesions.
• Uterine retroversion: In addition to the causes previously discussed, the patient may also have what is called uterine retroversion as a cause of their pain. This term refers to a uterus which is tilted backward in the pelvis, as opposed to the normally forward tilted orientation. This can be congenital or due to childbirth injury to the ligaments supporting the uterus. It may also be due to pelvic adhesions which pull the uterus backward into an abnormal location. This condition frequently requires gynecologic surgery for correction.

With an adequate history, physical examination, and laboratory testing, the doctor should be able to pinpoint the cause of dyspareunia. This will allow for the development of a plan of action that will afford the best possibility of resolution of the pelvic pain syndrome.

A woman may need to see the following specialists:

• Gynecologist: Thorough pelvic examination or testing
• Urologist: Evaluation of the bladder and urethra
• Behavioral health specialist: Evaluation of possible social or psychological contributors to the problem

In an attempt to prevent painful intercourse, a woman might avoid or discontinue use of the following:

• Perfumed soaps
• Douching
• Vaginal perfumes
• Bubble baths
• Scented or tinted toilet papers
• Panty liners or tight synthetic undergarments such as panty hose

The causes of pain during intercourse are often discoverable and responsive to treatment. For best results, a team approach is recommended involving all of the specialists listed above.