Dyspareunia is a feeling of discomfort or soreness in the area of the external genitals and pelvis that occurs in connection with sexual intercourse. In women, it can have both a psychological and an organic basis. Dyspareunia leads to sexual dissatisfaction, decreased sexual desire, avoidance of sexual contact, disruption of relationships with a partner, depression. The causes of dyspareunia are established in the process of gynecological examination, ultrasound, laboratory tests, consultation with a psychotherapist or sexologist. Treatment may include therapy of the underlying gynecological disease, psychotherapy, and the development of optimal sexual techniques.
ICD 10
N94.1 Dyspareunia
General information
Dyspareunia – unpleasant or painful sensations that occur in the genitals before, during or immediately after the end of coitus. It can occur in persons of both sexes, but most often such a disorder of sexual function is registered among women. Exact data on the prevalence of dyspareunia in the female population are unknown, since many patients, embarrassed by their problem, do not turn to specialists with it. According to various sources, episodes of dyspareunia are periodically experienced by 15% to 60% of women (in the postpartum period – 45%), however, specialized gynecological care is required by a much smaller number of patients.
Initially, the term “dyspareunia” was considered exclusively within the framework of sexology. At the same time, different researchers put different meanings into it, interpreting it both as an inability to get an orgasm, and as a decrease in sexual desire, sexual coldness, painful sexual intercourse. The causes of dyspareunia were mainly mental factors contributing to the occurrence of pathological sexual reactions. Currently, the multilateral, integral nature of dyspareunia has been proven, and therefore not only sexologists, but also specialists in the field of gynecology and andrology are engaged in solving this problem.
Causes of dyspareunia
An important role in the formation of dyspareunia belongs to constitutional and personal characteristics, heredity, reproductive health, forms of sexual behavior, previous sexual experience, etc. Organic causes of superficial dyspareunia may be associated with malformations of the vagina and vulva, fibrotic hymen. Quite often, when examining patients with this disorder, infectious diseases are detected – vulvitis, colpitis, vulvovaginitis of various etiologies, bartholinitis.
Sexual intercourse can become painful due to postoperative or post-radiation stenosis of the vestibule of the vagina, postpartum complications, the presence of condylomatous growths in the perineum and genitals. Some women have indications of vulvodynia – painful sensations that are not directly related to sexual intercourse. In pre- and postmenopausal patients, dyspareunia may be caused by vulvar dystrophy, atrophic colpitis. Vaginal dryness and discomfort during sexual intercourse is observed in Sjogren’s syndrome. The etiological prerequisites for deep dyspareunia are often retroflexia of the uterus, varicose veins of the pelvis, endometriosis, uterine fibroids, adhesions in the pelvis, STDs, interstitial cystitis, uterine prolapse.
In addition to organic pathology, the causes of pain during sexual intercourse may be an incorrectly sized condom or an allergic reaction to it (latex, lubricant, dyes or aromatic substances). Dyspareunic complaints may also be associated with the use of other types of contraception: IUDs, spermicides, caps, diaphragm, vaginal ring. The occurrence and severity of symptoms are influenced by sexual technique (sexual position, pace and rhythm of frictions, depth of penetration), behavior of the sexual partner (insufficient sexual stimulation, coercion, aggressiveness, etc.), lack of love and mutual trust in a couple. A certain role may be played by the fear of infection with sexually transmitted diseases or the onset of unwanted pregnancy.
Psychological prerequisites of dyspareunia usually lie in the area of a woman’s negative previous sexual experience or dissatisfaction with real partnerships. These circumstances directly affect the quality of sexual life. Pain that occurred during the first sexual intercourse or in connection with rape, inflammatory diseases, etc., can be firmly fixed in memory, as a result of which subsequent attempts at intimacy are also accompanied by pain. Sometimes dyspareunia is retained on the principle of secondary benefit, allowing a woman to avoid or significantly limit sexual intimacy with a partner who is unpleasant to her.
Classification
Depending on the factors causing dyspareunia, there are symptomatic, psychogenic and mixed forms.
Symptomatic (organic) dyspareunia occurs as a consequence of infectious-inflammatory, scarring, atrophic, traumatic, tumor, dishormonal pathological processes of the genitourinary sphere, but is not associated with disorders of sexual behavior.
Psychogenic dyspareunia is an independent sexual dysfunction and can be a reflection of an unconscious conflict, a manifestation of anxiety disorders, phobias and sexual perversions. There are two types of psychogenic dyspareunia among the patients: intrapersonal (type I) and interpersonal (type II). With type I sexual dysfunction, women indicate the presence of traumatic experiences in the past, feelings of guilt, deception or painful birth trauma. Type II patients have problems in their relationship with a partner in the present tense, which results in dyspareunia.
Mixed dyspareunia combines a primary developed organic form with psychogenic factors layered on it, which determine the perception of pain and sexual behavior of a woman.
When dyspareunia occurs from the very beginning of sexual life, it is said about its primary form, if pathological symptoms appear after a period of normal sexual reactions and sensations, then this violation is considered as secondary. According to the localization of painful sensations, there are superficial (in the area of the external genitalia and the entrance to the vagina) and deep dyspareunia (in the pelvic region).
Symptoms of dyspareunia
Dyspareunic pains can occur at the moment of sexual arousal, during the insertion of the penis into the vagina, during movements of the penis or after the completion of sexual intercourse. The nature of painful sensations women describe in different ways: some as aching, others – burning with itching, others – stabbing pain. The degree of painful sensations also varies – from discomfort to severe, unbearable pain. Usually, patients accurately indicate the localization of pain (superficial, deep or a combination of them), the dependence of their feelings on the situation and sexual posture. Due to the expectation of a repetition of pain, a fear of sexual intercourse is formed over time, a woman under all sorts of pretexts seeks to avoid intimacy with a sexual partner. Unlike vaginismus, with dyspareunia, spasm of the muscles of the entrance to the vagina does not occur.
Dyspareunia can occur both during sexual intercourse with different partners, and occur only during intimacy with a specific man. In some patients, dyspareunia is combined with other sexual disorders: decreased libido, impaired sexual arousal, anorgasmia. Long-lasting dyspareunia creates conditions for the development of neurotic reactions, depression, separation from a sexual partner, loss of interest in the sexual side of life.
Diagnostics
To diagnose dyspareunia, gynecological, psychological and sexological examination is required. Sometimes the consultation of a psychologist and a sexologist is also necessary for the patient’s permanent partner.
When talking to a woman, they find out various aspects that can shed light on the etiology of the problem (the time of the onset of pain, their localization, nature and intensity, circumstances of occurrence, previous treatment methods). Obstetric and gynecological anamnesis is carefully collected, special attention is paid to the presence of vaginal symptoms (pathological whites, burning, itching), past sexual infections and other diseases, birth trauma, abdominal surgery, methods of contraception.
When examining a patient in a chair, the gynecologist carefully examines the vulva area, visually identifying signs of inflammation, atrophy, and skin lesions of the perineum. Bimanual examination allows you to detect soreness in the area of the vestibule of the vagina, uterus, appendages. In order to exclude or confirm the organic causes of dyspareunia, smears are taken for flora, sexual infections, oncocytology; ultrasound of the pelvic organs is performed. In the absence of data for organic dyspareunia, a woman is referred to a psychotherapist or sexologist for specialized diagnostics.
Treatment of dyspareunia
In the presence of confirmed organic causes of dyspareunia, treatment is carried out by specialists of the appropriate profile (gynecologists, urologists, venereologists). Taking into account the identified etiological factors, drug therapy (anti-inflammatory, sedatives, HRT, local anesthetics), gynecological massage, physiotherapy are prescribed. According to the indications, surgical intervention is performed (correction of anatomical defects, vaginoplasty, dissection of the fibrotic hymen, removal of condylomas, removal of the cyst of the bartholinium gland, etc.). If necessary, a suitable method of contraception is selected. In case of genital prolapse, the use of a uterine ring is recommended.
