How can painful sexual intercourse (dyspareunia) be treated?

What causes painful sex (dyspareunia)?

Dyspareunia 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 is pain around the entrance to the vagina.

Superficial dyspareunia may be due to vulval problems (Q31.1), vestibulitis (Q31.13) or vaginal problems such as vaginitis (vaginal infections).Another possible cause is 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.

Endometriosis (Q 23.18) and pelvic inflammatory disease (Q 20.2)may produce deep dyspareunia. 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 (Q 23.8) and ectopic pregnancy (Q12.23) can present with pain at intercourse. When ovaries are conserved at hysterectomy (hysterectomy), they may become stuck in adhesions near the vault of the vagina resulting in dyspareunia.

Deep dyspareunia may not necessarily be related to gynaecological problems. 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 (Q 23.34), may cause pain during intercourse. Bowel symptoms together with dyspareunia 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 painful sexual intercourse (dyspareunia) be treated?

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

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.

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 a folliculitis (a boil), candida (Q 22. 6) or trichomonas (vaginal infections) will respond to appropriate medication. Superficial dyspareunia may be the first sign of infection of the Bartholin's duct (Q31. 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. 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.

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