What Causes Painful Sex (Dyspareunia)?

Painful sex is a very distressing problem, which may have dire effects on relationships with partners. As a result of intercourse difficulties couples sometimes split up because of it.

Emotions and self-esteem are likely to suffer.

Two types of painful sex relating to their site are recognised - superficial dyspareunia and deep dyspareunia. Sometimes there may be more than one causative factor involved.

Superficial Dyspareunia

Superficial dyspareunia is pain during sex associated with problems around the entrance to the vagina. It may be due to:-

• vulval problems - vulvitis - vulvodynia (1) including genital herpes sores and inflamed genital warts
• vestibulitis (13)
• vaginal problems such as vaginitis (vaginal infections). A foreign body such as a forgotten tampon will cause discharge and inflamation
• vaginismus where there is tension or spasm of the muscles around the vaginal entrance.

   

  This may be associated with a physical cause for the pain and emotional factors but can arise from sexual assault and perhaps rape.

   

  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.

• painful scar tissue following episiotomy or a vaginal tear injury during childbirth
• bruising - haematoma
  • endometriosis (18)
  • fibroids
  • pelvic inflammatory disease - PID (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 (varian-Cysts.htm">8)
  • misplaced ovary - for example if the ovaries are conserved at hysterectomy, they may be trapped low in the pelvis
  • 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 painful sex.
  • atrophic vaginitis - oestrogen levels fall at the menopause leading to vaginal dryness and reduced natural lubrication
  • cancer in the genital tract can be an common cause for painful intercourse
  • 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.
      • bladder infections, cystitis, urinary tract infection
      • urethral caruncle
    • The majority of women presenting with deep painful sex 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.
  • such as a folliculitis (a boil),
  • candida / thrush (Q 22. 6) or
  • trichomonas (vaginal infections)

Deep Dyspareunia Is Pain Deep Inside The Vagina And Pelvis.

The causes of deep painful sex include:

Diagnosis Of The Cause Of Painful Sex

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

Some doctors have a special interest in caring for patients with sexually related problems.

How Can Painful Sexual Intercourse (Dyspareunia) 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.

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:

will respond to appropriate medication.

Atrophic vaginitis may respond to topical estrogen such asPremarin 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.