Dyspareunia
A major obstacle to sexual enjoyment, dyspareunia is painful or difficult coitus. Although most sexually active women occasionally experience mild dyspareunia, persistent or severe dyspareunia is cause for concern. Dyspareunia may occur with attempted penetration or during or after coitus. It may stem from friction of the penis against perineal tissue or from jarring of deeper adnexal structures. The location of pain helps determine its cause.
Dyspareunia commonly accompanies pelvic disorders. However, it may also result from diminished vaginal lubrication associated with aging, the effects of drugs, and psychological factors—most notably, fear of pain or injury. A cycle of fear, pain, and tension may become established, in which repeated episodes of painful coitus condition the patient to anticipate pain, causing fear, which prevents sexual arousal and adequate vaginal lubrication. Contraction of the pubococcygeal muscle also occurs, making penetration still more difficult and traumatic.
Psychological factors include guilty feelings about sex, fear of pregnancy or of injury to the fetus during pregnancy, and anxiety caused by a disrupted sexual relationship or by a new sexual partner. Inadequate vaginal lubrication associated with insufficient foreplay and mental or physical fatigue may also cause dyspareunia.
History and physical examination
Begin by asking the patient to describe the pain. Does it occur with attempted penetration or deep thrusting? How long does it last? Is the pain intermittent or does it always accompany intercourse? Ask whether changing coital position or using a vaginal lubricant relieves the pain.
Next, ask about a history of pelvic, vaginal, or urinary tract infection. Does the patient have signs and symptoms of a current infection? Have her describe any discharge. Also, ask about malaise, headache, fatigue, abdominal or back pain, nausea and vomiting, and diarrhea or constipation.
Obtain a sexual and menstrual history. Determine whether dyspareunia is related to the patient’s menstrual cycle. Are her cycles regular? Ask about dysmenorrhea and metrorrhagia. Has the patient had a baby? If so, did she have an episiotomy? Note whether she’s breast-feeding. Ask about previous abortion, sexual abuse, or pelvic surgery. Also, find out what contraceptive method the patient uses. Does her partner use condoms? Does he or could he have a latex allergy? Then try to determine her attitude toward sexual intimacy. Does she feel tense during coitus? Is she satisfied with the length of foreplay? Does she usually achieve orgasm? Ask about a history of rape, incest, or sexual abuse as a child.
Next, perform a physical examination, starting with vital signs. Palpate the abdomen for tenderness, pain, or masses and for inguinal lymphadenopathy. Finally, inspect the genitalia for lesions and vaginal discharge.
Medical causes
Allergies
Allergic reactions to diaphragms or condoms may result in dyspareunia.
Atrophic vaginitis
In postmenopausal and breast-feeding women, decreased estrogen secretion may lead to inadequate vaginal lubrication and dyspareunia, which intensifies as intercourse continues. Accompanying signs and symptoms include pruritus, burning, bleeding, and vaginal tenderness. Patients may complain of a watery discharge at the same time that they’re feeling “dry.”
Bartholinitis
This inflammatory disorder may produce throbbing pain accompanied by vulvar tenderness during intercourse. The patient may also complain of pain with walking or sitting. Chronic inflammation causes a purulent discharge from the infected cyst.
Cervicitis
This inflammatory disorder causes pain with deep penetration. It may also cause dull lower abdominal pain, a purulent vaginal discharge, backache, and metrorrhagia.
Condylomata acuminata
These papular, mosaic, warty growths occur on the vulva, vaginal and cervical walls, and perianal area. They may bleed, itch, cause burning or paresthesia in the vaginal introitus, and become tender during and after intercourse. A profuse, odorless vaginal discharge may also occur.
Cystitis
Dyspareunia may occur if the patient has inflammation or infection of the bladder. Associated findings include dysuria; urinary urgency, frequency, or incontinence; pyuria; and, after coitus, hematuria.
Endometriosis
This disorder causes intense pain during deep coital penetration. In addition, aching pain may occur during gentle thrusting or during a pelvic examination. The pain is usually in the lower abdomen or behind the uterus and may be worse on one side. It may be relieved by changing coital positions. Other signs and symptoms include dysmenorrhea, irregular menses, infertility, painful urination or defecation, and rectal bleeding and hematuria during menses. Typically, a tender, fixed adnexal mass is palpable on bimanual examination.
Herpes genitalis
During intercourse, friction against lesions on the labia, vulva, vagina, or perianal skin causes pain and itching. The lesions are fluid-filled and usually painless at first, but may rupture and form shallow, painful ulcers with erythema and edema. Related findings include leukorrhea, fever, malaise, headache, inguinal lymphadenopathy, myalgia, and dysuria.
Occlusive or rigid hymen
Dyspareunia may prevent penetration in this condition.
Ovarian cyst or tumor
In this disorder, lower abdominal pain accompanies deep penetration during intercourse. Other signs and symptoms include chronic lower back pain; a tender, palpable abdominal mass; constipation; urinary frequency; menstrual irregularities; and hirsutism.
Pelvic inflammatory disease
Deep penetration causes severe pain that’s unrelieved by changing coital positions. Uterine tenderness may also occur with gentle thrusting or during a pelvic examination. This disorder also causes fever; malaise; a foul-smelling, purulent vaginal discharge; menorrhagia; dysmenorrhea; a soft, enlarged uterus; severe abdominal pain; nausea and vomiting; cervical motion tenderness; and diarrhea.
Uterine prolapse
Sharp or aching pain occurs when the penis strikes the descended cervix of a patient with uterine prolapse. Other effects are dysmenorrhea, pelvic pressure, leukorrhea, urine retention and urinary incontinence, and chronic lower back pain.
Vaginitis
This infection produces dyspareunia along with vulvar pain, burning, and itching during and for several hours after coitus. These symptoms may be aggravated by sexual arousal aside from intercourse. Vaginal discharge is typical; the type varies with the causative organism. Candida albicans produces a curdlike, odorless to musty-smelling discharge; Trichomonas vaginalis produces a yellow-green, frothy, fish-smelling discharge; bacterial vaginosis and Neisseria gonorrhoeae produce a profuse whitish yellow, foul-smelling discharge. Pruritus and dysuria may also occur.
Other causes
Contraceptive and hygienic products
Some spermicidal jellies, douches, and vaginal creams and deodorants cause irritation and edema, resulting in dyspareunia.
Diaphragms and intrauterine devices
An ill-fitting diaphragm may produce cramps with intercourse. An incorrectly placed intrauterine device may cause dyspareunia during orgasm.
Drugs
Antihistamines, decongestants, and nonsteroidal anti-inflammatory drugs decrease lubrication, resulting in dyspareunia.
Episiotomy
If the episiotomy scar constricts the vaginal introitus or narrows the vaginal barrel, the patient may experience perineal pain with coitus.
Pelvic irradiation
Radiation therapy for pelvic cancer may cause pelvic and vaginal scarring, resulting in dyspareunia.
Special considerations
Prepare the patient for a pelvic examination. Explain that it involves inspection of the vagina and cervix and bimanual palpation of the uterus, fallopian tubes, and ovaries. Remind her to breathe deeply and evenly during the examination. If an antimicrobial or anti-inflammatory drug is prescribed, teach her how to apply the cream or insert the vaginal suppository.
Pediatric pointers
Dyspareunia can also be an adolescent problem. Although about 40% of adolescents are sexually active by age 19, most are reluctant to initiate a frank sexual discussion. Obtain a thorough sexual history by asking the patient direct but nonjudgmental questions.
Geriatric pointers
In postmenopausal women, the absence of estrogen reduces vaginal diameter and elasticity, which causes tearing of the vaginal mucosa during intercourse. These tears as well as inflammatory reactions to bacterial invasion cause fibrous adhesions that occlude the vagina. Dyspareunia can result from any of these conditions.
Patient counseling
Encourage the patient to discuss dyspareunia openly. A woman may hesitate to report dyspareunia because of embarrassment and modesty.
To minimize dyspareunia, advise the patient to apply a vaginal lubricant before intercourse, to attempt different coital positions, and to increase foreplay time. Teach her Kegel exercises to reduce muscle tension. (See How to do Kegel exercises, page 263.)
Pictures
Book Source Details
- Book Title: Professional Guide to Signs & Symptoms (Fifth Edition)
- Author(s): Springhouse
- Year of Publication: 2006
- Copyright Details: Professional Guide to Signs & Symptoms (Fifth Edition), Copyright © 2006 Lippincott Williams & Wilkins.
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Copyright Details: Professional Guide to Signs & Symptoms (Fifth Edition), Copyright © 2008 Williams & Wilkins.
More About Causes of Intercourse symptoms
» Next page: Impotence (Professional Guide to Signs & Symptoms (Fifth Edition))
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