Dyspareunia is painful sexual intercourse due to medical or psychological causes. The pain can primarily be on the external surface of the genitalia, or deeper in the pelvis upon deep pressure against the cervix. It can affect a small portion of the vulva or vagina or be felt all over the surface. Understanding the duration, location, and nature of the pain is important in identifying the causes of the pain. There are numerous physical, psychological, and social/relationship causes that can contribute to pain during sexual encounters. Commonly multiple underlying causes contribute to the pain. The pain can be acquired or congenital. Symptoms of dyspareunia may also occur after menopause. Diagnosis is typically by physical examination and a medical history. Treatment is determined by the underlying causes. Many women experience relief when physical causes are identified and treated. Even when the pain can be reproduced during a physical examination, the possible role of psychological factors in either causing or maintaining the pain must be acknowledged and dealt with in treatment. Globally, dyspareunia has been estimated to affect between 8-21% of women, at some point in their lives. Signs and symptoms Women who experience pain with attempted intercourse describe their pain in many ways. This reflects how many different and overlapping causes there are for dyspareunia. The location, nature, and time course of the pain help to understand potential causes and treatments. Some women describe superficial pain at the opening of the vagina or surface of the genitalia when penetration is initiated. Other women feel deeper pain in the vault of the vagina or deep within the pelvis upon deeper penetration. Some women feel pain in more than one of these places. Determining whether the pain is more superficial or deep is important in understanding what may be causing a woman's pain. Some women have always experienced pain with intercourse from their very first attempt. Other women begin to feel pain with intercourse after an injury or infection or cyclically with menstruation. Sometimes the pain increases over time. When pain occurs, the woman may be distracted from feeling pleasure and excitement. Both vaginal lubrication and vaginal dilation decrease. When the vagina is dry and undilated, penetration is more painful. Fear of being in pain can make the discomfort worse. Even after the original source of pain has disappeared, a woman may feel pain simply because she expects pain. Fear, avoidance, and psychologic distress around attempting intercourse can become large parts of a woman's experience of dyspareunia. Physical examination of the vulva (external genitalia) may reveal clear reasons for pain including lesions, thin skin, ulcerations or discharge associated with vulvovaginal infections or vaginal atrophy. An internal pelvic exam may also reveal physical reasons for pain including lesions on the cervix or anatomic variation. When there are no visible findings on vulvar exam that would suggest a cause for superficial dyspareunia, a cotton-swab test may be performed. This is a test to assess for localized provoked vulvodynia.A cotton tip applicator is applied at several points around the opening of the vagina and a woman reports whether she experiences pain on a scale from 0-10.

Causes Women The cause of the pain may be anatomic or physiologic, including but not limited to lesions of the vagina, retroversion of the uterus, urinary tract infection, lack of lubrication, scar tissue, or abnormal growths. More commonly the cause may be psychosomatic, which can include fear of pain or injury, feelings of guilt or shame, ignorance of sexual anatomy and physiology, and fear of pregnancy. In women, common causes for discomfort during sex include Infections. Infections that mostly affect the labia, vagina, or lower urinary tract like yeast infections, chlamydia, trichomoniasis, urinary tract infections, or herpes tend to cause more superficial pain. Infections of the cervix, or fallopian tubes like pelvic inflammatory disease tend to cause deeper pain. Tissue Injury. Pain after trauma to the pelvis from injury, surgery or childbirth. Anatomic variations. hymenal remnants, vaginal septa,[9] thickened undilatable hymen, hypoplasia of the introitus retroverted uterus or uterine prolapse can contribute to discomfort. Hormonal Causes: endometriosis and adenomyosis Estrogen deficiency is a particularly common cause of sexual pain complaints related to vaginal atrophy among postmenopausal women and may be a result of similar changes in menstruating women on hormonal birth control. Estrogen deficiency is associated with lubrication inadequacy, which can lead to painful friction during intercourse.Vaginal dryness is often reported by lactating women as well. Women undergoing radiation therapy for pelvic malignancy often experience severe dyspareunia due to the atrophy of the vaginal walls and their susceptibility to trauma. Presence of objects that take up space in the pelvic like ovarian cysts [13] tumors [14] and uterine fibroids can cause deep pain Pain from bladder irritation: Dyspareunia is a symptom of a disease called interstitial cystitis (IC). Patients may struggle with bladder pain and discomfort during or after sex. For men with IC, pain occurs at the moment of ejaculation and is focused at the tip of the penis. For women with IC, pain usually occurs the following day, the result of painful, spasming pelvic floor muscles. Interstitial cystitis patients also struggle with urinary frequency and/or urinary urgency Vulvodynia: Vulvodynia is a diagnosis of exclusion in which women experience either generalized or localized vulvar pain most often described as burning without physical evidence of other causes on exam. Pain can be constant or only when provoked (as with intercourse). Localized provoked vulvodynia is the most recent terminology for what used to be called vulvar vestibulitis when the pain is localized to the vaginal opening. Conditions that affect the surface of the vulva including LSEA (lichen sclerosus et atrophicus), or xerosis (dryness, especially after the menopause). Vaginal dryness is sometimes seen in Sjögren's syndrome, an autoimmune disorder which characteristically attacks the exocrine glands that produce saliva and tears. Muscular dysfunction- For example, levator ani myalgia Psychologic, such as vaginismus Men In men, as in women, there are a number of physical factors that may cause sexual discomfort. Pain is sometimes experienced in the testicular or glans area of the penis immediately after ejaculation. Infections of the prostate, bladder, or seminal vesicles can lead to intense burning or itching sensations following ejaculation. Men suffering from interstitial cystitis may experience intense pain at the moment of ejaculation. Gonorrheal infections are sometimes associated with burning or sharp penile pains during ejaculation. Urethritis or prostatitis can make genital stimulation painful or uncomfortable. Anatomic deformities of the penis, such as exist in Peyronie's disease, may also result in pain during coitus. One cause of painful intercourse is due to the painful retraction of a too-tight foreskin, occurring either during the first attempt at intercourse or subsequent to tightening or scarring following inflammation or local infection. Another cause of painful intercourse is due tension in a short and slender frenulum, frenulum breve, as the foreskin retracts on entry to the vagina irrespective of lubrication. In one study frenulum breve was found in 50% of patients who presented with dyspareunia. During vigorous or deep or tight intercourse or masturbation, small tears may occur in the frenum of the foreskin and can bleed and be very painful and induce anxiety which can become chronic if left unresolved. If stretching fails to ease the condition, and uncomfortable levels of tension remain, a frenuloplasty procedure may be recommended. Frenuloplasty is an effective procedure, with a high chance of avoiding circumcision, giving good functional results and patient satisfaction. The psychological effects of these conditions, while little understood, are real, and are visible in literature and art. Differential diagnosis Dyspareunia is a condition that has many causes and is not a diagnosis of itself. It is combined with vaginismus into genito-pelvic pain/penetration disorder in the DSM V. Criteria for Genito-Pelvic Pain/Penetration Disorder include multiple episodes of difficulty with vaginal penetration, pain associated with intercourse attempts, anticipation of pain due to attempted intercourse,and tensing of the pelvis in response to attempted penetration. In order to meet criteria for this disorder the symptoms must be experienced for at least 6 months and cause significant distress. The differential diagnosis for dyspareunia is long as a result of its complicated and multifactorial nature. Often there are physiologic conditions underlying the pain, as well as psychosocial components that all must be assessed to find appropriate treatment that will provide relief. A differential diagnosis of underlying physical causes can be guided by whether the pain is deep or superficial: Superficial dyspareunia or vulvar pain: infection, inflammation, anatomic causes, tissue destruction, psychosocial factors, muscular dysfunction Superficial Dyspareunia without visible exam findings: When no other physical etiology is found the diagnosis of vulvodynia should be considered. Vaginal atrophy may also not be seen clearly on exam but commonly affects postmenopausal women and is generally associated with estrogen deficiency. Deep Dyspareunia or pelvic pain: endometriosis, ovarian cysts, pelvic adhesions, inflammatory diseases (interstitial cystitis, pelvic inflammatory disease), infections, congestion, psychosocial factors Dyspareunia is a complex problem and frequently has a multifactorial aetiology. A new way has been recently suggested to define dyspareunia by dissecting it into primary, secondary, and tertiary sources of pain.

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