What is dyspareunia?

It is pain experienced before, during or after sexual intercourse.  It can occur in both sexes but women experience it much more frequents. The incidence is difficult to be determined as the majority of women are too shy to come forward and tell their doctors or nurses.   

Dyspareunia can be divided into 2 types:

1. Primary:
   pain occurring during sexual intercourse from the first time. In the majority of such cases there is no obvious pathological cause.
2. Secondary:
   pain that occurred during sexual intercourse, having had a pain free sexual intercourse earlier. It is usually caused by a pathology in the pelvis such as endometriosis, pelvic inflammatory disease (infection in the pelvis) or a local pathology in the vulva or vagina (see below).

Location

1. Superficial: pain at the region of the vulva or introitus (entrance of the vagina) during insertion of the penis.  The pain may be described as sharp, ‘hot’ or abrasive.  It is more common in women with vulvodynia (see below) or vaginismus (see below).  It can also be experienced in women with vaginal infections or dryness.
2. Deep: pain occurs when the penis is deep in the vagina. The woman may also complain of pain in the pelvis rather than in the vagina.  Causes include endometriosis, pelvic infection, abnormal growth in the pelvis (ovarian mass), previous vaginal operation or vaginal infection (see below).  Sometimes sexual positions or an aggressive or rough sexual intercourse may also contribute to deep dyspareunia.

Causes

1. In Women: main causes include:
   • Post natal period: sexual intercourse within a few days to a few weeks after vaginal delivery can cause dyspareunia. The pain can be felt at the episiotomy wound or at the sutured vaginal wall (tear). The vagina and perineum may also be a little swollen post delivery and need time to subside.    
   • Endometriosis: can lead to pelvic and low back pain (see endometriosis)
   • Vaginal dryness:
     1. Menopause: the vaginal membrane or its surrounding areas are dry from menopause.
     2. Inadequate ‘stimulation’ (foreplay) before sexual intercourse.
     3. Vaginal or bladder infection
   • Conditions of chronic pain around the vagina, vulva, or perineal area. 
     1. “Vulvodynia”: pain at the vulva
     2. ‘interstitial cystitis”: pain at the urinary bladder
     3. Chronic pelvic pain:  pain below the umbilicus and pelvic area for longer than 6 months.
   • Skin diseases around the vulva or vagina e.g. eczema, abrasion etc.
   • Psychology: feeling uncomfortable with her partner or herself during sexual intercourse.
   • Experiences: This could also be due to unpleasant sexual related experiences in their past.
   • Oral contraceptive pills: some women may experience dyspareunia while using OCP but this is rare and may not be directly related to its use.
   • Congenital vagina condition: vaginal septum causing vaginal constriction.  The patient may be born with vaginal septum.
2. In men: main causes include:
   • Infection:
     • Prostate infection or genital infection.
     • Sexually transmitted infections
   • Skin conditions around the penis e.g. eczema, abrasion etc.
   • Psychology: feeling uncomfortable, pain or unease during sexual intercourse either to himself or with his partner.

What should I do?

See a doctor if you have dyspareunia.  You doctor will take a detailed history, do the necessary examinations and may performed some tests.  Treatment depends on the symptoms, age and individual conditions.  Your doctor may perform some simple tests and this may include a urine and vaginal test to rule out infections. An ultrasound scan of the pelvis may be needed to exclude a problem in the pelvis. In women with chronic pelvic pain, a diagnostic laparoscopic examination may be required.

Treatment

Treatment for women:

1. Antibiotics or anti-fungal: if the cause is due to bacteria or yeast infections
2. Cream or gel: to moist the vagina in vaginal dryness or skin condition around the vulva.
3. Anaesthetic gel: applied around the vagina before sexual intercourse.
4. Physiotherapy: to reduce muscle spasm around the vaginal area (in vaginismus). Botox has also been used effectively to reduce the vaginal spasm.
5. Counselling: in cases where psychological support or therapy may be required to help them overcome their ‘fear’ or issues with sexual relationships.
6. Operation: if the cause is due to an anatomical pathology such as vaginal septum or foreign bodies in the vagina.  Endometriosis may need operation and medical therapy.

Treatment for men:

1. Antibiotics
2. Skin medications
3. Skin treatment around the penis or perineum
4. Counselling: As with women, in cases where psychological support or therapy may be required to help them overcome their ‘fear’ or issues with sexual relationships.