Pain with Sex

Dyspareunia is a sexual dysfunction where pain is experienced during, before, or after sex. It often leads to disruption of normal sexual activity and relationships problems. It can be a localized pain or general discomfort.

What else can it occur with? Often, Dyspareunia can be seen with chronic pelvic pain, IBS, urinary urgency, bowel urgency, or tampon discomfort. Only when symptoms are severe enough do we women seek medical treatment, but the actual number of women who experience it is unknown. It can be brought on by physical or psychological events.

Psychological causes can include: Sexual abuse during childhood, feelings of shame or guilt towards sex, and fear of intercourse or pain from first intercourse.

In addition, dyspareunia can be classified as being either superficial or deep, and whether it occurs all the time, or just with certain partners or situations.

What are common causes of superficial pain during sexual intercourse?

Vulvar pain (vulvodynia) may be described as a burning sensation or pain with penetration. It can be lifelong or develop with age. Some common causes are menopause, vulvar infection, lichen sclerosis and idiopathatic reasons.

Vaginismus is rare but is the involuntary spasm of the entryway muscles of the vagina from psychological stress.

What are some of the causes of deep pain during sexual intercourse?

Chronic Pelvic Pain (CPP) which can be pain of the pelvic floor muscles or related to Painful Bladder Syndrome/Interstitial Cystitis.

Endometriosis- common symptoms include abnormal menstrual bleeding, pelvic pain, premenstrual spotting, and sometimes infertility.

Pelvic Inflammatory Disease (PID) if chronic. Pelvic scarring can cause the uterus to become fixed in place and lead to deep pain during sex.

Perineal Trauma from Chiildbirth occurs quite commonly and is often thought to be related to episiotomy. Approximately 90% of woman will have perineal pain after childbirth (which is expected), however, the painful sexual may not resolve for 4-6 months after vaginal delivery. This is not necessarily a sexual dysfunction as much as it is normal tissue recovery. Resumption of sex too soon after childbirth may not be giving the vaginal tissues enough healing time. However, resumption of sex after childbirth depends heavily on: the mode of childbirth (vaginal vs. C-section), the severity of perineal tearing, maternal age, breastfeeding status and cultural issues. Women with 3rd or 4th degree tears were much five times likely to resume sex when compared to women with no tearing. Moreover, approximately ¼ of new mothers report loss of sensation and inability to achieve orgasm at 6 months post partum.

The doctor’s approach to dyspareunia should be thoroughly investigative since most women will not present with this specific complaint. Rather, dyspareunia may be present with other pelvic health conditions and direct question can lead to diagnosis. A physical exam of the abdomen and vagina with careful palpation both without and with a speculum, and often bimanual exam will yield the most information.

How Can Dyspareunia be Treated?

Psychological Assessment if appropriate

Medical treatment depends on the cause of pain. Often, lubricants or topical estrogen can improve dryness. Changing sexual positions may help as well. Vaginal massage or painful trigger points can sometimes help CPP. Pelvic floor relaxation with stretching, yoga or warm baths can aide in this as well. Antibiotic therapy can be given to treat PID. Pain meds or anti-inflammatories can help with CPP. Vulvodynia and CPP can sometimes be addressed with anti-depressants or local topical numbing creams. Vaginismus often responds to a combination of behavior and psychological retraining, and vaginal dilators.

Surgical treatment also depends on the cause of pain. Endometriosis is often diagnosed and treated with laparoscopy. Benign cysts, tumors and cutting adhesions can be performed but are uncommon findings. Treating superficial vulvar skin conditions may require biopsy or cutting scar tissue that can develop from childbirth.

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• Painful Sexual Intercourse