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Latest revision as of 19:27, 28 September 2020

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Vishnu Vardhan Serla M.B.B.S. [2]Roghayeh Marandi

Overview

Dyspareunia is painful sexual intercourse due to medical or psychological causes. The term is used almost exclusively in women, although the problem can also occur in men. Even when long-standing, the causes are often reversible, but self-perpetuating pain is a factor after the original cause has been removed. Dyspareunia is considered to be primarily a physical, rather than an emotional problem until proven otherwise. In most instances of dyspareunia, there is an original physical cause. Extreme forms, in which the woman's pelvic floor musculature contracts involuntarily, is termed vaginismus.Based on Diagnosis Statistical Manual of Mental Disorders (DSM-5; American Psychiatric Association, 2013),dyspareunia and vaginismus were typically classified as distinct sexual pain disorders. This new classification unifies vaginismus and dyspareunia into one category called "genito-pelvic pain/penetration disorder" due to the clinical difficulties in distinguishing these conditions. GPPPD is an umbrella term for two sexual pain disorders:dyspareunia and vaginismus, because in practice, it is difficult to differentiate these two from each other. Sometimes the pain may cause pelvic muscle spasms or involuntary pelvic muscle spasms in vaginismus to cause pain. However, possible medical causes of dyspareunia should be ruled out or treated before considering a diagnosis of genito-pelvic pain/penetration disorder(GPPPD). If a medical cause is successfully treated, and pain has not been resolved yet, a diagnosis of vulvodynia or genito-pelvic/penetration disorder is appropriate to be considered.

Historical Perspective

There is limited information about the historical perspective of dyspareunia.

Classification

Dyspareunia may be classified into different types based on its location, onset, and frequency in women. Male dyspareunia is divided into broad categories of underlying causes ranging from anatomic anomalies to psychosocial problems.

Pathophysiology

pathophysiology of genito-pelvic pain/penetration disorder can be considered as multifactorial, multisystemic, or complex. If pain is due to a physical cause, the pathophysiology of the underlying cause should be considered.

Causes

Common causes of dyspareunia in premenopausal women include the most frequent biological etiologies of dyspareunia which are vulvar vestibulitis/provoked vestibulodynia, with recurrent candida infections and/or a hyperactive pelvic floor in the background, and painful outcomes of delivery (either because of episiotomy/rraphy, or traumatic deliveries). Endometriosis, chronic pelvic pain, and pelvic inflammatory disease are leading contributors of deep dyspareunia in premenopausal women. Common causes of dyspareunia in postmenopausal women include vaginal dryness and vulvovaginal dystrophy, which are the leading etiological factors of dyspareunia, and may concur to deep dyspareunia, with iatrogenic factors such as surgical shortening of the vagina and/or radiotherapy contributing to deep sexual pain. Possible medical causes of dyspareunia should be ruled out or treated before considering a diagnosis of Genito-Pelvic Pain/Penetration Disorder(GPPPD). If a medical cause is successfully treated and pain has not been resolved yet, a diagnosis of vulvodynia or genito-pelvic/penetration disorder is appropriate to be considered.

Differential Diagnosis

Genito-pelvic/penetration disorder(GPPPD) must be differentiated from other medical causes of dyspareunia in women. The medical causes of dyspareunia such as Endometriosis,Atrophic vaginitis,Vaginal dryness, Infections(Human papillomavirus, Herpes simplex virus, Pelvic inflammatory disease, Chronic salpingitis, uterine fibroids, pelvic adhesions, adnexal pathology, retroverted uterus, chronic cervicitis, pelvic congestion, genitourinary( urethritis, cystitis, Interstitial cystitis, psychological problems such as anxiety, depression, inadequate sexual stimuli,lichen sclerosis,pelvic inflammatory disease.

Epidemiology and Dermographics

The World Health Organization reported a global prevalence of dyspareunia ranging between 8% and 21.1% in 2006, which varied by country.

Risk factors

Risk factors vary base on the underlying cause of dyspareunia. For example, the history of Physical abuse, Sexual abuse are risk factors of vaginismus.

Natural history, Complications, and Prognosis

The symptom of dyspareunia is pain during intercourse/penetration, which could be either introital (at the vaginal entrance), deep (in the vagina or pelvis), or both. Dyspareunia can have a negative impact on a patient's mental and physical health, body image, relationships with partners, and efforts to conceive. It can affect the quality of life. It can lead to, or be associated with other female sexual dysfunction disorders, such as decreased libido, decreased arousal, and anorgasmia. Prognosis may vary based on the cause of dyspareunia.

Diagnosis

Diagnostic criteria

There are no established criteria for the diagnosis of dyspareunia. Based on Diagnosis Statistical Manual of Mental Disorders (DSM-5; American Psychiatric Association, 2013),dyspareunia and vaginismus were typically classified as distinct sexual pain disorders. This new classification unifies vaginismus and dyspareunia into one category called “genito-pelvic pain/penetration disorder” due to the clinical difficulties in distinguishing these conditions. GPPPD is an umbrella term for two sexual pain disorders:dyspareunia and vaginismus, because in practice, it is difficult to differentiate these two from each other. Sometimes the pain may cause pelvic muscle spasms or involuntary pelvic muscle spasms in vaginismus to cause pain. However, possible medical causes of dyspareunia should be ruled out or treated before considering a diagnosis of Genito-Pelvic Pain/Penetration Disorder(GPPPD). If a medical cause is successfully treated and pain has not been resolved yet, a diagnosis of vulvodynia or genito-pelvic/penetration disorder is appropriate

History and Symptoms

The hallmark of dyspareunia is pain before, during, or after sexual activity. Symptoms such as :itching, burning, irritation, abnormal discharge can be associated with it.

Physical Examination

The presence of erythema, discharge, atrophy or ulceration, growth, deformity, or warts on external genitalia or lesions on the cervix and internal genitalia can be suggestive of dyspareunia. The presence of pain on the cotton-swab test is diagnostic of localized provoked vulvodynia.

Laboratory Findings

Different laboratory findings can be seen in patient with dyspareunia based on the underlying cause.Laboratory tests that help to the diagnosis of the underlying cause of dyspareunia include:Vaginal secretions analysis for infections, NAAT test for gonorrhea, chlamydia, trichomonas, Herpes simplex virus (HSV) culture, HSV-1 and HSV-2 type-specific IgG antibodies, Rapid plasma reagent (RPR), Vulvar or vaginal biopsy for dermatological problems, malignancy, Urine analysis, culture for urological problems, Blood count, Glucose, Hormones: prolactin, TSH, FSH,LH, Testosterone

X-Ray

There are no x-ray findings associated with dyspareunia.

Echocardiography and Ultrasound

There are no echocardiography findings associated with dyspareunia. Ultrasound may be helpful in the diagnosis of the underlying cause of dyspareunia.

CT Scan

Ct-Scan may be helpful in the diagnosis of the underlying cause of dyspareunia such as pelvic tumors.

MRI

There are no MRI findings associated with dyspareunia.

Other Imaging Findings

There are no other imaging findings associated with dyspareunia.

Other Diagnostic Studies

Laparoscopy may be helpful in the diagnosis of the underlying cause of dyspareunia.

Treatment

Medical Therapy

The mainstay of treatment for dyspareunia is the treatment of the underlying cause. Non-Medical treatment also should be considered.Educate patients about pelvic anatomy, physiology, and lifestyle modification. Psychological intervention, often in the form of CBT can be helpful.

Surgery

Surgery is performed as a last resort when all conservative and medical management options have failed or when surgery is indicated in situations such as endometriosis to remove the topic uterine tissue.

Primary prevention

There are no established measures for the primary prevention of dyspareunia, but can prevent of some of the causes of dyspareunia, for example: prevent sexually transmitted diseases (STDs) by using condoms or other barriers, get proper routine medical care, use proper hygiene, wait at least six weeks before resuming sexual intercourse after childbirth.

Secondary prevention

Effective measures for the secondary prevention of dyspareunia depends on the underlying cause of it, for example: using a water-soluble lubricant when vaginal dryness is an issue, encouraging natural vaginal lubrication with enough time for foreplay and stimulation, doing exercise to relieve muscular tightness in vaginismus.

Future or investigational treatment

More research must be done to suggest a strong genetic link with Genito-Pelvic Pain/Penetration Disorder (GPPPD).

@@ Line 3: / Line 3: @@
 {{CMG}} {{AE}} {{VVS}}[[Roghayeh Marandi]]
 ==Overview==
-Dyspareunia is painful [[sexual intercourse]], due to medical or psychological causes. The term is used almost exclusively in women, although the problem can also occur in men. The causes are often reversible, even when long-standing, but self-perpetuating pain is a factor after the original cause has been removed. Dyspareunia is considered to be primarily a physical, rather than an emotional, problem until proven otherwise. In most instances of dyspareunia, there is an original physical cause. Extreme forms, in which the woman's pelvic floor musculature contracts involuntarily, is termed [[vaginismus]].
-==historical perspective==
+Dyspareunia is painful [[sexual intercourse]] due to [[medical]] or [[psychological]] causes. The term is used almost exclusively in women, although the problem can also occur in men. Even when long-standing, the causes are often reversible, but self-perpetuating pain is a factor after the original cause has been removed. [[Dyspareunia]] is considered to be primarily a physical, rather than an emotional problem until proven otherwise. In most instances of [[dyspareunia]], there is an original physical cause. Extreme forms, in which the woman's [[pelvic floor]] [[musculature]] contracts involuntarily, is termed [[vaginismus]].Based on [[DSM|Diagnosis Statistical Manual of Mental Disorders]] (DSM-5; American Psychiatric Association, 2013),[[dyspareunia]] and [[vaginismus]] were typically classified as distinct [[sexual pain disorders]]. This new classification unifies [[vaginismus]] and [[dyspareunia]] into one category called "genito-pelvic pain/penetration disorder" due to the clinical difficulties in distinguishing these conditions. GPPPD is an umbrella term for two sexual pain disorders:[[dyspareunia]] and [[vaginismus]], because in practice, it is difficult to differentiate these two from each other. Sometimes the pain may cause pelvic muscle spasms or involuntary [[pelvic]] muscle spasms in [[vaginismus]] to cause pain. However, possible medical causes of [[dyspareunia]] should be ruled out or treated before considering a diagnosis of genito-pelvic pain/penetration disorder(GPPPD). If a medical cause is successfully treated, and pain has not been resolved yet, a diagnosis of [[vulvodynia]] or genito-pelvic/penetration disorder is appropriate to be considered.
+==Historical Perspective==
 There is limited information about the historical perspective of [[dyspareunia]].
 ==Classification==
-It may be classified into two types in women: [[superficial]], which occurs in or around the vaginal entrance, and is characterized by initial discomfort in initial or attempted penetration of the vaginal introitus. Deep dyspareunia is a pain that occurs with deep [[vaginal]] penetration. which resulting from pelvic thrusting during intercourse. Causes are divided into three groups according to Onset, Frequency as well. Based on the onset, [[dyspareunia]] can be divided into two groups based on the onset in women: Primary (onset with first sexual experience) Often has psychological causes, such as sexual abuse in childhood, feeling of guilt or shame toward sex, or fear of intercourse or painful first intercourse, and secondary dyspareunia that its beginning is after a previous sexual activity that was not painful. Dyspareunia can be Persistent, which occurs in all situations, possibly due to physical or psychological factors, or conditional dyspareunia that occurs in certain situations. Abdomino-pelvic disorders such as [[endometriosis]], [[imperforate hymen]], [[vaginal septum]], or organic [[vulvodynia]] due to infection, [[Lichen sclerosus|lichen sclerosis]], or vestibulitis, vaginal infections, [[prolapse]], [[trauma]], or vaginal dryness can cause [[dyspareunia]]. It can also be due to [[gastrointestinal disorders]] such as [[chronic constipation]], diverticular diseases, [[inflammatory bowel disease]]/[[proctitis]]. Scarring due to previous pelvic surgery, [[episiotomy]], and perineorraphy, or urological causes such as [[cystitis]], [[interstitial cystitis]], or [[urethritis]] can cause [[dyspareunia]] as well. Male [[dyspareunia]] is divided into broad categories of underlying causes ranging from [[anatomic]] anomalies to [[psychosocial]] problems. Male dyspareunia is related to the following anatomical structures: 1) [[prepuce]], 2) [[glans penis]], 3) penile shaft, 4) [[testicles]], and 5) [[urethra]] and [[prostate gland]]. Another classification system defines four broad categories: Isolated painful [[ejaculation]], [[Chronic prostatitis/chronic pelvic pain syndrome|Chronic prostatitis/chronic pelvic pain]], [[Medical]] causes, [[psychological]] causes.
+[[Dyspareunia]] may be classified into different types based on its location, onset, and frequency in women. Male [[dyspareunia]] is divided into broad categories of underlying causes ranging from [[anatomic]] anomalies to [[psychosocial]] problems.
 ==Pathophysiology==
-[[Dyspareunia]]  is caused by  [[medical causes]], [[psychological]] problems, and pathophysiology can be considered as multifactorial, multisystemic or complex. dyspareunia vary based on the underlying causes . For example, estrogen deficiency causes atrophic vaginitis or ectopic uterine tissues in endometriosis causes dyspareunia.
+[[pathophysiology]] of genito-pelvic pain/penetration disorder can be considered as multifactorial, [[multisystemic]], or [[complex]]. If pain is due to a physical cause, the [[pathophysiology]] of the underlying cause should be considered.
 ==Causes==
-Common causes of dyspareunia include localized [[infectious]] and [[congenital]] disorders of the [[vulva]], [[vagina]], and [[perianal]] regions. Additional causes include systemic conditions and diseases.
+Common causes of [[dyspareunia]] in [[premenopausal]] women include the most frequent [[biological]] [[etiologies]] of  [[dyspareunia]]  which are [[vulvar vestibulitis]]/provoked vestibulodynia, with recurrent [[Candida|candida]] infections and/or a hyperactive [[pelvic floor]] in the background, and painful outcomes of [[delivery]] (either because of [[episiotomy]]/rraphy, or traumatic deliveries). [[Endometriosis]], [[chronic pelvic pain]], and [[pelvic inflammatory disease]] are leading contributors of deep [[dyspareunia]] in [[premenopausal]] women. Common causes of [[dyspareunia]] in [[postmenopausal]] women include  [[vaginal dryness]] and vulvovaginal [[dystrophy]], which are the leading etiological factors of  [[dyspareunia]], and may concur to deep [[dyspareunia]], with [[iatrogenic]] factors such as surgical shortening of the [[vagina]] and/or [[radiotherapy]] contributing to deep sexual pain. Possible medical causes of [[dyspareunia]] should be ruled out or treated before considering a [[diagnosis]] of [[Genito-Pelvic |Genito-Pelvic Pain/Penetration Disorder]](GPPPD). If a medical cause is successfully treated and pain has not been resolved yet, a diagnosis of [[vulvodynia]] or [[genito-pelvic/penetration disorder]] is appropriate to be considered.
-==Differential diagnosis==
+==Differential Diagnosis==
-[[Endometriosis]], [[Vulvodynia]], [[Vaginismus]], [[Atrophic vaginitis]], and difficulty with lubrication, Vulvar vestibulitis, [[Vaginal dryness]],Infections(Human papillomavirus, Herpes simplex virus, Pelvic inflammatory disease, Chronic salpingitis,uterine fibroids, pelvic adhesions,Adnexal pathology,Retroverted uterus, pelvic relaxation, Chronic cervicitis, Pelvic congestion, Genitourinary( Urethral, Cystitis, Interstitial cystitis, Psychological problems such as anxiety, depression in women and [[Erectile dysfunction]] in the male, Inadequate sexual stimuli,[[Lichen sclerosis]],[[Pelvic inflammatory disease]], Premature ejaculation in the male,Isolauted painful ejaculation, chronic pelvic syndrome, Genitourinary problems such as urethritis, and psychological problems in men.
+[[Genito-pelvic/penetration disorder]](GPPPD) must be differentiated from other medical causes of [[dyspareunia]] in women. The medical causes of [[dyspareunia]] such as  [[Endometriosis]],[[Atrophic vaginitis]],[[Vaginal dryness]], Infections([[Human papillomavirus]], [[Herpes simplex virus]], [[Pelvic inflammatory disease]], Chronic [[salpingitis]], [[uterine fibroids]], pelvic [[adhesions]], [[adnexal]] pathology, retroverted [[uterus]], chronic [[cervicitis]], [[pelvic]] congestion, [[genitourinary]]( [[urethritis]], [[cystitis]], [[Interstitial cystitis]], [[psychological]] problems such as [[anxiety]], [[depression]], inadequate sexual stimuli,[[lichen sclerosis]],[[pelvic inflammatory disease]].
-==Epidemiology and dermographics==
+==Epidemiology and Dermographics==
-The prevalence of dyspareunia is unknown of the overall population. Nonetheless, it is estimated that 15% of women in North America notify recurrent pain during intercourse.
+The [[World Health Organization]] reported a global [[prevalence]] of [[dyspareunia]] ranging between 8% and 21.1% in 2006, which varied by country.
 ==Risk factors==
-Risk factors vary base on the underlying cause of dyspareunia. for example, history of [[Physical abuse]], [[Sexual abuse]] are risk factors of vaginismus.
+Risk factors vary base on the underlying cause of [[dyspareunia]]. For example, the history of [[Physical abuse]], [[Sexual abuse]] are risk factors of [[vaginismus]].
-==Natural history,complications and prognosis==
+==Natural history, Complications, and Prognosis==
-It is more common in women. rarely can be seen in men. [[Dyspareunia]] can have a negative impact on a woman's [[mental]] and physical health, [[body image]], relationships with partners, and efforts to conceive.
+The symptom of [[dyspareunia]] is pain during intercourse/penetration, which could be either introital (at the [[vaginal]] entrance), deep (in the [[vagina]] or [[pelvis]]), or both. [[Dyspareunia]] can have a negative impact on a patient's mental and [[physical]] health, body image, relationships with partners, and efforts to [[Conceive a child|conceive]]. It can affect the quality of life. It can lead to, or be associated with other female sexual dysfunction disorders, such as [[decreased libido]], [[arousal|decreased arousal]], and [[anorgasmia]]. [[Prognosis]] may vary based on the cause of [[dyspareunia]].
-It can affect the quality of life. It can lead to, or be associated with, other female [[sexual dysfunction]] disorders, such as [[decreased libido]], decreased [[arousal]], and [[anorgasmia]]. Prognosis Depending on the cause of [[dyspareunia]], the prognosis may vary.
 ==Diagnosis==
 ===Diagnostic criteria===
-Diagnosis Statistical Manual of Mental Disorders (DSM-5; American Psychiatric Association, 2013) dyspareunia and vaginismus were typically classified as distinct sexual pain disorders.This new classification unifies vaginismus and dyspareunia into one category called “genito-pelvic pain/penetration disorder” due to the clinical difficulties to distinguishing these condition.
+There are no established [[criteria]] for the diagnosis of [[dyspareunia]]. Based on [[DSM|Diagnosis Statistical Manual of Mental Disorders]] (DSM-5; American Psychiatric Association, 2013),[[dyspareunia]] and [[vaginismus]] were typically classified as distinct [[sexual pain disorders]]. This new classification unifies [[vaginismus]] and [[dyspareunia]] into one category called “genito-pelvic pain/penetration disorder” due to the clinical difficulties in distinguishing these conditions. GPPPD is an umbrella term for two sexual pain disorders:[[dyspareunia]] and [[vaginismus]], because in practice, it is difficult to differentiate these two from each other. Sometimes the pain may cause pelvic [[muscle spasms]] or involuntary pelvic [[muscle spasms]] in vaginismus to cause pain. However, possible medical causes of [[dyspareunia]] should be ruled out or treated before considering a diagnosis of Genito-Pelvic Pain/Penetration Disorder(GPPPD). If a medical cause is successfully treated and [[pain]] has not been resolved yet, a diagnosis of vulvodynia or genito-pelvic/penetration disorder is appropriate
 ===History and Symptoms===
-Patients with [[dyapreunia]] may have a positive history of genitourinary infection, sexual abuse, or psychological problems. The most common symptoms of dyspareunia is pain just before, during, or after intercourse.
+The hallmark of [[dyspareunia]] is [[pain]] before, during, or after [[sexual activity]]. Symptoms such as :[[itching]], burning, [[irritation]], abnormal [[discharge]] can be associated with it.
 ==='''Physical Examination'''===
-Physical examination findings of patients with dyspareunia vary based on the underlying cause.
+The presence of [[erythema]], [[discharge]], [[atrophy]] or [[ulceration]], [[growth]], [[deformity]], or [[warts]] on external genitalia or lesions on the [[cervix]] and [[internal genitalia]] can be suggestive of  [[dyspareunia]]. The presence of pain on the [[cotton-swab test]] is diagnostic of localized provoked [[vulvodynia]].
 ===Laboratory Findings===
-Different laboratory findings can be seen in patient with dyspareunia based on the underlying cause.
+Different laboratory findings can be seen in patient with [[dyspareunia]] based on the underlying cause.Laboratory tests  that help to the diagnosis of the underlying cause of [[dyspareunia]] include:[[Vaginal Discharge|Vaginal secretions]] analysis for [[infections]], [[NAAT |NAAT test]] for [[gonorrhea]], [[chlamydia]], [[trichomonas]], [[Herpes simplex virus]] (HSV) culture, [[HSV-1]] and [[HSV-2]] type-specific [[IgG|IgG antibodies]], [[Rapid plasma reagent]] (RPR), Vulvar or vaginal [[biopsy]] for [[dermatological]] problems, [[malignancy]], [[Urine analysis]], [[culture]] for [[urological]] problems, [[Blood count]], [[Glucose]], [[Hormones]]: [[prolactin]], [[TSH]], [[FSH]],[[LH]], [[Testosterone]]
-===X-Ray Findings'''===
-There are no x-ray findings associated with dyspareunia.
+===X-Ray===
-===echocardioraphy and ultrasound===
+There are no x-ray findings associated with [[dyspareunia]].
-There are no echocardiography findings associated with dyspareunia. Ultrasound may be helpful in the diagnosis of the underlying cause of dyspareunia.
-===CT-Scan Findings===
+===Echocardiography and Ultrasound===
-Ct-Scan may be helpful in the diagnosis of the underlying cause of dyspareunia such as pelvic tumors.
+There are no echocardiography findings associated with [[dyspareunia]]. Ultrasound may be helpful in the diagnosis of the underlying cause of [[dyspareunia]].
+===CT Scan ===
+Ct-Scan may be helpful in the diagnosis of the underlying cause of [[dyspareunia]] such as [[pelvic tumor|pelvic tumors]].
 ===MRI===
 There are no MRI findings associated with [[dyspareunia]].
-===other imaging findings===
+===Other Imaging Findings===
 There are no other imaging findings associated with [[dyspareunia]].
 ===Other Diagnostic Studies===
-[[Laprascopy]] may be helpful in the diagnosis of [[dyspareunia]].
+Laparoscopy may be helpful in the diagnosis of the underlying cause of  [[dyspareunia]].
 ==Treatment==
 ===Medical Therapy===
-It depends on the underlying cause and subsequent therapy(see table below for details). Educate patients about pelvic anatomy, physiology, and lifestyle modification.
+The mainstay of treatment for [[dyspareunia]] is the treatment of the underlying cause. Non-Medical treatment also should be considered.Educate patients about [[pelvic]] [[anatomy]], [[physiology]], and [[Lifestyle|lifestyle modification]]. [[Psychological]] intervention,  often in the form of  [[CBT]] can be helpful.
 ===Surgery===
-[[Surgery]] is performed as a last resort when all conservative and medical management options have failed or when [[surgery]] is indicated in situations such as Endometriosis to remove the topic uterine tissue.
+[[Surgery]] is performed as a last resort when all conservative and medical management options have failed or when [[surgery]] is indicated in situations such as [[endometriosis]] to remove the topic [[uterine]] tissue.
 ===Primary prevention===
-There are no established measures for the primary prevention of [[dyspareunia]], but can prevent of some of the causes of dyspareunia, for example:prevent sexually transmitted diseases (STDs) by using condoms or other barriers,get proper routine medical care,Use proper hygiene, wait at least six weeks before resuming sexual intercourse after childbirth.
+There are no established measures for the [[primary prevention]] of [[dyspareunia]], but can prevent of some of the causes of [[dyspareunia]], for example: prevent [[sexually transmitted diseases]] ([[STDs]]) by using [[condoms]] or other barriers, get proper routine medical care, use proper [[hygiene]], wait at least six weeks before resuming sexual [[intercourse]] after [[childbirth]].
 ===Secondary prevention===
-Effective measures for the secondary prevention of [[dyspareunia]] depends on the underlying cause of it, for example: using a water-soluble lubricant when vaginal dryness is an issue,encouraging natural vaginal lubrication with enough time for foreplay and stimulation, doing exercise to relieve muscular thightness in [[vaginismus]].
+Effective measures for the [[secondary prevention]] of [[dyspareunia]] depends on the underlying cause of it, for example: using a water-soluble [[lubricant]] when [[vaginal dryness]] is an issue, encouraging natural [[vaginal]] lubrication with enough time for foreplay and stimulation, doing exercise to relieve [[muscular]] tightness in [[vaginismus]].
-===Future or investigational therapies===
-==References==
+==Future or investigational treatment==
-{{reflist|2}}
+More research must be done to suggest a strong [[Genetic linkage|genetic link]] with [[Genito-Pelvic Pain/Penetration Disorder]] (GPPPD).
-{{WH}}
-{{WS}}
 [[Category:Gynecology]]
 [[Category:Psychiatry]]
 [[Category:Sexual and gender identity disorders]]