Dyspareunia overview
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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. 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
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 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, Medical causes, psychological causes.
Pathophysiology
Dyspareunia is caused by medical causes, psychological problems, and pathophysiology can be considered as multifactorial, multisystem or complex. dyspareunia vary based on the underlying causes . For example, estrogen deficiency causes atrophic vaginitis or ectopic uterine tissues in endometriosis causes dyspareunia.
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.
Differential Diagnosis
Possible medical causes of dyspareunia should be ruled out or treated before considering a diagnosis of Genito-Pelvic Pain/Penetration Disorder(GPPPD). Endometriosis,Atrophic vaginitis,Vaginal dryness,Infections(Human papillomavirus, Herpes simplex virus, Pelvic inflammatory disease, Chronic salpingitis, uterine fibroids, pelvic adhesions, adnexal pathology, retoverted uterus,chronic cervicitis, pelvic congestion, genitourinary( urethral, cystitis, Interstitial cystitis, psychological problems such as anxiety, depression in women and inadequate sexual stimuli,lichen sclerosis,pelvic inflammatory disease, premature ejaculation in the male, isolated painful ejaculation, chronic pelvic syndrome, genitourinary problems such as urethritis, and psychological problems in men.
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.
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.
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. 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.
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.
Physical Examination
Physical examination findings of patients with dyspareunia vary based on the underlying cause.
Laboratory Findings
Different laboratory findings can be seen in patient with dyspareunia based on the underlying cause.
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 dyspareunia.
Treatment
Medical Therapy
It depends on the underlying cause and subsequent therapy(see table of causes). Educate patients about pelvic anatomy, physiology, and lifestyle modification.
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.