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
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. 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
pathophysiology can be considered as multifactorial, multisystemic, or complex.
Causes
In premenopausal women,the most frequent biological etiologies of dyspareunia are vulvar vestibulitis/provoked vestibulodynia, with recurrent candida infections and/or an 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.In postmenopausal women, vaginal dryness and vulvovaginal dystrophy are 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.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. GPPPD is actually an umbrella term for two sexual pain disorders:dyspareunia and vaginismus.
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
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. In fact, 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.
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.