Dyspareunia

Dyspareunia - pain when inserting the penis into the vagina or during sexual intercourse; pain may occur at the moment of penetration (at the entrance to the vagina), during deeper insertion, during movements of the penis, or after sexual intercourse.

The patient may not mention the problem herself, so ask her about her sensations during intercourse. The patient's attitude to the gynecological examination can tell you as much as the examination itself. Ask her to show where the pain is felt. If there is true vaginismus, do not insist on the examination and limit yourself to consultation and psychotherapy.

Dyspareunia may be superficial (around the vaginal opening). Infection is often the cause, so look for ulcers and discharge during examination. Is there vaginal dryness? If so, could estrogen deficiency or lack of sexual stimulation be the cause? Has the patient recently had perineal suturing after childbirth? A suture or scar may be the cause of localized pain that can be relieved by excision of the scar and local administration of analgesics? If the vaginal opening has become too narrow as a result of surgery, a second operation is necessary.

Deep dyspareunia is felt internally. It is caused by endometriosis and septic process in the pelvic area; if possible, try to influence the cause. If the ovaries are located in the recto-vaginal pocket or a hysterectomy has been performed, the ovaries can be injured during thrusts during intercourse, suggest trying another position.

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Causes of dyspareunia

Pelvic muscle hypertonicity and high rigidity are characteristic of all types of chronic dyspareunia. The most common cause of superficial dyspareunia is vestibulitis. Vestibulitis (inflammation of the vulva) is the most common form of chronic pelvic pain syndrome, in which incoming impulses to the nervous system from peripheral receptors and the cerebral cortex are remodulated for unknown reasons. As a result of this sensitization, the patient perceives this stimulus not as a normal contact, but as significant pain (allodynia). Many women have concomitant genitourinary disorders (e.g., vulvovaginal candidiasis, hyperoxaluria), but the etiologic role of these disorders is unproven. Some women also have other pain disorders (for example, irritable bowel syndrome). The appearance of pain in vestibulitis is noted immediately upon insertion of the penis into the vagina, during movement and during ejaculation in men. With vestibulitis, burning and dysuric disorders may appear after sexual intercourse. With vaginismus, pain appears upon insertion of the penis into the vagina, but the pain stops when the movements of the penis stop and resumes again; pain may persist with vaginismus when the movements of the penis stop; pain may disappear during sexual intercourse, despite continued movements of the penis.

Other causes of superficial dyspareunia include atrophic vaginitis, vulvar lesions or disorders (eg, lichen sclerosus, vulvar dystrophies), congenital malformations, fibrosis after radiation therapy, postoperative stenosis of the vaginal vestibule, and rupture of the posterior commissure of the labia.

Causes of deep dyspareunia include pelvic muscle hypertonicity and uterine or ovarian disorders (e.g., fibroids, endometriosis). The size and depth of penile insertion influence the occurrence and severity of symptoms. Damage to the genital sensory or autonomic nerve fiber bundles, as well as the use of selective serotonin inhibitors, can lead to acquired orgasmic dysfunction.

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Diagnosis of dyspareunia

To diagnose superficial dyspareunia, an examination of the entire vulva is performed, including the skin, the folds between the labia minora and labia majora (areas characteristic of the appearance of cracks typical of chronic candidiasis), the hood of the clitoris, the opening of the urethra, the hymen, the open ducts of the large glands of the vaginal vestibule (in case of atrophy, signs of inflammation and skin lesions typical of lichen sclerosing). Vestibulitis can be diagnosed by using a cotton swab to detect allodynia (pain when touched); non-painful external zones are affected by moving the cotton swab to more typical painful areas (to the opening of the hymen, to the opening of the urethra). Hypertonicity of the pelvic muscles can be suspected if pain occurs during intercourse; can be diagnosed by palpating the deep muscles that lift the anus, especially around the ischial spines. Pathological pain can be detected by palpating the urethra and bladder.

Diagnosis of deep dyspareunia requires a thorough bimanual examination to detect pain during movement of the cervix, uterus and palpation of the appendages. Pain is characteristically felt when nodules are detected in the utero-rectal space and in the vaginal vaults. A rectal examination is recommended to palpate the recto-vaginal septum, the posterior surface of the uterus and appendages.

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Treatment of dyspareunia

Treatment is indicated for specific causes (eg, endometriosis, lichen sclerosus, vulvar dystrophy, vaginal infections, congenital malformations of the genital organs, radiation fibrosis - see the relevant sections of the Guidelines). The optimal treatment for vestibulitis is unclear; many approaches are currently used, but there are still undefined subtypes of the disorder that require different treatment methods. Systemic drugs (eg, tricyclic antidepressants, anticonvulsants) or topical agents (eg, 2% cromoglycate or 2-5% lidocaine in Glaxal cream) are commonly used to interrupt the chronic pain cycle. Chromoglycate stabilizes the membranes of leukocytes, including mast cells, interrupting the neurogenic inflammation that underlies vestibulitis. Chromoglycate or lidocaine should be applied to the area of allodynia with a 1 ml syringe without a needle. It is recommended to perform this manipulation under the supervision of a doctor and with the use of mirrors (at least initially). Some patients with vestibulitis may benefit from psychotherapy and sexual therapy.

Local estrogens are recommended for patients with atrophic vaginitis and posterior commissure tears. Women with pelvic muscle hypertonicity may improve their condition by doing pelvic floor muscle strengthening exercises, possibly with biofeedback to relax the pelvic muscles.

After treating specific causes, sexual couples should develop satisfying forms of non-penetrative sex and be treated for disorders of sexual desire (interest) and sexual arousal.