Dyspareunia

Dyspareunia - pain when the penis is inserted into the vagina or during sexual intercourse; pain can occur at the time of penetration (at the entrance to the vagina), with a deeper introduction, with penile movements or after sexual contact.

The patient may not say the same about the problem, so ask her about the feelings during sexual intercourse. The attitude of the patient to the gynecological examination can tell you just as much as the examination itself. Ask her to show where the pain is. If there is true vaginismus, do not insist on examination and limit yourself to counseling and psychotherapy.

Dyspareunia can be superficial (around the entrance to the vagina). The cause is often an infection, so pay attention to ulcers and discharge during examination. Is dryness of the vagina? If so, is not the cause of estrogen deficiency or lack of sexual stimulation? Was the patient not recently sutured the perineum after childbirth? A seam or scar can be the cause of a clearly localized pain eliminated by excising the scar and local administration of analgesics? If, as a result of the operation, the entrance to the vagina became too narrow, a second operation is necessary.

Deep dyspareunia is felt inside. It is caused by endometriosis and a septic process in the pelvic region; if possible try to work on the cause. If the ovaries are located in the recogovaginal pocket or a hysterectomy has been performed, the ovaries can be injured during aftershocks during sexual intercourse, suggest a different position.

[1], [2], [3], [4], [5], [6], [7]

Causes of dyspareunia

Hypertonus of pelvic muscles and their high rigidity are characteristic for all types of chronic dyspareunia. The most characteristic cause of superficial dyspareunia is vestibulitis. Vestibulitis (inflammation of the vulva) is the most common form of chronic pelvic pain syndrome, with incoming impulses to the nervous system from the peripheral receptors and the cerebral cortex remodulated for unknown reasons. As a result of this sensitization, the patient perceives this stimulus not as an ordinary contact, but as a significant pain (allodynia). Many women have concomitant genitourinary disorders (for example, vulvovaginal candidiasis, hyperoxaluria), but the etiological role of these disorders is unproven. Some women also have other pain disorders (for example, irritable bowel syndrome.) The appearance of pain in vestibulitis occurs immediately after the introduction of the penis into the vagina, during movement and during ejaculation in men.With vestibulitis, burning and dysuric disorders may occur after sexual contact. There is pain in the introduction of the penis into the vagina, but the pain stops when the movements of the penis stop and again resumes, the pain can persist with vaginismus, when the movement of the polo th member shall be terminated; the pain may disappear during sexual intercourse, despite the continuing movement of the penis.

Other causes of superficial dyspareunia include atrophic vaginitis, vulvar damage or disorders (eg sclerosing lichen, vulvar dystrophy), congenital malformations, fibrosis after radiation therapy, postoperative narrowing of the vestibule, and rupture of the posterior adhesion of the labia.

The causes of deep dyspareunia are hypertonic pelvic muscles and uterine or ovarian disorders (eg, fibroids, endometriosis). The size and depth of the introduction of the penis affect the appearance and severity of the symptoms. Damage to sexual sensory or vegetative bundles of nerve fibers, as well as the use of selective serotonin inhibitors, can lead to acquired disruption of orgasm.

[8], [9], [10], [11]

Diagnosis of dyspareunia

For the diagnosis of superficial dyspareunia, the whole vulva, including the skin, is folded between the small and large labia (places typical for the appearance of cracks typical of chronic candidiasis), the clitoral hood, the urethral opening, the hymen, the open ducts of the large glands of the vagina vestibule atrophy, signs of inflammation and skin lesions, typical of sclerosing lichen). Vestibulitis can be diagnosed by using a cotton swab to identify allodynia (tenderness when touching); touched untouched outer zones when moving the cotton swab into more typical painful places (to the hole of the hymen, to the opening of the urethra). Hypertension of the pelvic muscles may be suspected when pain occurs during sexual intercourse; can be diagnosed by palpation of the deep muscles that lift the anus, especially around the sciatic ligaments. With palpation of the urethra and bladder, it is possible to reveal pathological soreness.

Diagnosis of deep dyspareunia requires a careful bimanual examination to identify pain during movement of the cervix, uterus and palpation of the appendages. Characterized by the appearance of pain in the detection of nodules in utero-rectum and in the vaginal vaults. It is recommended to perform a rectal examination for palpation of recto-vaginal septum, posterior surface of uterus and appendages.

[12], [13]

Treatment of dyspareunia

Treatment is prescribed for specific causes (eg, endometriosis, sclerosing lichen, vulvar dystrophy, vaginal infections, congenital malformations of the genital organs, post-radiation fibrosis - see the relevant sections of the Guidelines). Optimal treatment of vestibulitis is unclear; Many approaches are currently used, but there are still vague subtypes of disorders that require different treatment methods. Typically, systemic drugs are used (for example, tricyclic antidepressants, anticonvulsants) or topical preparations (eg 2% chromoglycate or 2-5% lidocaine-based glaxal cream) to interrupt the chronic pain cycle. Chromoglycate stabilizes the leukocyte membranes, including mast cells, interrupting the neurogenic inflammation that underlies vestibulitis. Chromoglycate or lidocaine should be applied to the allodynia area with a 1 ml syringe without a needle. It is recommended to perform this manipulation under the supervision of a doctor and using mirrors (at least initially). Some patients with vestibulitis can benefit from psychotherapy and sexual therapy.

Local estrogens recommend patients with atrophic vaginitis and with tears in the posterior spike of the labia. Women with hypertension of the pelvic muscles can improve their condition by gymnastics to strengthen the pelvic floor muscles, possibly with biofeedback, to bring the pelvic muscles to relaxation.

After curing for specific reasons, sexual couples should develop satisfying forms of non-penetrating sex and be treated for violations of sexual desire (interest) and sexual arousal.