Sexual Health Counselling - Pain During Intercourse

Dyspareunia bad or difficult mating ie pain assoc. with sexual intercourse

- Describes a symptom rather than a disorder
- Can happen just before, during or after sex
- Physical stimulation of pelvic structures during vaginal intercourse can
lead to pain preventing sexual intercourse. Anxiety and fear increase
the perception of pain!!!
- May have a physical or psychogenic (emotional) cause and these may
overlap.
- More commonly assoc. in connection w female sexual dysfunction
HOWEVER small subset of Male population also suffers from dyspareunia
- Women do not often bring this up in the consult Swedish Study (uptodate-
http://0-www.uptodate.com.library.newcastle.edu.au/contents/differential-diagnosis-of-sexual-pain-in-
women?source=search_result&search=pain+during+intercourse&selectedTitle=1%7E150#H1) reported
only 28% of women w a hx of prolonged and severe pain with sex
consulted a physician for their symptoms.
-


Females
- Pain at the vulva, inside vagina or in lower belly

- Dont Miss:
o Malignancies
Frank cervical cancer
Vaginal Neoplasia
Pelvic tumour any
Vulvar, uterin or ovarian carcinoma
o Ectopic pregnancy
o Appendicitis, cholecystitis, diverticulitis IBD
o Acute or chronic pyelonephritis
o Pelvic abscess secondary to surgery, diverticulitis.
o Serious psychogenic causes (inc depression, past traumatic
experiences and others)

- Common causes
o Insufficient Foreplay
o Vulvar Pain Syndromes
Localised provoked vulvodynia formerly vestinulodynia
Generalised vulvodynia
o Urogenital atrophy
Most common cause of dyspareunia in peri and
postmenopausal women
Hypo-oestrogenism- Vulvar, vaginal and urinary tract
epithelium express large no. of oestrogen receptors hence
are susceptible to decreasing levels of oestrogen that occur
w ovarian failure (natural ie menopause, or otherwise).
Hypo-oestrogenism causes changes in the vagina and lack
of adequate vaginal lubrication w sexual arousal both
result in dyspareunia.
Mild hypo-oestrogenism decreased levels of oestrogen are
also seen in other conditions and can cause atrophy inc post
partum period, breastfeeding, certain meds (low oestrogen
OCP, tamoxifen, GnRH agonists and depot
medroxyprogesterone acetate- progestin contraceptive)
and hypothalamic pituitary disorders.
Unrelated to hypo estrogenic states in younger
women assoc. with inhibited arousal resulting from
inadequate foreplay technique, relationship issues,
interpersonal conflict, and some meds used to r high BP or
depression. Other meds w signif. Effect inc first ge H1
blockers (antihistamines) and anticholinergic agents.
Sjogrens Syndrome.
Other clinical manifestations inc vaginal dryness, burning,
pruritis, discharge possible vaginal bleeding.
o Vaginismus
Traditionally defined as a muscle spasm of pelvic floor
muscles surrounding vaginal orifice preventing insertion of
an object (penis, digit, instrument) this definition now
being called into question though (see Uptodate).
Primary vaginismus usually related to psychological issue,
Secondary vaginismus usually represents a conditioned
response to pain from a physical cause or new relationship
issues.
o Hypertoncity of local musculature
o Urinary Tract Disease ask about bladder and urinary symptoms
Interstitial Cystitis (painful bladder syndrome)
Cystitis
Urethral Diverticulum
o Vulvovaginitis
Inflam or irritation around vulva and vagina
Common, may cause superficial genital pain during
intercourse.
Can be infectious causes eg C albicans or Group B and D
strep or non infectious eg dermitis from contact with
bubble baths or perfumed toilet papers.
Common causes inc Candida albicans or Trichomonas
vaginalis, dermatitis (common cause for vulvitis)
o Post partum
Research suggests 7-10% of women have dyspareunia 12
months post partum
Distortion of anatomy, persistent inflamed granulation
tissue or development of a trigger point are poss causes.
Rx depends on aetiology.
o Endometriosis
Deep dyspareunia is a commo symptom esp if uterosacral
ligaments or rectovaginal septum are involved.
o Pelvic Adhesions
o Uterine retroversion
Although a normal position variant of the uterus, some
women have pain on deep penile thrusting.
Positional change during coitus is usually helpful
Laparoscopic uterine suspension is another possible rx.
o Pelvic organ relapse
Usually not a cause of pain but can cause pain on marked
descent.
o Post Op. dyspareunia
Inc hysterectomy and surgery for repair of pelvic relaxation
o Leiomyomata
Benign tumours of smooth muscle- think here we are
referring to uterine leiomyomatas
Women w leiomyomatas do not have a higher prevalence of
dyspareunia than women without these tumours, however
in an individual person a leiomyomata can be a source of
pain esp if large and impacted during intercourse.
o Adnexal pathology
Eg ovarian cyst
Deep dyspareunia usually
o Seminal Plasma allergy
Characterised by post coital vulvovaginal itching, burning,
oedema, and erythema w or w/o systemic signs and
symptoms (eg dyspnoea, dysphagia, rhinoconjuctival
complaints, generalised uticaria, angioedema and more).
Women usually most affected are <40yrs w a fam hax of
atopy.
Onset immed or within 1 hr of contact w seminal plasma.
o Psychogenic Dyspareunia
Various causes/ ideas behind what causes this, inc sexual
abuse, prev painful sexual experience, faulty learning, and
more.
Described as a hysterical or conversion symptom
symbolising an unconscious intrapsychic conflict.
o Dermatological
Lichen Planus (pic from UptoDate)
Most common type of vulvar lichen planus-
often involves vagina as well.
Desquamative, erosive, chronic dermatitis



Lichen Scleroisis (pic from UptoDate)
White atrophic papules that may coalesce into
plaques.
Labia minora and/or labia majora are most commonly
affected.

Men
- Subject to significantly less research than female dyspareunia
o Few long term stat significant studies have been published
- Pain in the penis, testis, belly and sometimes rectum.
- Prevalence seems to be less but whether this is a reflection of the social
stigma assoc. w male sexual disorders or a true reflection is unknown.
o An increase in open discussion regarding sexuality among men in
recent yrs has resulted in larger no. of men discussing dyspareunia
w clinicians.
o Suggested prevalence in 2008 in Australia (UptoDate) 5% of men
suffer pain assoc. w sexual intercourse.
- Should always ask patient if pain occurs with non coital sexual activity inc
masturbation an underlying psychological basis should be considered
for patients with no pain on masturbation.
- Causes
o Main dyspareunia is UNLIKELY to have an INFECTIOUS aetiology.
(from UptoDate would have thought that it would be MOST
COMMON aetiology though??) I think it is to do with the
definition of dyspareunia as being for >/= 3 months in duration
see above.
o Hence perhaps why STIs had been left of the list?? (or perhaps
they dont cause dyspareunia?- think perhaps some dont cause
dyspareunia)
o One way of classifying causes of dyspareunia in men is by x4 broad
categories
Isolated painful ejaculation
- One of the ejaculatory dysfunctions (can have anejaculation, delayed,
retrograde, premature and painful).
- Only ejaculatory condition where PAIN is the main complaint
- Incidence in men age >/=50yrs is 1.0-6.7%
- Multiple causes see table below inc inflam, surgical, drugs etc
- Common presentations inc:
o Penile pain, perineal ache or suprapubic discomfort occurring
during or after the ejaculatory period.
o Can be sometimes experienced in testicular or glans area of the
penis immed post ejaculation, or result from perineal muscle
spasm.
o Atypical pain w ejaculation can also occur in the abdomen, urethral
meatus or rectum.

Chronic prostatitis/chronic pelvic pain
- Frequently assoc. w male dyspareunia
- Both inflam and non inflam conditions of the prostate have been assoc. w
chronic pelvic pain and painful intercourse.
-
Medical Causes
- Peyronies Disease
o Formation of inelastic scar or plaque of the turnia auginea that
may cause a pathological curvature of the penis and painful
eerrections.
o Common cause of dyspareunia in men.
- Phimosis
o Leads to inability to retract the foreskin in the uncircumcised male
and can cause discomfort w attempted intercourse.
- Frenulum breve
o Shortened frenulum which may restrict the glans in the erect state
o Leads to pain w erections and attempts at intercourse.
- Hernia Repair
- Pudendal N entrapment
- Infections
o STIs- eg gonorrhoea, Herpes Simplex virus.
o Infection of prostate, bladder seminal vesicle or urethra
- Interstitial Cystitis
o May experience intense pain at moment of ejaculation and w
intercourse
o Compression of bladder during intercourse causes pain sufficient
enough to inhibit intercourse.
- Dermatological
o Inc STIs
o Linchen planus
o Lichen Sclerosis
o Zoons (plasma cell) balanitis
o Balanoposthitis
o Penile carcinoma
- Medications
o Inc antidepressants
o Antipsychotics.
Other
o Relationship problems (about partner or self)/psychological
o Anodyspareunia pain w receptive anal intercourse was found to
occur in MSM in 14% in one study.















Summary Tables
Women












Common Dont Miss
Insufficient foreplay Malignancy various, see sheet
Post partum Ectopic Pregnancy
Vulvar pain Syndromes A[[emdicitis, cholecystitis,
diverticulitis, IBD
Urogenital Atrophy oestrogen lack
(ususally) very common in peri and
post menopausal women
Acute or chronic pyelonephritis
Vaginismus Pelvic Abscess secondary to surgery or
diverticulitis
Hypertonicity of local musculature Serious psychogenic causes eg
Depression, past traumatic
experiences.
UTI (inc badder infections)
Vulovaginitis inflam of vulva and
vagina (can be just vulvitis or vaginitis
though) can be infectious or non
infectious causes.

Endometriosis
Pelvic adhesions
Uterine retroversion
Pelvic organ relapse
Post op
Leomyomata (benign tumour of
smooth muscle)

Adnexal Pathology eg ovarian cyst
Seminal plasma allergy
Dermatological common is lichen
planus or lichen Sclerosis

Psychogenic- important, remember
problem doesnt have to be
psychogenic OR physiolocial, there can
be elements of BOTH (explore both!!)


Men

Isolated Painful ejaculation (one of the
ejaculatory dysfunctions)
Incidence - >/= 50yrs is 1.0-6.7%
Inflam eg urethritis, prostatis,
epididymitis
Malignancy eg bladder cnacer,
prostate cancer
Benign eg inguinal hernia, vesical
calculi, benign prostate hyperplasia
Surgical eg radical prostatectomy,
vasectomy, hernia repair
Medications eg tricyclic
antidepressants, SSRIs, MAOIs,
Antipsychotics
Psychogenic

Chronic Prostatitis/chronic pelvic pain Frequently assoc. w male dyspareunia
Medical Causes
Peyronies Disease (plaques of turnica
auginea)
Phimosis
Frenulum Breve
Hernia Repair
Pudendal N entrapment
Infections STIs, prostate, bladder,
urethra or seminal vesicle.
Interstitial cystitis
Dermatological inc STIs, lichen
planus
Medications- inc antidepressant and
antipsychotics
Other
Relationship Problems
Anodyspareunia pain w repective
anal intercourse found to iccur ni
MSM in 14% in one UptoDate study.











References
- http://0-
www.uptodate.com.library.newcastle.edu.au/contents/dyspareunia-
painful-sex-the-
basics?source=search_result&search=dyspareunia&selectedTitle=4%7E1
50
- http://0-
www.uptodate.com.library.newcastle.edu.au/contents/differential-
diagnosis-of-sexual-pain-in-
women?source=search_result&search=pain+during+intercourse&selecte
dTitle=1%7E150#H1
- http://0-
www.uptodate.com.library.newcastle.edu.au/contents/approach-to-the-
woman-with-sexual-
pain?source=search_result&search=pain+during+intercourse&selectedTi
tle=2%7E150#H1
- http://0-www.uptodate.com.library.newcastle.edu.au/contents/male-
dyspareunia?source=search_result&search=pain+during+intercourse&sel
ectedTitle=14%7E150
- Good for malignancies that can be a cause of dyspareunia - http://0-
www.mdconsult.com.library.newcastle.edu.au/das/pdxmd/body/444818
285-4/1520365327?type=med&eid=9-u1.0-_1_mt_1014319
-