SEX can be painful. This is true more often for women but it can also be painful for men. Repeated episodes (of painful sex) often establishes a cycle of pain, in which the anxiety and fear of pain leads to avoidance of the sexual activity that produces it. This results in arousal difficulties and failure to reach an orgasm, and consequently, may lead to negative impact on the couple’s relationship.
This refers to pain in the female genitals that is associated with sexual intercourse. It usually occurs on penetration but it can also occur with genital stimulation. It is termed primary, when it has always occurred since the initial episode of sexual intercourse and secondary, when it occurs after a period of pain-free sexual intercourse.
Dyspareunia can be superficial or deep.
The causes of superficial pain include:
Lack of lubrication or dryness due to anxiety, failure to relax, menopause and unskilled foreplay.
Infections like moniliasis, trichomoniasis, herpetic blisters and infected warts (human papilloma virus).
Injury like episiotomy or tears in childbirth and following sexual assault.
Foreign bodies like a forgotten tampon which has become infected.
The causes of deep dyspareunia include:
Cervical conditions like infections can lead to pain on deep penetration, a condition called acollision dyspareuniaa.
Uterine conditions like fibroids.
Endometriosis, a condition in which the lining of the uterine cavity is found outside the uterus and/or in the muscle of the uterus. Penile pressure on an endometriotic spot or mass causes deep intense pain especially around the time of the periods.
Pelvic inflammatory disease (PID) is an infection of the female genital organs in the abdomen, a common cause of which is chlamydia, especially when it is inadequately treated. The pressure of intercourse on the inflamed pelvic organs produces deep intense pain.
Ovarian conditions like cysts. Pain can also result from a normal ovary which is unusually sited.
Ectopic pregnancy is a pregnancy that is sited outside the uterine cavity. Pressure on it can be very painful and may cause it to rupture, resulting in a life threatening emergency.
Vaginal pain is the least common category of dyspareunia. This is because sensory nerves are only found in the lower third of the vagina. If this occurs, the pain is usually felt at the entrance to the vagina and the causes are the same as that of superficial pain.
The management of dyspareunia starts with history taking and physical examination, including a pelvic examination in which there is insertion of the doctor’s examining fingers into the vagina.
Depending on the cause(s), laboratory and imaging investigations may be carried out. Sometimes, surgical intervention may be necessary to elucidate and treat the cause for example, in the case of endometriosis, ovarian conditions or ectopic pregnancy.
The treatment is that of the physical cause such as hormones and lubricants in menopausal dryness, antimicrobials for infections, hormones and/or surgery for endometriosis, surgery for ectopic pregnancy.
Cognitive behavioural therapy may also be helpful. It is important that the woman understands and adapts to the problem. Many have been able to have a good quality sexual life with penetration. Successful treatment is much dependent on the woman having ownership and control of her sexual activity.
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