Dyspareunia

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Basics

Description

  • Recurrent and persistent genital or pelvic pain associated with sexual activity, which is not exclusively due to intensity of intercourse, lack of lubrication or vaginismus. It can be associated with distress and can negatively impact relationships, self-esteem, and sexual satisfaction.
  • It is important to note that while dyspareunia and vaginismus have previously been viewed as separate conditions, they were combined into genito-pelvic pain and penetration disorder as described by the DSM-5 (1).
    • Many individuals have sexual practices that do not include penetration; these individuals can also be impacted by these conditions (1).
  • May be the result of organic, emotional, or psychogenic causes
    • Primary: present throughout one’s sexual history
      • Potential relationship exists between primary dyspareunia and vaginismus, low libido, and arousal disorders.
    • Secondary: arising from a specific event or condition (e.g., menopause, endometriosis, pelvic inflammatory disease [PID], depression, drugs)
    • Superficial: pain at, or near, the introitus or vaginal barrel associated with penetration
    • Deep: pain after penetration located at the cervix or lower abdominal area
    • Complete: present under all circumstances
    • Situational: occurring selectively with specific situations
    • Idiopathic: no identifiable cause or presence despite treatment
  • System(s) affected: reproductive

Epidemiology

  • Predominant age: all ages
  • Predominant sex: female > male

Incidence
>50% of all sexually active women will report dyspareunia at some time.

Geriatric Considerations
Incidence increases dramatically in postmenopausal women primarily because of vaginal atrophy.

Prevalence

Most sexually active women will experience dyspareunia at some time in their lives.

  • ~15% (4–40%) of adult women will have dyspareunia on a few occasions during a year.
  • ~1–2% of women will have painful intercourse on a more-than-occasional basis.
  • Male prevalence is ~1%.

Etiology and Pathophysiology

  • Disorders of vaginal outlet
    • Adhesions
    • Condyloma
    • Clitoral irritation
    • Episiotomy scars
    • Fissures
    • Hymenal ring abnormalities
    • Inadequate lubrication
    • Infections
    • Lichen planus
    • Lichen sclerosus
    • Postmenopausal atrophy
    • Psoriasis
    • Trauma
    • Vulvar papillomatosis
    • Vulvar vestibulitis/vulvodynia
  • Disorders of vagina
    • Abnormality of vault owing to surgery or radiation
    • Congenital malformations
    • Inadequate lubrication
    • Infections
    • Inflammatory or allergic response to foreign substance
    • Masses or tumors
    • Pelvic relaxation resulting in rectocele, uterine prolapse, or cystocele
  • Disorders of pelvic structures
    • Endometriosis
    • Levator ani myalgia/spasm
    • Malignant or benign tumors of the uterus
    • Ovarian pathology
    • Pelvic adhesions
    • PID
    • Pelvic venous congestion
    • Prior pelvic fracture
    • Uterine fibroids
  • Disorders of the GI tract
    • Constipation
    • Diverticular disease
    • Fistulas
    • Hemorrhoids
    • Inflammatory bowel diseases
  • Disorders of the urinary tract
    • Interstitial cystitis
    • Ureteral or vesical lesions
    • Urethritis
  • Chronic disease
    • Behçet syndrome
    • Diabetes
    • Sjögren syndrome
    • Fibromyalgia
    • Multiple sclerosis
    • Neuropathies and chronic pain syndromes
  • Male
    • Peyronie disease
    • Cancer of penis
    • Genital muscle spasm
    • Infection or irritation of penile skin
    • Infection of seminal vesicles
    • Lichen sclerosus
    • Musculoskeletal disorders of pelvis and lower back
    • Penile anatomy disorders
    • Phimosis
    • Prostate infections and enlargement (e.g., chronic prostatitis)
    • Testicular disease
    • Obstruction of ejaculatory duct (e.g., torsion of spermatic cord, calculus, cyst)
    • Urethritis
  • Psychological disorders
    • Anxiety
    • Conversion reactions
    • Depression
    • Fear
    • Hostility toward partner
    • Phobic reactions
    • Psychological trauma/PTSD

Risk Factors

  • Fatigue
  • Stress
  • Depression and anxiety
  • Diabetes
  • Estrogen deficiency
    • Menopause
    • Lactation
  • Previous PID
  • Vaginal surgery or trauma
  • Alcohol/marijuana consumption
  • Medication side effects (antihistamines, tamoxifen, bromocriptine, low-estrogen oral contraceptives, SSRIs, depo-medroxyprogesterone, desipramine)
  • History of sexual abuse
  • Black race

Pregnancy Considerations

  • Pregnancy has a potent influence on sexuality; dyspareunia is common in late pregnancy and postpartum.
    • Breastfeeding, perineal pain, fatigue, and stress can be risk factors in postpartum period.
  • Episiotomies do not have a protective effect.
    • Women who experience delivery interventions including episiotomy are at greater risk than women who deliver over an intact perineum or have an unsutured tear.

General Prevention

N/A

Commonly Associated Conditions

Vaginismus

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Basics

Description

  • Recurrent and persistent genital or pelvic pain associated with sexual activity, which is not exclusively due to intensity of intercourse, lack of lubrication or vaginismus. It can be associated with distress and can negatively impact relationships, self-esteem, and sexual satisfaction.
  • It is important to note that while dyspareunia and vaginismus have previously been viewed as separate conditions, they were combined into genito-pelvic pain and penetration disorder as described by the DSM-5 (1).
    • Many individuals have sexual practices that do not include penetration; these individuals can also be impacted by these conditions (1).
  • May be the result of organic, emotional, or psychogenic causes
    • Primary: present throughout one’s sexual history
      • Potential relationship exists between primary dyspareunia and vaginismus, low libido, and arousal disorders.
    • Secondary: arising from a specific event or condition (e.g., menopause, endometriosis, pelvic inflammatory disease [PID], depression, drugs)
    • Superficial: pain at, or near, the introitus or vaginal barrel associated with penetration
    • Deep: pain after penetration located at the cervix or lower abdominal area
    • Complete: present under all circumstances
    • Situational: occurring selectively with specific situations
    • Idiopathic: no identifiable cause or presence despite treatment
  • System(s) affected: reproductive

Epidemiology

  • Predominant age: all ages
  • Predominant sex: female > male

Incidence
>50% of all sexually active women will report dyspareunia at some time.

Geriatric Considerations
Incidence increases dramatically in postmenopausal women primarily because of vaginal atrophy.

Prevalence

Most sexually active women will experience dyspareunia at some time in their lives.

  • ~15% (4–40%) of adult women will have dyspareunia on a few occasions during a year.
  • ~1–2% of women will have painful intercourse on a more-than-occasional basis.
  • Male prevalence is ~1%.

Etiology and Pathophysiology

  • Disorders of vaginal outlet
    • Adhesions
    • Condyloma
    • Clitoral irritation
    • Episiotomy scars
    • Fissures
    • Hymenal ring abnormalities
    • Inadequate lubrication
    • Infections
    • Lichen planus
    • Lichen sclerosus
    • Postmenopausal atrophy
    • Psoriasis
    • Trauma
    • Vulvar papillomatosis
    • Vulvar vestibulitis/vulvodynia
  • Disorders of vagina
    • Abnormality of vault owing to surgery or radiation
    • Congenital malformations
    • Inadequate lubrication
    • Infections
    • Inflammatory or allergic response to foreign substance
    • Masses or tumors
    • Pelvic relaxation resulting in rectocele, uterine prolapse, or cystocele
  • Disorders of pelvic structures
    • Endometriosis
    • Levator ani myalgia/spasm
    • Malignant or benign tumors of the uterus
    • Ovarian pathology
    • Pelvic adhesions
    • PID
    • Pelvic venous congestion
    • Prior pelvic fracture
    • Uterine fibroids
  • Disorders of the GI tract
    • Constipation
    • Diverticular disease
    • Fistulas
    • Hemorrhoids
    • Inflammatory bowel diseases
  • Disorders of the urinary tract
    • Interstitial cystitis
    • Ureteral or vesical lesions
    • Urethritis
  • Chronic disease
    • Behçet syndrome
    • Diabetes
    • Sjögren syndrome
    • Fibromyalgia
    • Multiple sclerosis
    • Neuropathies and chronic pain syndromes
  • Male
    • Peyronie disease
    • Cancer of penis
    • Genital muscle spasm
    • Infection or irritation of penile skin
    • Infection of seminal vesicles
    • Lichen sclerosus
    • Musculoskeletal disorders of pelvis and lower back
    • Penile anatomy disorders
    • Phimosis
    • Prostate infections and enlargement (e.g., chronic prostatitis)
    • Testicular disease
    • Obstruction of ejaculatory duct (e.g., torsion of spermatic cord, calculus, cyst)
    • Urethritis
  • Psychological disorders
    • Anxiety
    • Conversion reactions
    • Depression
    • Fear
    • Hostility toward partner
    • Phobic reactions
    • Psychological trauma/PTSD

Risk Factors

  • Fatigue
  • Stress
  • Depression and anxiety
  • Diabetes
  • Estrogen deficiency
    • Menopause
    • Lactation
  • Previous PID
  • Vaginal surgery or trauma
  • Alcohol/marijuana consumption
  • Medication side effects (antihistamines, tamoxifen, bromocriptine, low-estrogen oral contraceptives, SSRIs, depo-medroxyprogesterone, desipramine)
  • History of sexual abuse
  • Black race

Pregnancy Considerations

  • Pregnancy has a potent influence on sexuality; dyspareunia is common in late pregnancy and postpartum.
    • Breastfeeding, perineal pain, fatigue, and stress can be risk factors in postpartum period.
  • Episiotomies do not have a protective effect.
    • Women who experience delivery interventions including episiotomy are at greater risk than women who deliver over an intact perineum or have an unsutured tear.

General Prevention

N/A

Commonly Associated Conditions

Vaginismus

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