Pain During Sex (Dyspareunia) – What You Need to Know

Dyspareunia is the term used to describe pain during intercourse. Part of the definition of dyspareunia is that the pain is persistent. An isolated single episode of pain with intercourse should not be included in the diagnosis of dyspareunia.

The pain can be primary which implies that intercourse has always been painful or it can be secondary which indicates that the pain has developed after a period of time where intercourse has been painless.

There have been a number of studies that have looked at the incidence of dyspareunia, around 45% of women will experience dyspareunia at some stage during their life. Persistent, or longstanding dyspareunia whether superficial or deep pain occurs in somewhere between 10-20% of all sexually active women.

The type of pain experienced with intercourse can vary enormously and varies with the site of the pain. Superficial dyspareunia which usually implies pain on penetration is often described as a sharp or burning pain. Pain that occurs higher in the vagina is often described as more of a contraction or acute pain. Pain that occurs in the lower abdomen can either be a sharp or throbbing pain or again, some women notice it as a contraction-like pain. In particular, with deep dyspareunia, words such as aching or throbbing are often used to describe the feeling.

The actual cause of dyspareunia varies according to the site of the pain.

Entry Pain

Pain on penetration or superficial dyspareunia can be due to:

• Vaginal infection
• Intrinsic vulval or vaginal skin disorders; including common conditions such as eczema or dermatitis
• Vulvodynia (pain within the vulva)– which often occurs for no known reason and implies over the firing of the nerve fibres in the skin, often resulting in a burning sensation
• Congenital anatomical disorders of the female genital tract – imperforate hymen or partial absence of the vagina. These abnormalities of the formation of the female genital tract can occur in up to 1% of all women.
• Genitourinary syndrome of menopause – often described as burning pain, due to the effects of the lack of oestrogen on the vaginal skin
• Vaginismus – an involuntary contraction of the muscles at the opening of the vagina or of the lower vagina which narrows the vaginal opening and makes intercourse uncomfortable. This can occur for psychological reasons, often because of previous painful intercourse or a history of being the victim of sexual violence.

Deep Dyspareunia

In the case of deep dyspareunia, there are often different causes:

• Pelvic inflammatory disease – chlamydia being the commonest organism
• Overactivity of the pelvic floor muscles leads to vaginismus
• Endometriosis or scarring leads to immobility of the pelvic organs
• Adenomyosis results in an enlarged more vascular uterus which is more sensitive when moved during intercourse
• Other pelvic masses such as ovarian cysts

Emotional Factors

Painful intercourse, especially associated with vaginismus or involuntary contractions of the muscles of the pelvis can occur for a variety of reasons. These may include:

• Previous painful intercourse
• Other emotional factors such as anxiety or depression
• Relationship issues particularly when these issues are associated with a lack of desire for intercourse
• A history of sexual assault

Understandably. all of these conditions can be associated with painful intercourse and need to be addressed.

Dyspareunia is diagnosed primarily according to the symptoms described by the woman. It is always important to ask for the site of the pain, the nature of the pain and the history of the pain. With the patient’s consent, a Q-Tip or cotton bud can be used to gently test for sensitivity both of the vulva, the vaginal opening and in the vagina itself. An ultrasound is particularly important if the dyspareunia is felt in the lower abdomen or upper vagina to exclude conditions such as endometriosis or adenomyosis.

Dyspareunia is treated depending upon the underlying cause. Where there is no underlying disease and it appears that painful intercourse occurs due to overactive muscles either at the opening of the vagina or deeper within the vagina, then a physiotherapist with experience in this area can be invaluable, although the treatment often takes some months and involves relaxation therapy and sometimes the use of vaginal dilators as a gradual way of learning how to relax important muscles.

Underlying conditions such as endometriosis or adenomyosis which are associated with deep pelvic pain need to be treated. The treatment of vulvodynia or sensitive vulval or lower vaginal skin, especially the posterior aspect of the vaginal opening often involves the use of medications called neuromodulators which are creams and oral tablets that reduce the firing activity of the nerves within the skin. This is often combined with physiotherapy.

Whenever painful intercourse becomes a persistent problem, especially if the actual pain prevents intercourse from occurring, it needs to be fully investigated and treated appropriately.

It is also important that follow-up occurs to make sure that the treatment is working and that intercourse is becoming more comfortable with time.

Dr Len Kliman understands that this is a distressing time, which is why he offers early appointments so that a diagnosis can be made and treatment can be commenced as early as possible. Len has over 35 years of experience in managing women with the distressing symptom of painful intercourse. He is a member of the ISVVD and ANZVS (the International and Australian Societies that specialise in vulval and vaginal skin disorders including pain with intercourse) and keeps abreast of all scientific data regarding this condition and modern treatments.