Painful Sex in Women (Dyspareunia)

Dyspareunia (painful sex) is defined as persistent or recurrent genital pain that occurs just before, during or after intercourse. There are two types:

  • entry (superficial) dyspareunia, where pain is felt at the entrance to, or within the vagina
  • deep (abdominal) dyspareunia, where pain is felt in the abdomen.

Dyspareunia is common and may cause considerable distress to women and their sexual partners. It may be caused by structural, infective and inflammatory diseases of the vulva, vagina and internal organs. Psychosocial factors inevitably contribute to, and result from, dyspareunia.

  • Dyspareunia may be primary, i.e. occurred with the first attempt at intercourse and ever since; or secondary, i.e. occurring later, having previously had no pain with intercourse.
  • Pain can occur on every attempt at intercourse or only on certain occasions or in certain situations.

Entry Dyspareunia

The most common vulval skin diseases resulting in superficial or entry dyspareunia include:

  • Dryness or eczema/dermatitis especially when due to contact irritant or, less often, contact allergic factors (e.g. latex allergy), or chronic rubbing/scratching leading to lichen simplex
  • Primary fissuring of posterior fourchette
  • Medications that dry the skin, particularly isotretinoin
  • Genital herpes or other sexually transmitted infections
  • Lichen sclerosus
  • Lichen planus
  • Plasma cell vulvitis

Dyspareunia associated with dry vagina or vaginal inflammation (vaginitis) may be due to:

  • Insufficient lubrication due to lack of sexual arousal or inability to reach orgasm
  • Hormonal changes such as birth control medication, lactation, cancer treatment or menopause (atrophic vaginitis)
  • Irritation from vaginal lubricants, creams, foams, douches, pessaries, condoms or devices
  • Medications that dry mucosal surfaces, such as antihistamines or antidepressant medications such as amitriptyline
  • Dry mucosae due to Sjogren syndrome
  • Vulvovaginal candidiasis
  • Bacterial vaginosis
  • Chlamydia infection
  • Trichomoniasis
  • Erosive vaginal lichen planus
  • Desquamative inflammatory vaginitis
  • Radiation induced vaginitis following treatment for uterine or cervical cancer.

Dyspareunia may also result from:

  • Malformation of the genitalia, e.g., narrowed vagina, labial adhesion, vaginal septa, imperforate hymen
  • Injury, e.g., during childbirth, genital mutilation or surgery
  • Urinary tract infection
  • Interstitial cystitis (painful bladder syndrome)
  • Any pain affecting the vestibule (if cause is unknown, this is called vestibulodynia)
  • Any pain affecting the vulva (if cause is unknown, this is called vulvodynia)
  • Tense pelvic floor muscles and/or vaginismus (involuntary pelvic muscle contractions during attempted intercourse)
  • Low libido related to fear, anxiety and relationship problems including sexual abuse.

Deep Dyspareunia

Deep dyspareunia means sexual pain that is felt in the abdomen, rather than in the vagina. Causes may include:

  • Recent pregnancy / childbirth
  • Retroverted uterus (this refers to the position of the womb)
  • Uterine prolapse
  • Pelvic inflammatory disease or infection
  • Endometriosis
  • Ovarian cysts
  • Uterine fibroids
  • Bowel disease especially irritable bowel syndrome (IBS)
  • Lumbosacral arthritis
  • Adhesions following previous surgery or radiation
  • Genital tract cancer.
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